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C 2005, Lippincott Williams & Wilkins. All rights reserved.The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:

nervousness or paresthesia.throbbing headache or dizziness.drowsiness or blurred vision.tinnitus or diplopia.

RATIONALE: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?

Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeterIncrease in systemic blood pressurePresence of premature ventricular contractions (PVCs) on cardiac monitorIncrease in intracranial pressure (ICP)

RATIONALE: Lidocaine drips are commonly used to treat clients whose arrhythmias haven't been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren't as significant as PVCs in this situation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about which medication?

Acetaminophen (Tylenol)Dopamine (Intropin)Tamoxifen (Nolvadex)Progesterone (Gesterol 50)

RATIONALE: Tamoxifen is an estrogen-blocker used to treat both premenopausal and postmenopausal breast cancer and to prevent breast cancer in certain women who are at high risk. Acetaminophen is a nonnarcotic analgesic. Dopamine is a vasoconstrictor used to treat hypotension. Progesterone is a hormone used to treat amenorrhea or dysfunctional uterine bleeding. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who is taking an anticoagulant. The nurse should teach the client to:

report incidents of diarrhea.avoid foods high in vitamin K.use a straight razor when shaving.take aspirin for pain relief.

RATIONALE: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but this isn't an effect of taking an anticoagulant. An electric razor - not a straight razor - should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding, so acetaminophen should be used for pain relief. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is delivering the client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is the most appropriate for the nurse to take?

Leave the medications on the client's bedside table.Ask the client's roommate to keep the medications for the client until he returns.Lock the medications in the medicine preparation area until the client returns.Have the client skip that dose of medication.

RATIONALE: Whenever a client isn't immediately available to take the medication, the nurse must put the medicine in a secured area. The nurse should never leave drugs unattended in a client's room or in the care of a roommate. The nurse also shouldn't omit doses of medication without an order from the physician. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

leaving the hair intact.shaving the area.clipping the hair in the area.removing the hair with a depilatory.

RATIONALE: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions, and depilatories can irritate the skin. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?

The PCA pump can't infuse narcotics continuously.Pain relief is initiated by the client as needed.No complications related to narcotic delivery by the pump exist.The nurse prescribes the dosage of narcotic for delivery.

RATIONALE: The PCA pump allows for a continuous dose of the narcotic delivery and a demand dose initiated by the client. PCA also prevents the client from receiving an accidental overdose because of a programmed interval during which the pump can't be activated (usually 6 to 10 minutes). The client may still experience complications of narcotic delivery. The physician, rather than the nurse, prescribes the narcotic dose. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:

I.M. or subcutaneous glucagon.an I.V. bolus of dextrose 50%.15 to 20 g of a fast-acting carbohydrate such as orange juice.10 U of fast-acting insulin.

RATIONALE: This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who is hypoglycemic; this action will further compromise

the client's condition. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:

delirium.depression.excessive drug use.Alzheimer's disease.

RATIONALE: Alzheimer's disease is the most common cause of dementia in the elderly. Approximately 10% of people over age 65 have Alzheimer's disease; about 50% of people over age 85 have the disease. Delirium, or acute confusion, is caused by an underlying disease and isn't itself a cause of dementia. Depression is common in the elderly but, in many cases, manifests itself in apathy, self-deprecation, or inertia - not dementia. Excessive drug use, commonly stemming from the client seeing multiple physicians who are unaware of drugs that other physicians have prescribed, can cause dementia. Although it's a problem among the elderly, it isn't as common as Alzheimer's disease. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?

Bone fractureLoss of estrogenNegative calcium balanceDowager's hump

RATIONALE: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause - not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:

perform breast self-examination annually.have a mammogram annually.have a hormonal receptor assay annually.have a physician conduct a clinical examination every 2 years.

RATIONALE: The American Cancer Society guidelines state that women older than age 40 should have a mammogram annually and a clinical examination at least annually (not every 2 years); all women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:

at the end of her menstrual cycle.on the same day each month.on the 1st day of the menstrual cycle.immediately after her menstrual period.

RATIONALE: Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the 1st and last days of the cycle, the woman's breasts are still very tender. Postmenopausal women, because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

cancerous lumps.areas of thickness or fullness.changes from previous self-examinations.fibrocystic masses.

RATIONALE: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?

Carcinoembryonic antigen (CEA) test after age 50Flexible sigmoidoscopy after age 30Annual digital examination after age 50Barium enema after age 20

RATIONALE: The American Cancer Society recommends an annual digital examination after age 50 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer; it helps monitor a client's response to treatment as well as detect metastasis or recurrence. Flexible sigmoidoscopy is recommended every 5 years for people older than age 50. A double contrast Barium enema is one option recommended every 5 years for those over age 50. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client with a history of renal calculi has progressively lost renal function and is admitted to the unit with a diagnosis of chronic renal failure. The physician has prescribed polystyrene sulfonate (Kayexalate). Which of the following is the best reason to use this drug in renal failure?

To lower serum phosphate levelsTo correct acidosisTo exchange potassium for sodiumTo prevent constipation from sorbitol use

RATIONALE: In renal failure, clients become hyperkalemic because they can't excrete potassium in urine. Polystyrene sulfonate provides the mechanism for potassium excretion by pulling potassium into the bowels and exchanging it for sodium. The potassium is then excreted in the feces. Phosphate binders, such as aluminum hydroxide gel, are given to lower phosphate levels. Diet changes, sodium bicarbonate, or dialysis might be used to help control acidosis. Polystyrene sulfonate is itself constipating and must be given with a laxative such as sorbitol. NURSING PROCESS

STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA male client who has had spinal anesthesia is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages him to comply with the order. By complying, the client can avoid which of the following?

HypotensionRespiratory depressionHeadachePain at the lumbar injection site

RATIONALE: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat doesn't help reduce these effects. Pain at the lumbar injection site typically isn't a problem. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationYou're participating in a cancer-screening program for colorectal cancer. Which of the following clients presents the fewest risk factors for colon cancer?

A 45-year-old woman with a 25-year history of ulcerative colitisA 50-year-old man with a father who died of colon cancerA 60-year-old man who follows a diet low in fat and high in fiberA 72-year-old woman with a history of breast cancer

RATIONALE: Although this man is over age 40, he follows an appropriate diet and doesn't present other common risk factors. Inflammatory bowel disease of long duration and a family history of colon cancer are risk factors for colorectal cancer. Advanced age and breast cancer increase the risk of colorectal cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 55-year-old female with autoimmune Addison's disease has been admitted to your nursing unit with dehydration. Your initial assessment confirms a nursing diagnosis of deficient fluid volume. Which of the following etiologic factors establishes this nursing diagnosis?

Glucocorticoid excessMineralocorticoid deficiencyMelanocyte-stimulating hormone excessMelanocyte-stimulating hormone deficit

RATIONALE: Mineralocorticoid deficiency in Addison's disease causes increased losses of sodium, chloride, water, and potassium in urine, which leads to a fluid volume deficit. Addison's disease is associated with a glucocorticoid deficit. Melanocyte-stimulating hormone excess doesn't cause fluid volume deficit. Addison's disease is characterized by a melanocyte-stimulating hormone excess. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client has severe pruritus from hepatitis B. Which of the following nursing measures would best enhance the client's comfort?

Use hot water to increase vasodilation.Use cold water to decrease itching sensation.Give tepid water baths.Avoid lotions and creams.

RATIONALE: Measures to treat pruritus include tepid sponge baths and the use of emollient creams and lotions. Hot water should be avoided because capillary dilation may increase pruritus. Warm water is preferred to cold. The use of emollient creams and lotions on dry skin is recommended. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA 46-year-old male client is admitted to the hospital with a suspected diagnosis of hepatitis B. He is jaundiced and complains of weakness. Which of the following should the nurse include in the client's care plan?

Rest periods after small, frequent mealsA low-protein dietMenus selected by the clientRegular exercise

RATIONALE: Rest periods and small, frequent meals are necessary for clients with hepatitis B. A diet high in protein is recommended to enhance recovery of injured liver cells. The client needs some guidance selecting his food choices. Choices can be made from high-protein foods. Rest, not exercise, is indicated during the acute phase of the disease. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which of the following is most important for the nurse to be aware of when providing care for this client?

Using a stethoscope for auscultating the fistula is contraindicated.The client feels best immediately after the dialysis treatment.Taking a blood pressure reading on the affected arm can cause clotting of the fistula.The client shouldn't feel pain during initiation of dialysis.

RATIONALE: Pressure on the fistula or on the extremity can decrease blood flow and precipitate clotting. Auscultation of a bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, the needle stick is still painful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA 30-year-old teacher performs breast self-examinations monthly. Which of the following findings should she report promptly?

Areolae that are bilaterally darkened in colorFreely movable masses that become tender before the menstrual periodMultiple tender, round masses in both breastsA hard, nontender mass in the upper outer quadrant of the left breast

RATIONALE: Hard, nontender masses are associated with cancerous tumors. The upper outer quadrant is the most common site. Darkened areolae are associated with hormonal changes, such as those caused by pregnancy. Multiple tender, round masses in both breasts that become tender before a menstrual period indicate fibrocystic breast problems. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationPolicy and procedure dictates that hand washing is a requirement when caring for clients. Which statement about hand washing is true?

Frequent hand washing reduces transmission of pathogens from one client to another.Wearing gloves is a substitute for hand washing.Bar soap, which is generally available, should be used for hand washing.Waterless products shouldn't be used in situations where running water is unavailable.

RATIONALE: Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?

Presence of an indwelling urinary catheterRectal temperature of 100% F (37.8% C)Red, warm, tender incisionWhite blood cell (WBC) count of 8,000/ml

RATIONALE: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection but alone doesn't indicate infection. A rectal temperature of 100% F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/ml. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with a fractured hip. The client is combative and confused, and he's trying to get out of bed. The nurse should:

leave the client and get help.obtain a physician's order to restrain the client.read the facility's policy on restraints.order soft restraints from the storeroom.

RATIONALE: It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is assessing a client for the risk of falls. The nurse should collect:

gait and balance information.the agency's restraint policy.the family's psychosocial history.the client's dietary preferences.

RATIONALE: Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Turn and reposition the client a minimum of every 8 hours.Vigorously massage lotion into bony prominences.Post a turning schedule at the client's bedside.Slide the client, rather than lift, when turning.

RATIONALE: A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours - not every 8 hours - for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to avoid shearing. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with late-stage Alzheimer's disease. The client's wife tells the nurse that the client has become very dependent. The client's wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which of the following outcomes to assist the client's wife?

The caregiver learns to explain to the client why she needs time for herself.The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited.The caregiver leaves the client at home alone for short periods of time to encourage independence.The caregiver avoids asking other family members to help for fear of imposing on them.

RATIONALE: The caregiver must learn to distinguish obligations that she must fulfill and limit those that aren't necessary. The caregiver can tell the client when she leaves but she shouldn't expect that the client will remember or won't become angry with her for leaving. The caregiver shouldn't leave the client home alone for any length of time because it may compromise the client's safety. The nurse can provide support to the primary caregiver if she needs to ask other family members for assistance. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn't wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client's problem is:

hopelessness.powerlessness.disturbed body image.fear.

RATIONALE: Disturbed body image is a negative perception of self that makes healthful functioning more difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part, not looking at a body part, and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may have any of the other diagnoses, but the signs and symptoms described in the case most closely match the defining characteristics disturbed body image. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

Tell the client's spouse or partner to be supportive while she recovers.Encourage the client to proceed with the next phase of treatment.Recommend that the client remain cheerful for the sake of her children.Refer the client to the American Cancer Society's Reach for Recovery program or another support program.

RATIONALE: The client isn't withdrawn or showing other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client's spouse or partner to listen for concerns, but the nurse shouldn't tell the client's spouse what to do. The client must consult with her physician

and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can't be expected to be cheerful at all times. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife, and he becomes tearful. He expresses that he's spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?

Situational low self-esteemUnilateral neglectSocial isolationRisk for loneliness

RATIONALE: The signs and symptoms stated in this case are typical of a client with situational low self-esteem. The diagnosis of unilateral neglect occurs in neurologic illness or trauma when the client shows a lack of awareness of a body part. This client is at risk for social isolation and loneliness, but there's no indication in the case study that these diagnoses are present. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention isn't appropriate for this client?

Acknowledging the client's spiritual distressInviting the client's clergyman to visit himEncouraging the client to discuss religious beliefs and practicesEncouraging the client to discuss concerns with the clergy

RATIONALE: The nurse shouldn't invite his clergyman to visit the client, unless the client specifically asks to see that member of the clergy. Acknowledging the client's spiritual distress may help the nurse build a therapeutic relationship with the client. Encouraging the client to discuss religious beliefs and practices is a first step in developing a plan for the client. It's also appropriate for the nurse to encourage the client to discuss his concerns with the clergy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Avoiding the use of recreational drugs and alcoholRefraining from telling anyone about the diagnosisFollowing safer-sex practicesTelling potential sex partners about the diagnosis, as required by law

RATIONALE: It's essential that AIDS clients follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although it's helpful if AIDS clients avoid using recreational drugs and alcohol, for purposes of avoiding transmission it's more important that I.V. drug users use clean needles and dispose of used needles. Whether the AIDS client chooses to tell anyone about an AIDS diagnosis is the client's decision; there's no legal obligation to do so. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:

establish unresponsiveness.call for help.open the airway.assess the client for a carotid pulse.

RATIONALE: The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg, and he complains of dizziness. Which medication would be used to treat his bradycardia?

AtropineDobutamine (Dobutrex)Vasopressin (Pitressin)Lidocaine (Xylocaine)

RATIONALE: I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Vasopressin is used to treat ventricular fibrillation. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

suctioning the tracheostomy tube frequently.using a cuffed tracheostomy tube.using the minimal air leak technique with cuff pressure less than 25 cm H2Okeeping the tracheostomy tube plugged.

RATIONALE: To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

limit oral fluid intake for 1 to 2 weeks.report the presence of fine, sandlike particles through the nephrostomy tube.notify the physician about cloudy or foul-smelling urine.report bright pink urine within 24 hours after the procedure.

RATIONALE: The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal due to residual stone products. Hematuria is common after lithotripsy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

hypernatremia.

hypokalemia.hyperkalemia.hypercalcemia.

RATIONALE: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:

use cosmetic camouflage techniques.protect the graft from direct sunlight.continue physical therapy.apply lubricating lotion to the graft site.

RATIONALE: To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are all helpful to the client and his recovery but are less important. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

apply suction to the NG tube every hour.clamp the NG tube if the client complains of nausea.irrigate the NG tube gently with normal saline solution.reposition the NG tube if pulled out.

RATIONALE: The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously - not every hour. The NG tube shouldn't be clamped postoperatively because secretions and gas will accumulate, stressing the suture line. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

AssessmentAnalysisImplementationEvaluation

RATIONALE: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who recently underwent a total hip replacement. The nurse should:

ease the client onto a low toilet seat.allow the client's legs to be crossed at the knees when out of bed.use soft chairs when the client is sitting out of bed.limit client hip flexion when sitting.

RATIONALE: Instruct the client to limit hip flexion to 90 degrees while sitting. Supply an elevated toilet seat so the client can sit without having to flex his hip more than 90 degrees. Instruct the client not to cross his legs, to avoid dislodging or dislocating the prosthesis. Caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should do all of the following except:

position the client to prevent airway obstruction.keep the client in one position to decrease bleeding.administer I.V. fluid as ordered and monitor the client for signs of fluid volume excess.maintain the client in a quiet environment.

RATIONALE: The nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhen caring for a client who's being treated for hyperthyroidism, it's important to:

provide extra blankets and clothing to keep the client warm.monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.balance the client's periods of activity and rest.encourage the client to be active to prevent constipation.

RATIONALE: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism, not hyperthyroidism, complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, often feel lethargic and sluggish, and are prone to constipation. Therefore, the nurse should encourage clients with hypothyroidism to be more active to prevent constipation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhich intervention should the nurse try first with a client who exhibits signs of sleep disturbance?

Administer sleeping medication before bedtime.Ask the client each morning to describe the quality of sleep during the previous night.Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

RATIONALE: The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common-sense interventions fail. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisWhen preparing a client for an enema, the nurse should help him into the:

left-lateral Sims' position.prone position.right-lateral Sims' position.right Fowler's position.

RATIONALE: Left-lateral Sims' position will facilitate the flow by gravity into the descending colon. Only if this position is contraindicated will the nurse place the client on his back or right side. The prone position isn't used when giving an enema. If the client can't lie flat, semi-Fowler's position may be used. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with a right ankle sprain. When applying cold to a client's injury, the nurse should:

apply it immediately after the injury occurs.use sterile technique.secure the cooling device with pins so that the device doesn't fall off.discontinue any application longer than 3 hours.

RATIONALE: Apply cold immediately to minimize edema. Use sterile technique when applying cold to any open wound or when applying cold to the eyes. Don't secure cooling devices with pins because an accidental puncture could allow cold fluids to leak out and burn the client's skin. Cold applications shouldn't be left on for longer than 1 hour at a time because of the risk of reflexive vasodilation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

avoid focusing on his weight.increase his activity level.follow a regular diet.continue leading a high-stress lifestyle.

RATIONALE: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is:

immunosuppression.radiation exposure.exposure to the sun.burns.

RATIONALE: The sun is the best known and most common cause of basal cell epithelioma. Immunosuppression, radiation, and burns are less common causes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical?

Using crutches properlyExercising joints above and below the cast, as orderedAvoiding walking on a leg cast without the physician's permissionReporting signs of impaired circulation

RATIONALE: Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the physician's permission. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for:

atelectasis.anemia.dehydration.peripheral edema.

RATIONALE: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or if he continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

helping him communicate.keeping his airway patent.encouraging him to perform activities of daily living.preventing him from developing an infection.

RATIONALE: Maintaining a patent airway is the most basic and most critical human need. All other interventions are important to the client's well-being, but they aren't as important as having sufficient oxygen to breathe. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.thoracotomy.hemorrhoidectomy.cystectomy.

RATIONALE: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. Thoracotomy and cystectomy clients may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following?

Avoid lifting objects weighing more than 5 lb (2.27 kg).Lie on your abdomen when in bed.Keep rooms brightly lit.

Avoid straining during bowel movement or bending at the waist.RATIONALE: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7 kg) - not 5 lb. Instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisWhen caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

position the client in a supine position.elevate the head of the bed 90 degrees during meals.encourage the client to remove dentures.encourage thin liquids for dietary intake.

RATIONALE: The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position - not a supine position - when lying down to reduce the risk of aspiration. Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened liquids, not thin liquids, decrease aspiration risk. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationWhen performing an assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. These signs and symptoms indicate which nursing diagnosis?

Health-seeking behaviorImpaired physical mobilityDisturbed sensory perceptionDeficient knowledge

RATIONALE: Impaired physical mobility is a limitation of physical movement that's identified by the characteristics found in this client. Health-seeking behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or the environment in order to move toward optimal health. Disturbed sensory perceptions are changes in the characteristics of incoming stimuli. Deficient knowledge exists when the client requires further teaching. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisBefore weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?

Fluid intake for the last 24 hoursBaseline arterial blood gas (ABG) levelsPrior outcomes of weaningElectrocardiogram (ECG) results

RATIONALE: Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with genital herpes. Education for this client should include an explanation of:

the need for the use of petroleum products.why the disease is transmittable only when visible lesions are present.the option of disregarding safer-sex practices, now that he's already infected.the importance of informing his partner of the disease.

RATIONALE: Clients with genital herpes should inform their partners of the disease. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is transmittable only when visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health status, should follow safer-sex practices. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her:

every month, timing isn't important.every month, 7 to 10 days after menses starts.every month, 7 to 10 days before menses starts.breast self-examinations aren't necessary until after the first mammography.

RATIONALE: Breast self-examinations should be performed every month, 7 to 10 days after menses start. Timing is important and breast self-examinations are recommended for all women. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA male client should be taught about testicular examinations:

when sexual activity starts.after age 60.after age 40.before age 20.

RATIONALE: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeWhen performing an abdominal assessment, the nurse should follow which examination sequence?

Inspection, auscultation, percussion, and palpationInspection, auscultation, palpation, and percussionInspection, percussion, palpation, and auscultationInspection, palpation, percussion, and auscultation

RATIONALE: 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. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms:

yearly after age 40.after the birth of the first child and every 2 years thereafter.after the first menstrual period and annually thereafter.every 3 years between ages 20 and 40 and annually thereafter.

RATIONALE: The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are incorrect. It's recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client asks the nurse what PSA is. The nurse should reply that it stands for:

prostate-specific antigen, used to screen for prostate cancer.protein serum antigen, used to determine protein levels.pneumococcal strep antigen, a bacteria that causes pneumonia.Papanicolaou-specific antigen, used to screen for cervical cancer.

RATIONALE: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:

gender, obesity, family history, and smoking.inactivity, stress, gender, and smoking.obesity, inactivity, diet, and smoking.stress, family history, and obesity.

RATIONALE: The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that can't be controlled. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is performing an admission assessment on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should:

always count for 30 seconds and multiply by 2.count the apical pulse only.count for 60 seconds.count for 15 seconds and multiply by 4.

RATIONALE: When assessing a pulse rate, the nurse should count for 60 seconds. Counting for 30 seconds then multiplying by 2 isn't always accurate. The radial pulse may be assessed as well as the apical. Counting for 15 seconds and multiplying by 4 isn't enough time to adequately assess the regularity of the pulse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhen inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:

initiate a stream of urine.breathe deeply.turn to the side.hold the labia or shaft of penis.

RATIONALE: When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

destroys the odor-proof seal.won't affect the colostomy system.is appropriate for relieving the gas in a colostomy system.destroys the moisture barrier seal.

RATIONALE: Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag and unclamping it are the only appropriate methods for relieving gas. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse must administer an enema to an adult client. The appropriate depth for inserting an enema into an average-sized adult is:

1" to 2" (2.5 to 5 cm)3" to 4" (7.5 to 10 cm)4" to 6" (10 to 15 cm)6" to 8" (15 to 20 cm)

RATIONALE: Appropriate depth for inserting an enema into an average size adult client is 3" to 4". NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:

help relax tense muscles.prevent stiffness and further loss of mobility.reduce swelling and inflammation.block painful stimuli traveling over small nerve fibers.

RATIONALE: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers. Massage is used to relax tense muscles. Range-of-motion exercises are used to prevent stiffness and further loss of mobility. Elevation and repositioning are used to reduce swelling and inflammation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:

overhydration causes the skin to tent.dehydration causes the skin to appear edematous and spongy.inelastic skin turgor is a normal part of aging.normal skin turgor is moist and boggy.

RATIONALE: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

coma or seizures.sunken eyeballs and poor skin turgor.

increased heart rate with hypotension.thirst or confusion.

RATIONALE: Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:

prevent leaning.distribute weight away from the involved side.maintain stride length.prevent edema.

RATIONALE: Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won't maintain stride length or prevent edema. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:

isn't necessary.should begin immediately postoperatively.should begin the day after surgery.begins at a rehabilitation center.

RATIONALE: Exercise should begin the day after surgery. Exercise is necessary to maintain the muscle tone of the remaining limb. Immediately after the surgery, the client usually isn't alert enough to participate and may be in too much pain. Exercise needs to begin before discharge to a rehabilitation center. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:

decrease the possibility of absorption on the nurse's skin.allow distribution of medication.prevent soiling of the client's clothes.avoid administering more than the prescribed dose.

RATIONALE: The nurse should remove previously applied topical medications before applying new medications to prevent accumulation of medication that exceeds the prescribed dose. Wearing gloves will decrease the possibility of absorption on the nurse's skin. Spreading topical medications evenly will allow for distribution of medication. Placing a dressing, if allowable, over the medication will prevent soiling of client's clothes. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:

conjunctival sac.pupil.sclera.vitreous humor.

RATIONALE: The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eye's shape and size. The vitreous humor maintains the retina's placement and the shape of the eye. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the nurse should gently pull the:

auricle down and back.tragus down and back.auricle up and back.tragus up and back.

RATIONALE: To straighten the ear canal in an adult client to instill eardrops, gently pull the auricle up and back. Repositioning the tragus won't straighten the ear canal. Pull the auricle down and back for a child. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is teaching a client about using vaginal medications. The nurse should instruct the client to:

use a tampon after insertion to increase medication absorption.release and pull up on the applicator before removal.never refrigerate suppositories.use only a water-soluble lubricant when inserting a suppository.

RATIONALE: The nurse should instruct the client to use only a water-soluble lubricant when inserting a suppository. Tampons shouldn't be used because the tampon will absorb some medication, making the medication less effective. When removing the applicator, the client should keep the plunger depressed. Suppositories may be refrigerated to keep their form. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication:

in the cheek.on the tip of the tongue.under the tongue.under the lower lid of the eye.

RATIONALE: Sublingual medication should be placed under the tongue. Buccal medication should be placed in the cheek. Eyedrops should be instilled in the lower lid in the conjunctival sac. Oral medications should be placed on the tongue and swallowed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA client has an order for 5,000 U of subcutaneous (S.C.) heparin, every 12 hours. When injecting heparin S.C., the nurse should:

aspirate after the injection.use the Z-track method.use a 90-degree angle for insertion.always use the same injection site.

RATIONALE: When injecting heparin S.C., the nurse shouldn't aspirate. Rather, the nurse should inject at a 90-degree angle and rotate injection sites. The Z-track method is used for I.M. injections that may irritate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is preparing a client for insertion of an I.V. catheter. When selecting a site on the hand or arm for insertion of an I.V. catheter, the nurse should:

choose a proximal site.choose a distal site.have the client hold his arm over his head.leave the tourniquet on for at least 5 minutes.

RATIONALE: When selecting a site for insertion of an I.V. catheter, the nurse should choose a distal site - not a proximal site. Doing so leaves the upper veins available for subsequent cannulations. Have the client hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:

hyperactive.hypoactive.high-pitched.blowing.

RATIONALE: If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction, or diarrhea. High-pitched sounds may signify a dilated bowel. A blowing sound may be a bruit from a partially obstructed abdominal aorta. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

encouraging ambulation to prevent pooling of blood.providing warmth to the extremity.elevating the extremity to prevent pooling of blood.forcing blood into the deep venous system.

RATIONALE: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this isn't how they prevent DVT. Elevating the extremity will decrease edema but won't prevent DVT. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:

below 70 mg/dl.between 70 and 120 mg/dl.between 120 and 180 mg/dl.above 180 mg/dl.

RATIONALE: A blood glucose level below 70 mg/dl is considered hypoglycemic. A normal blood glucose level is between 70 and 120 mg/dl. Above 120 mg/dl indicates hyperglycemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionA client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?

Cover the cast with a blanket until the cast dries.Keep your right leg elevated above heart level.Use a knitting needle to scratch itches inside the cast.A foul smell from the cast is normal.

RATIONALE: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

use commercial preparations to remove corns.cut toenails by rounding edges.wash and inspect feet daily.walk barefoot at least once each day.

RATIONALE: Diabetic clients should wash their feet daily to allow for daily inspection of the feet. The client should wear nonconstrictive shoes. Corns should be treated by a podiatrist, not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

wearing gloves.administering antibiotics.washing hands.assigning private rooms for clients.

RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Antibiotics should be initiated when an organism is identified. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should:

start with the first voiding.start after a known voiding.always be with first morning urine.always be the evening's last void as the last sample.

RATIONALE: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but they're commonly started in the morning. NURSING PROCESS STEP: Planning CLIENT

NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Administering oxygen, coughing, breathing deeply, and maintaining bed restCoughing, breathing deeply, maintaining bed rest, and using an incentive spirometerCoughing, breathing deeply, frequent repositioning, and using an incentive spirometerAdministering pain medications, frequent repositioning, and limiting fluid intake

RATIONALE: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationWhen developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients in this age group?

Selecting vocation, becoming financially independent, and managing a homeDeveloping leisure activities, preparing for retirement, and resolving empty-nest crisisManaging a home, developing leisure activities, and preparing for retirementAdjusting to retirement, deaths of family members, and decreased physical strength

RATIONALE: Challenges faced in older adulthood (ages 65 and older) include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood (ages 18 to 35) include selecting a vocation, becoming financially independent, and managing a home. Challenges faced in middle adulthood (ages 35 to 65) include developing leisure activities, preparing for retirement, and resolving empty-nest crisis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:

less subcutaneous tissue and muscle mass than a younger client.more subcutaneous tissue and less muscle mass than a younger client.less subcutaneous tissue and more muscle mass than a younger client.more subcutaneous tissue and muscle mass than a younger client.

RATIONALE: When administering I.M. injections, the nurse should remember that an older client has less subcutaneous tissue and muscle mass than a younger client. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging change is:

cloudy vision.incontinence.diminished reflexes.tremors.

RATIONALE: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA person's psychosocial needs during the dying process of a relative may include:

flexible visitation, participation in client care, and rest breaks.flexible visitation, denial of imminent death, and rest breaks.limited visitation, participation in client care, and rest breaks.short, frequent, limited periods of visitation; participation in client care; and rest breaks.

RATIONALE: A person's psychosocial needs during the dying process of a relative may include flexible visitation, participation in client care, and rest breaks. Denial of death may be a response to the situation but isn't classified as a need. Visitation should accommodate wishes of the family member as long as client care isn't compromised. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 42-year-old male complains of extreme fatigue and weakness after his 1st week of radiation therapy. Which of the following responses by the nurse would best reassure him?

"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and X-ray studies.""These symptoms are part of your disease and can't be helped.""Don't be concerned about these symptoms. Everybody feels this way after having radiation therapy.""This is a good sign. It means that only the cancer cells are dying."

RATIONALE: Fatigue and weakness result from radiation treatment and usually don't represent deterioration or disease progression. The symptoms associated with radiation therapy usually decrease after therapy ends. The symptoms may concern the client and shouldn't be belittled. Radiation destroys both cancerous and normal cells. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA female client experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of Disturbed body image and Situational low self-esteem. Which of the following actions would best indicate that the client is meeting the goal of improved body image and self-esteem?

The client requests that her family bring her makeup and wig.The client begins to discuss the future with her family.The client reports less disruption from pain and discomfort.The client cries openly when discussing her disease.

RATIONALE: Requesting her wig and makeup indicates that the client with alopecia is becoming interested in looking her best and that her body image and self-esteem may be improving. The other options may indicate that other nursing goals are being met, but they don't assess improved body image and self-esteem. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisAn 18-year-old male has suffered a C5 spinal cord contusion that has resulted in quadriplegia. His mother is crying in the waiting room 2 days after the injury has occurred. When you sit down to talk to her, she asks whether her son will ever play football again. Which of the following responses would be best?

Reassure her that given time and motivation, he will return to normal function.Advise her that it isn't in his best interest for her to be so upset, and explain the importance of moral support.Reflect on how she's feeling, and encourage her to express other fears that she has about his injury.Explain that you aren't sure, but you will call the physician to talk to her right away.

RATIONALE: Listening and encouraging her to express her feelings will be most therapeutic and will allow the nurse to gather more data about the mother's understanding of the injury. Telling her that her son will return to normal functioning is false reassurance; in many cases, spinal cord contusion results in permanent loss of function. The mother needs to be allowed to voice her concerns rather than being burdened right now about giving moral support. The physician won't be able to answer her question either; definitive prognosis isn't possible so soon after a spinal cord

contusion. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is in the first postoperative day after a total laryngectomy and radical neck dissection. Which of the following is a priority goal?

Communicate by use of esophageal speech.Improve body image and self-esteem.Attain optimal levels of nutrition.Maintain a patent airway.

RATIONALE: Although all of these options are appropriate postoperative goals, maintaining a patent airway takes priority, especially on the first postoperative day. A laryngectomy tube is most likely to be in place, and suctioning is commonly needed to clear secretions. Edema and hematoma formation at the surgical site also can increase the risk of a blocked airway. Communicating by use of esophageal speech and attaining optimal level of nutrition are important but wouldn't take priority on the first postoperative day. Improving body image is a long-term goal. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client undergoes a rhinoplasty to repair a nasal fracture in which displacement has caused an airway obstruction. Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with bright red blood. Which is the best action for the nurse to take?

Offer the client an ice pack to decrease edema and control bleeding.Offer the client a cold drink to soothe the throat.Explain to the client that a tube was in the throat for the anesthetic.Check the pharynx with a penlight for bleeding, and notify the physician.

RATIONALE: Repeated swallowing after a rhinoplasty is a sign of postnasal bleeding; the physician should be notified. Neither an ice pack nor a cold drink will control the bleeding. Rhinoplasty is performed under a local, not general, anesthetic, so an endotracheal tube isn't used. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisIn the stages of death and dying as defined by Elizabeth Kubler-Ross, loss, grief, and intense sadness are symptoms of:

depression.denial.anger.acceptance.

RATIONALE: Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeTo maintain a therapeutic environment with a client and his family, the nurse can use such communication techniques as the clarification technique. An example of the clarification technique is:

"How is it going?""You say you aren't concerned, but you've asked me many questions on this same subject.""What do you mean when you say...?""For now, I would like to concentrate on..."

RATIONALE: Option C is an example of clarification or seeking validation. Option A isn't a communication technique. Option B is an example of confrontation. This technique calls attention to discrepancies in what the client is saying. Option D is an example of focusing or helping the client direct his thoughts. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationStandard precautions were designed for the care of all clients in hospitals, regardless of their diagnosis or infection status. Guidelines for standard precautions include:

immediately recapping used needles.disposing of sharp instruments into an impervious container.wearing gloves only for sterile procedures.substituting regular eyeglasses for eye protection.

RATIONALE: Disposing sharp instruments into an impervious container is included in the guidelines for standard precautions. Used needles are never recapped; they should be disposed of in a sharps container. Gloves are used if contact with body fluids is anticipated. OSHA-approved goggles are used for eye protection. Eyeglasses aren't an acceptable form of protection because they're open at the sides. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when:

inserting an indwelling urinary catheter.giving a back rub on intact skin.changing an oxygen system.inserting an I.V. catheter.

RATIONALE: Inserting an indwelling urinary catheter is the only sterile procedure listed here. Gloves aren't necessary when giving a back rub on intact skin or when changing an oxygen system. Nonsterile gloves would be worn when inserting an I.V. catheter. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ComprehensionThe nurse is placing a client on airborne precautions. The client asks the nurse to leave his door open. The best reply to this is:

"I must keep your door shut at all times. I'll open the curtains so that you don't feel so closed in.""I'll keep the door open for you; standard precautions are sufficient in containing your infection.""I can open your door because you're taking your antibiotics.""I must keep your door shut at all times. I'll open your window so that you won't feel so closed in."

RATIONALE: The nurse is placing the client on airborne precautions, which require that doors and windows be closed at all times. Opening the curtains is acceptable. Antibiotics and standard precautions aren't enough to allow the client's door to be open; negative cultures are necessary to remove a client from airborne precautions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?

Contact precautionsDroplet precautionsAirborne precautionsStandard precautions

RATIONALE: This client requires droplet precautions because the organism can be transmitted through airborne droplets when the client coughs, sneezes, or doesn't cover his mouth. Airborne precautions would be instituted for a client infected with tuberculosis. Standard precautions would be instituted for a client when contact with body substances is likely. Contact precautions would be instituted for a client infected with an organism that is transmitted through skin-to-skin contact. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, the nurse should:

crisscross the flaps in the back.ensure that the vest is wrapped tightly.tie a regular knot to secure the straps.allow room for movement.

RATIONALE: When applying a vest restraint, allow room for movement. Never crisscross the flaps in the back; the client may choke himself. Wrapping the vest tightly may impede respirations. Tying a bow-knot, rather than a regular knot, secures the straps but allows for quick release. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client's identity, the nurse should:

ask the client his name.check the name posted outside the client's room.ask a family member the identity of the client.check the client's identification bracelet.

RATIONALE: To verify the client's identity, check the identification bracelet. If confused, the client may give an inaccurate answer. The name posted outside the door may be inaccurate or another client may have wandered into the wrong room. A family member with whom the nurse is unfamiliar isn't a reliable source. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client asks about the medication he's receiving. The nurse's reply is based on the knowledge that:

if the physician ordered it, he must have explained the medication to the client.the client has a right to know the medication he's getting and its adverse effects.a client can't refuse his medications.a delay in medications can affect client care, so explain medications after the client receives them.

RATIONALE: The client has a right to know the medication he's getting and its adverse effects. If the physician has explained the medication to the client, it's the nurse's responsibility to reinforce the explanation. A client has the right to refuse medications. Explanation of medications should be done before the client receives them. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

call the physician.place saline-soaked sterile dressings on the wound.take a blood pressure and pulse.pull the dehiscence closed.

RATIONALE: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

progressively deeper breaths followed by shallower breaths with apneic periods.rapid, deep breathing with abrupt pauses between each breath.rapid, deep breathing and irregular breathing without pauses.shallow breathing with an increased respiratory rate.

RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

tracheal.fine crackles.coarse crackles.friction rubs.

RATIONALE: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. The reason for this change is that:

the attack is over.the airways are so swollen that no air can get through.the swelling has decreased.crackles have replaced wheezes.

RATIONALE: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:

continuous inflow and outflow of irrigation solution.intermittent inflow and continuous outflow of irrigation solution.continuous inflow and intermittent outflow of irrigation solution.intermittent flow of irrigation solution and prevention of hemorrhage.

RATIONALE: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhile auscultating heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as:

a first heart sound (S1).a third heart sound (S3).a fourth heart sound (S4).a murmur.

RATIONALE: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there's turbulent blood flow across the valves. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his back, remove dangerous objects, and insert a bite block.place the client on his side, remove dangerous objects, and insert a bite block.place the client on his back, remove dangerous objects, and hold down his arms.place the client on his side, remove dangerous objects, and protect his head.

RATIONALE: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skinKussmaul's respirations, dry skin, hypotension, and bradycardiaPolyuria, polydipsia, hypotension, and hypernatremiaPolyuria, polydipsia, polyphagia, and weight loss

RATIONALE: Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionAfter insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. For what cause of tension pneumothorax should the nurse check?

Infection of the lungKinked or obstructed chest tubeExcessive water in the water-seal chamberExcessive chest tube drainage

RATIONALE: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeAn adult client's vital signs are: temperature, 98.9% F (37.2% C), heart rate, 102 beats/minute; respirations, 12 breaths/minute; and blood pressure, 95/60 mm Hg. The nurse should assess these findings as:

febrile, tachycardia, normal respiratory rate, and normotension.afebrile, tachycardia, normal respiratory rate, and normotension.afebrile, tachycardia, normal respiratory rate, and hypotension.febrile, tachycardia, normal respiratory rate, and hypotension.

RATIONALE: Normal vital signs are: temperature, 96.7% to 100.5% F (36% to 38% C); heart rate, 60 to 100 beats/minute; respiratory rate, 16 to 20 breaths/minute; blood pressure, 100 to 140 mm Hg/60 to 90 mm Hg. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

The wound should remain moist from the dressing.The wet-to-dry dressing should be tightly packed into the wound.The dressing should be allowed to dry out before removal.A plastic sheet-type dressing should cover the wet dressing.

RATIONALE: A wet-to-dry saline dressing should always keep the wound moist. Tight packing or dry packing can cause tissue damage and pain. A dry gauze dressing - not a plastic sheet-type dressing - should cover the wet dressing. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAs a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:

stand him up and perform the abdominal thrust maneuver from behind.lay him down, straddle him, and perform the abdominal thrust maneuver.leave him to get assistance.stay with him but not intervene at this time.

RATIONALE: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium?

1 cup of low-fat yogurt1 cup of skim milk1 oz of cheddar cheese1 cup of ice cream

RATIONALE: One cup of low-fat yogurt contains 415 mg of calcium. One cup of skim milk has 302 mg of calcium. One ounce of cheddar cheese has 20 mg of calcium. One cup of ice cream has 176 mg of calcium. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationAn 83-year-old female client arrives at the emergency department (ED) after falling on the ice outside her senior citizens' housing facility. The admitting diagnosis is right hip fracture. Which of the following would be most important for the nurse to assess?

Leg shorteningComplaints of painNeurovascular compromiseInternal or external rotation

RATIONALE: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe physician has prescribed restraints for a client. The nurse knows that it's inappropriate to apply restraints on a client when:

a postlaryngectomy client is attempting to pull out his tracheostomy tube.a client in hypovolemic shock is trying to pull out his I.V. catheter.the unit is short-staffed, so the nurse restrains for staffing convenience.a paranoid client has just tried to commit suicide and is refusing restraints.

RATIONALE: Restraints should never be applied for staff convenience. The situations described in options A, B, and D could result in client harm; therefore, it's appropriate to apply restraints in these instances. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationDuring afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take?

Allow him to continue to scratch inside the cast with a pencil.Give him a sterile metal object to use for scratching instead of the pencil.Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists.Obtain an order for a sedative, such as diazepam (Valium), to prevent him from scratching.

RATIONALE: Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Clients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 26-year-old woman is admitted to the hospital after being involved in a motor vehicle accident. X-rays reveal that she has a comminuted fracture of the left femur. Which of the following best explains why narcotics are contraindicated for the leg pain?

She can't provide a medical history.She has diabetes with a high blood glucose count.An open reduction of the fracture is anticipated.A head injury is suspected and is being evaluated.

RATIONALE: Narcotics are contraindicated in trauma cases because of the depressive effect on the respiratory center, which can result in hypoxia and increased ICP. All medications would need to be given with caution if there's no medical history. Nothing specifically makes narcotics more contraindicated than other drugs. Narcotics should be used with caution in diabetic clients, but they aren't flatly contraindicated. This situation in itself wouldn't contraindicate narcotics. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who was given pain medication before leaving the recovery room. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take?

Tell the client that she must wait 4 hours for more pain medication.Give half of the ordered as-needed dose.Document the client's complaint.Notify the physician that the client is continuing to complain of pain.

RATIONALE: The physician should be notified of the client's complaint so that new medication orders can be established. New surgical clients complaining of pain shouldn't have to wait 4 hours for pain relief. A nurse can't alter a dose without first consulting the physician; this could result in a nurse being charged with practicing medicine without a license. The complaint should be documented; however, a follow-up on the complaint is also necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse is caring for four clients on a step-down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:

has a respiratory infection.is intubated and on a ventilator.has pleural chest tubes.is receiving feedings through a jejunostomy tube.

RATIONALE: When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artifical airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. With standard procedures the other choices wouldn't be at high risk. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client infected with methicillin-resistant 1 Staphylococcus aureus (MRSA). What's the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting?

Using antibacterial soap when bathing clients with MRSAConducting culture surveys periodicallyEnsuring that personnel wash their hands before and after contact with every clientUsing specific housekeeping practices for environmental cleaning

RATIONALE: Hand washing is the major infection control measure to reduce the risk of transmission of MRSA and other nosocomial pathogens. No convincing evidence exists to support that bathing clients with antibacterial soap is effective. Culture surveys can help establish the true prevalence of MRSA in a facility but is used only to help implement where and when infection-control measures need to be implemented. Because contaminated environmental surfaces aren't an important reservoir for MRSA, specific housekeeping practices aren't warranted. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeA nurse received an accidental needle stick while giving an I.M. injection. The greatest threat for the nurse is:

hepatitis B (HBV).

hepatitis C (HCV).human immunodeficiency virus (HIV).hepatitis A (HAV).

RATIONALE: The Centers for Disease Control and Prevention report that 1 in 6 contaminations stems from HBV, 1 in 20 contaminations stems from HCV, and 1 in 300 contaminations stems from HIV. HAV is contracted from eating contaminated food - not from needle sticks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

placing the call light for easy access.keeping the bed in the lowest possible position.instructing the client not to get out of bed without assistance.keeping the bedpan available so the client doesn't have to get out of bed.

RATIONALE: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls - for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is preparing to administer a unit of blood to a client who's anemic. After its removal from the refrigerator, the blood should be administered within:

1 hour.2 hours.4 hours.6 hours.

RATIONALE: After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Extended time out of refrigeration increases the risk of contamination and growth of bacteria. The client could experience fluid overload if the blood is administered too rapidly. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client has three children and his mother lives with them. This is called a:

nuclear family.dysfunctional family.blended family.extended family.

RATIONALE: An extended family consists of the biological or adoptive parents and one or more grandparent or other family member living together. A nuclear family consists of a husband, wife, and children. A dysfunctional family is one that demonstrates unhealthy relationship problems among family members. A blended family is one that includes children from previous marriages living together. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

having more frequent aches and pains.failing eyesight, especially close vision.increasing loss of muscle tone.accepting limitations while developing assets.

RATIONALE: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (between ages 46 and 64). More frequent aches and pains begin in the early late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood (between ages 31 and 45). NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing an 80-year-old widow. Which statement best describes the developmental stage of the client at this age?

The client realizes that she can provide others with an example of wisdom and courage.Self-realization is achieved.The client says that retirement allows time for expression of her creative energies.The client tends to withdraw from mental activity or overcompensate by trying impossible things.

RATIONALE: In later years, socialization allows the individual to provide examples of wisdom and courage. Self-realization is achieved during middle life (between ages 46 and 64); during middle life, individuals may also tend to withdraw from mental activity or overcompensate by trying impossible things. Retirement begins in the early later years (between ages 65 and 79). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?

General health for the last 10 yearsCurrent health promotion activitiesFamily history of diseasesMarital status

RATIONALE: 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 disease 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. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching a client about the importance of disease prevention. Why is disease prevention necessary in health promotion?

Prevention is emphasized in the link between personal behavior and health.The majority of deaths of Americans under age 60 aren't related to preventable causes.Health maintenance organizations now emphasize prevention as the main criterion of health care.The external environment affects the outcome of most disease processes.

RATIONALE: Linking health and personal behavior is extremely important to disease prevention. By promoting healthy behaviors, individuals are preventing disease and living longer, more productive lives. This issue affects all individuals, not just health maintenance organizations. The external environment is only one of many factors affecting disease processes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?

The family's ability to take care of the client's special diet needs

The family's expectation that the client will resume responsibilities and role-related activitiesEmotional support from the familyThe family's ability to understand the ups and downs of the illness

RATIONALE: Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for an 85-year-old client. For which important factor directly influencing this client's mental health should the nurse be most aware?

The client's attitude toward life circumstancesThe client's age, education level, social status, and economic levelThe number of children and grandchildren in the family and the client's relationship with themGrief issues related to loss, role changes, and physical stamina

RATIONALE: Elderly clients are in the psychosocial stage of continuation of ego integrity and acceptance. The client's attitude toward life circumstances would, therefore, be the most comprehensive. The other choices are valid and important, but option A encompasses all the other answers. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is instructing a client with a left fractured tibia how to walk with crutches. Which instruction would be appropriate?

Use the axillae to help carry the weight.All weight should be on the hands.Keep feet 11" (28 cm) apart to provide stability and a wide base of support.Take long strides to maintain maximum mobility.

RATIONALE: When using crutches, all weight should be on the hands. Constant pressure on the axillae from weight bearing can damage the brachial plexus nerve and produce crutch paralysis. Feet should be 6" to 8" (15 to 20 cm) apart to provide stability and support. Short strides - not long ones - provide safety and maximum mobility. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationHyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:

heat intolerance and systolic hypertension.weight gain and heat intolerance.diastolic hypertension and widened pulse pressure.anorexia and hyperexcitability.

RATIONALE: An increased metabolic rate in hyperthyroidism because of excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss - not gain - occurs due to the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat intolerance and widened pulse pressure do occur, but the other answers are incorrect. Clients with hyperthyroidism experience an increase in appetite - not anorexia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client dying of lung cancer. According to Maslow's hierarchy of needs, which dimension of care is considered primary in importance when caring for a dying client?

SpiritualSocialPhysiologicalEmotional

RATIONALE: Physical care is an individual's most basic need according to Maslow's hierarchy of needs. When physiological needs are met and the client feels comfortable, other dimensions of care can be addressed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is admitting a new client and focusing on risk factors that could affect the health of this client. What phase of the nursing process is the nurse performing?

EvaluationAssessmentAnalysisImplementation

RATIONALE: The nurse is performing an analysis and formulating a diagnosis by categorizing symptoms or potential health problems. Risk factors could become potential health problems. Evaluation is an integral part of the nursing process and is usually performed as the last phase, referring to the client's outcome and goals and determining if they've been met. Before determining an appropriate nursing diagnosis, a thorough assessment must be done. Implementation is the initiation of the nursing care plan. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionThe nurse is giving a bath to a comatose client confined to his bed. When giving a bed bath, what temperature should the water be?

97% to 100% F (36.1% to 37.8% C)100% to 110% F (37.8% to 43.3% C)110% to 115% F (43.3% to 46.1% C)115% to 120% F (46.1% to 48.9% C)

RATIONALE: The client should be protected from a chill. The water temperature should be 110% to 115% F to compensate for evaporative body cooling during and after the bath. Water that's the same temperature as the body, slightly cooler, or slightly warmer will eventually cool, which could cause discomfort and increase evaporative body cooling. Water that is 115% to 120% F would be too hot and would put the client at risk for burns or discomfort. Water should always be tested with a bath thermometer. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

daily weight.serum sodium levels.measured intake and output.blood pressure.

RATIONALE: Daily weight shows trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with fluid balance problems. However, if a client is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeWhen performing oral care on a comatose client; the nurse should:

apply lemon glycerin to the client's lips at least every 2 hours.brush the teeth with the client lying supine.place the client in a side-lying position, with the head of the bed lowered.clean the client's mouth with hydrogen peroxide.

RATIONALE: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and shouldn't be used. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be:

getting the client out of bed and into a chair for 30 minutes, twice daily.avoiding repositioning the client if he's comfortable.repositioning the client on alternate sides at least every 2 hours.positioning the client with the greatest pressure at the bony prominence.

RATIONALE: Changing the client's position frequently allows for increased circulation and helps to prevent skin breakdown. The immobilized client receives minimal benefit from sitting upright in a chair for 30 minutes, twice daily. The client shouldn't be left in one position for longer than 2 hours. The greatest pressure shouldn't be placed on bony prominences because these areas can break down from increased pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess for:

hearing loss.vision changes.decreased urine output.gait instability.

RATIONALE: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there's nephrotoxicity, but that situation is uncommon. Gait changes are also uncommon. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeClients commonly confuse adverse effects of a drug with allergic reactions to the drug. Which of the following would most likely be an adverse effect, not an allergic reaction?

Nausea and occasional vomiting after taking the drugThroat feeling tight with difficulty breathingAchy joints and an increased temperature of 101% F (38.3% C)Skin blisters accompanied by intense itching

RATIONALE: Nausea is a common adverse drug effect. Increasing fluid or food intake may alleviate the nausea. Difficulty breathing along with a sensation that the throat is closing up is a type I reaction (anaphylactic shock). Achy joints and temperature elevation are type II reactions (cytotoxic). An itchy rash with blisters is a type IV reaction (cell-mediated hypersensitivity). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is administering neomycin to a client. Which adverse effect should the nurse ask the client to report?

NauseaHearing lossDifficulty breathingLoose, watery stools

RATIONALE: Damage to the eighth cranial nerve, resulting in hearing loss, can occur with toxic levels of neomycin. Nausea is a common adverse effect of antibiotics, not specific to neomycin. Breathing difficulties are anaphylactic shock reactions, which are more common with penicillin. Erythromycin is the antibiotic that most commonly causes watery stools and diarrhea. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA client with cholecystitis is receiving propantheline bromide. The client is given this medication because it:

reduces gastric solution production and hypermobility.slows emptying of the stomach and reduces chyme in the duodenum.inhibits contraction of the bile duct and gallbladder.decreases bile secretions.

RATIONALE: Propantheline bromide is classified as a GI anticholinergic; the medication inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites. For gallbladder disease, propantheline has an antispasmodic effect on the bile duct and gallbladder. Although the medication reduces production of gastric solutions and also reduces hypermobility, it isn't the main reason for the medication. The drug doesn't slow emptying of the stomach or reduce chyme in the duodenum. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is preparing to administer morphine to a postoperative client. Before administering morphine, the nurse should assess the client's:

pulse rate.respiratory rate.skin turgor.urine output.

RATIONALE: Morphine depresses the medullary respiratory center. Therefore, the nurse should assess the rate, character, and rhythm of respirations and notify the physician if the rate is less than 12 breaths/minute. Clients could experience bradycardia; however, this isn't an initial adverse effect. Skin turgor isn't a problem. Urine retention could become a problem with toxic doses, but it isn't an early adverse effect. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis

A 78-year-old client with sensorineural hearing loss is admitted to a rehabilitation center after hip replacement surgery. A risk factor for this client would be:

altered perceptions.toxic levels of pain medication.impaired cognitive function.impaired sense of time.

RATIONALE: This client may be at risk for altered perceptions related to an unfamiliar environment. Nothing in this case relates to pain or medication for pain. Also, no information is given regarding the client's cognitive function. Impaired sense of time would be included in altered perceptions. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

restrict fluid intake to 1 qt (1,000 ml)/day.drink liquids only with meals.not drink liquids 2 hours before meals.drink liquids only between meals.

RATIONALE: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There's no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is administering preoperative medication to a client going to the operating room for an aortobifemoral bypass. After administering preoperative medication to the client, the nurse should:

allow him to walk to the bathroom unassisted.place the bed in low position with the side rails up.tell him that he'll be asleep before he leaves for surgery.take his vital signs.

RATIONALE: When the preoperative medication is given, the bed should be placed in low position, with the side rails raised. The client should void before the preoperative medication is given - not after. The client shouldn't get up without assistance. The client may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?

Poor control of blood glucose levelsInappropriate foot careCurrent or recent foot traumaAdvanced age

RATIONALE: Nonmodifiable risk factors are ones that aren't in the client's ability to change. Therefore, advanced age is the correct answer. The other choices are factors over which the client can exert some control. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe client most at risk for sensory overload is:

a 28-year-old pregnant client with complaints of nausea, vomiting, and fatigue.an 80-year-old client in the intensive care unit (ICU).a 4-year-old in a clinic for immunizations.a 72-year-old client having dressings changed by a home care nurse.

RATIONALE: Sensory overload is a condition in which the central nervous system receives much more auditory, visual, or other environmental stimuli per time frame than can be processed effectively. Because of all the monitors, beeping sounds, lights, and constant activity, an 80-year-old in the ICU is most at risk for sensory overload. The pregnant client is experiencing symptoms that aren't environmental stimuli. The other choices deal with less overwhelming stimuli. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client has just finished his glucose tolerance test. How many hours should it take for his blood glucose level to return to normal?

2 hours3 hours5 hours6 hours

RATIONALE: The blood glucose level should return to normal within 3 hours. Some hypoglycemia (a less than normal amount of glucose in the blood) within this time can be expected without causing problems. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who has hemoconcentration after fluid loss. Which I.V. fluids would be the most appropriate fluid replacement therapy for this client?

Distilled waterDextrose 5% in water (D5W) onlyD5W with 40 mEq of potassium chlorideDextrose 10% in saline

RATIONALE: Increasing fluid volume and urine output is the main consideration when fluid replacement therapy is indicated. Therefore, D5W and a hypotonic solution would be indicated. Distilled water is never given for I.V. replacement therapy, even though it's a hypotonic solution. Potassium chloride is added when adequate output is established, depending on the extent of hypokalemia determined by laboratory electrolyte studies. Dextrose 10% in saline is a hypertonic solution that increases the degree of osmotic pressure and would increase intracellular dehydration; therefore, it's contraindicated. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

genetic dysfunction.upper and lower motor neuron lesions.decreased conduction of impulses in an upper motor neuron lesion.a lower motor neuron lesion.

RATIONALE: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron. NURSING

PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client underwent a modified mastectomy and has a pressure dressing encircling her chest. Which postoperative nursing care function should the nurse anticipate to be difficult?

Promoting intakeChecking blood pressurePromoting turning, coughing, and deep breathingChecking dressings

RATIONALE: A fear of pain, tight dressings, and tearing the incision site tends to limit chest expansion and a willingness to cough and change positions. However, you'll need to perform these functions by facilitating movement of secretions to help prevent atelectasis. Promoting intake isn't an initial concern because the client is receiving I.V. therapy early postoperatively. Checking the blood pressure is incorrect because this can and should be done on the opposite arm from the operative site. Checking dressings initially isn't a problem. Later, when the dressings are changed, it's a difficult time for the client both physically and emotionally. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.palpate the abdomen.change the client's position.insert a rectal tube.

RATIONALE: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Suction the airway every hour and as needed.Elevate the head of the bed 15 to 30 degrees.Turn the client and change his position every 2 hours.Maintain a well-lit room.

RATIONALE: To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

Regular dietSkim milkNothing by mouthClear liquids

RATIONALE: Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk is incorrect. It increases gastric acid production that could prolong the bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA 52-year-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?

Eversion of the right nipple and mobile massNonmobile mass with irregular edgesMobile mass that's soft and easily delineatedNonpalpable right axillary lymph nodes

RATIONALE: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that's soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction - not eversion - may be a sign of cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by a:

breast self-examination.mammography.fine needle aspiration.chest X-ray.

RATIONALE: Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by:

encouraging a discussion of her problems and fears.asking her if she would like to talk to the chaplain.giving her reassurance.recommending a support group.

RATIONALE: Discussing problems and fears is an appropriate nursing intervention to assist a client with coping with or adapting to her illness. The nurse should express interest in the client and her concerns regarding her present state. After allowing the client to express her needs, it may be appropriate to ask her if she would like to see the chaplain or attend a support group. Giving the client reassurance is inappropriate at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with a small, well-defined breast nodule asks the nurse about her treatment options. Which treatments would be considered for this client?

Lumpectomy and radiation

Partial mastectomy and radiationPartial mastectomy and chemotherapyTotal mastectomy and chemotherapy

RATIONALE: Treatment for breast cancer depends on the disease stage and type, the client's age and menopausal status, and the disfiguring effects of the surgery. For this client, lumpectomy is the most likely option. Lumpectomy involves a small incision with removal of the surrounding tissue and, possibly, the nearby lymph nodes. The client usually undergoes radiation therapy afterward. In a partial mastectomy, the tumor is removed along with a wedge of normal tissue, skin, and possibly axillary lymph nodes. In a total (simple) mastectomy, the entire breast is removed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is developing a teaching plan for a client with genital herpes. She should include information about:

acyclovir (Zovirax).penicillin.doxycycline.tetracycline.

RATIONALE: Acyclovir reduces symptoms of herpes and also reduces viral shedding and healing time. Doxycycline and tetracycline are used to treat Lyme disease. Penicillin is used to treat syphilis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA female client is being treated for genital herpes. The client should receive teaching on the:

prevention of outbreaks of lesions.need to abstain from sexual contact.need to keep the perineal area moist.need to wear tight-fitting nylon underwear.

RATIONALE: The client with genital herpes should be instructed to avoid sexual intercourse until lesions completely heal. When the client is diagnosed with genital herpes, outbreaks may occur at any time. The perineal area should be kept dry. Clients should wear loose-fitting cotton underwear to promote drying of the lesions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeA 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:

to the bathroom.to the bedside commode.onto the bedpan.to a standing position so he can urinate.

RATIONALE: A client who is dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Duodenal ulcersHemorrhoidsWeight gainPolyps

RATIONALE: Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't a preexisting condition of colorectal cancer. Weight loss - not gain - is an indication of colorectal cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

Stool HematestCarcinoembryonic antigen (CEA)ColonoscopyAbdominal computed tomography (CT) scan

RATIONALE: Used to visualize the entire colon, colonoscopy aids in the detection of colorectal cancers. Abdominal CT scan is used to stage the presence of colorectal cancer. CEA may be elevated in colorectal cancer but isn't considered a confirming test. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA 65-year-old man comes to the emergency department with severe chest pain and shortness of breath. He's diaphoretic, pale, and weak. Suddenly, the client collapses. What should the nurse do first?

Check for a carotid pulse.Open the airway and check for spontaneous respirations.Give two full breaths.Gently shake and shout, "Are you OK?"

RATIONALE: Assessing level of consciousness is the first step in basic life support. Unconsciousness is confirmed by shaking the client's shoulders and shouting, "Are you OK?" Opening the airway and checking for respirations should occur next. If breathing is absent, two mouth-to-mouth breaths should be given. Then circulation is checked by palpating the carotid artery. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client is suspected of having herpes zoster. The nurse knows that the lesions of herpes zoster are typically:

grouped vesicles occurring on lips and oral mucous membranes.grouped vesicles occurring on the genitalia.rough, fresh, or gray skin protrusions.grouped vesicles in linear patches along a dermatome.

RATIONALE: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA 35-year-old client is undergoing a brain computed tomography (CT) scan because of continued migraine headaches. He's placed in the CT scanner and suddenly begins to complain of palpitations, sweating, shortness of breath, and shaking. The client is most likely experiencing:

an allergic reaction.

a myocardial infarction (MI).a panic attack.a hypoglycemic episode.

RATIONALE: Considering the circumstances surrounding these symptoms, they most probably signal a panic attack, which is a period of intense fear or discomfort that develops abruptly, and peaks in 10 minutes. An allergic reaction would have a precipitating cause and may also include a cutaneous reaction or edema. An MI would involve chest pain or cardiac compromise. Hypoglycemia rarely includes shortness of breath but would need to be differentiated by obtaining the client's blood glucose level. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client with heart failure develops pink frothy sputum, coarse crackles, and restlessness. Which of the following actions should the nurse take first?

Check the client's blood pressure.Place the client in high Fowler's position.Calculate the client's fluid balance.Notify the physician.

RATIONALE: Proper positioning can help reduce venous return to the heart. High Fowler's position also decreases lung congestion. Checking the client's blood pressure is important but doesn't take top priority. Calculating the client's fluid balance wouldn't be an immediate priority in an emergency. Notifying the physician should be done after the client has been repositioned and assessed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisTo encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:

stay with the client and encourage him to eat.help the client fill out his menu.give the client privacy during meals.fill out the menu for the client.

RATIONALE: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeA 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:

forget to eat.not change his position often.exhibit acquiescent behavior.wander.

RATIONALE: A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses' station makes it easier to monitor him and ensure his safety should he begin to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position often, or change his behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisAn elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:

hypoglycemia.fluid volume excess.aspiration.constipation.

RATIONALE: Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration - not fluid volume excess - is a concern because of decreased free water intake. Hyperglycemia, not hypoglycemia, is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeWhich of the following nursing interventions should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

Change the tube feeding solutions and tubing at least every 24 hours.Maintain the head of the bed at a 15-degree elevation continuously.Check the gastrostomy tube for position every 2 days.Maintain the client on bed rest during the feedings.

RATIONALE: Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if the feeding requires it. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisAn 84-year-old male is returning from the operating room (OR) after postinguinal hernia repair. The nurse notes that he has fluid volume excess from the OR and is at risk for left-sided heart failure. Which of the following signs and symptoms indicates left-sided heart failure?

Jugular vein distentionRight upper quadrant painBibasilar fine cracklesDependent edema

RATIONALE: Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using:

antiembolism stockings.oxygen.diuretics.anticoagulants.

RATIONALE: Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:

right-sided heart failure.acute pulmonary edema.pneumonia.cardiogenic shock.

RATIONALE: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:

administer oxygen.have the client take deep breaths and cough.place the client in high Fowler's position.perform chest physiotherapy.

RATIONALE: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively, but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisThe nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.paradoxical chest wall movement with respirations.tracheal deviation to the unaffected side.muffled or distant heart sounds.

RATIONALE: In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisThe 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:

keeping the chest drainage system below the level of the chest.keeping the head of the bed slightly elevated.checking and taping all connections.checking patency of the chest tube.

RATIONALE: Air leaks commonly occur if the system isn't secure. Checking all connections and taping 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. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with ambulation and deep breathing, the nurse should:

administer pain medication before having the client deep breathe, cough, or get out of bed.tell the client the importance of lung expansion.arrange a care schedule to provide rest periods.teach the client how to use an incentive spirometer.

RATIONALE: Administering pain medication and waiting for its effect before any activity will increase client compliance. Explaining the purpose of the intended treatment is important but won't decrease discomfort of the chest tube. Providing rest periods is essential, but won't relieve the client's discomfort. Incentive spirometry provides measurement of deep-breathing ability, prevents atelectasis, and is a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisTo assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:

oxygen saturation.hemoglobin level.partial pressure of carbon dioxide (PaCO2).partial pressure of oxygen (PaO2).

RATIONALE: Oxygen saturation obtained by pulse oximeter is the least invasive method of monitoring the client during a procedure. The client must receive an arterial stick to monitor the partial pressures of carbon dioxide (PaCO2) and oxygen (PaO2). Trends are more important to determine effectiveness of treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require:

arterial oxygen saturation (SaO2) monitoring.arterial blood gas (ABG) studies.chest auscultation.a chest X-ray.

RATIONALE: A chest X-ray confirms the diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax, but they typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation determines overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 50-year-old male is diagnosed with multiple myeloma; his prognosis is poor. He's tearful and trying to express his feelings, but he's having difficulty. The nurse should first:

ask if he would like her to sit with him while he collects his thoughts.

tell him that she will leave for now but will be back.offer to call pastoral care.tell him that she can understand how he's feeling.

RATIONALE: The client needs to feel that people are concerned with his situation. Leaving him doesn't show acceptance of his feelings. Offering to call pastoral care may be helpful for some clients but should be done after the nurse has spent time with the client. Telling the client that she understands how he's feeling is inappropriate because it doesn't help him express his feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:

a decreased serum creatinine level.hypocalcemia.Bence Jones protein in the urine.a low serum protein level.

RATIONALE: Presence of Bence Jones protein in the urine almost always confirms the disease, but absence doesn't rule it out. Serum calcium levels are elevated because calcium is lost from the bone and reabsorbed in the serum. Serum electrophoresis shows elevated globulin spike. The serum creatinine level may also be increased. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:

chronic liver failure.acute heart failure.pathologic bone fractures.hypoxemia.

RATIONALE: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA 74-year-old man with a history of heart failure is admitted to the coronary care unit with acute pulmonary edema. He's intubated and placed on a mechanical ventilator. Which of the following parameters should the nurse closely monitor in assessing the client's response to a bolus dose of I.V. furosemide (Lasix)?

Daily weight24-hour intake and outputSerum sodium levelsHourly urine output

RATIONALE: Furosemide administered by I.V. bolus takes effect almost immediately (within 5 minutes). Daily weight, 24-hour intake and output, and serum sodium levels would span repeated doses of furosemide and so would be less valuable in monitoring the client's initial reaction to the drug. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with multiple myeloma. A sign that a client with multiple myeloma isn't coping well with his prognosis is that he:

becomes tearful when discussing his condition.asks questions about his prognosis.shows concern about his family during his treatment.avoids any conversation concerning his health.

RATIONALE: The client who avoids conversation may be denying his condition, which can interfere with treatment. Crying is a normal response to his disease. Asking questions about his prognosis is a normal coping response, as is showing concern for his family. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is:

congenital deformity.age.trauma.obesity.

RATIONALE: Age is the most significant risk factor for developing osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA client with possible osteoarthritis is having X-rays performed on both knees. X-rays of an osteoarthritic joint reveal:

enlargement of the joint space or margin.fluid deposition in joint spaces.osteophyte formation.cartilage growths at weight-bearing joints.

RATIONALE: In osteoarthritis, osteophytes form in joint spaces. Narrowing of joint spaces or margins, cystlike bony deposits in the joints, and long-bone growths at weight-bearing areas are other X-ray findings. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to:

install safety devices in his home.wear comfortable shoes.get help when lifting objects.wear protective devices when exercising.

RATIONALE: Most accidents occur in the home and safety devices are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or picking up objects. Protective devices aren't usually necessary for the client to perform exercises. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:

administration of narcotics for pain control.bed rest for painful exacerbations.administration of nonsteroidal anti-inflammatory drugs (NSAIDs).

vigorous physical therapy for the joints.RATIONALE: NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation that causes pain. Narcotics aren't used for pain control in osteoarthritis. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 ml for the first hour and the same for the second hour. The nurse should suspect:

Cushing's syndrome.diabetes mellitus.adrenal crisis.diabetes insipidus.

RATIONALE: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone, commonly lacking in clients with diabetes insipidus?

Antidiuretic hormone (ADH)Thyroid-stimulating hormone (TSH)Follicle-stimulating hormone (FSH)Luteinizing hormone (LH)

RATIONALE: ADH is the hormone lacking in diabetes insipidus. The client's TSH, FSH, and LH levels won't be affected. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:

insulin.furosemide (Lasix).potassium chloride.vasopressin (Pitressin).

RATIONALE: Vasopressin is given subcutaneously in the acute management of diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA 48-year-old foreman at a local electric company comes to the hospital complaining of severe substernal chest pain radiating down his left arm. He's admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). Which of the following nursing assessment activities is a priority on admission to the CCU?

Begin electrocardiogram (ECG) monitoring.Obtain information about family history of heart disease.Auscultate lung fields.Determine if the client smokes.

RATIONALE: ECG monitoring should be started as soon as possible; life-threatening arrhythmias are the leading cause of death in the first hours after MI. Obtaining information about family history of heart disease and whether the client smokes aren't immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationAn 82-year-old client is hospitalized with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:

distended neck veins.hypothermia.hypertension.tachycardia.

RATIONALE: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended neck veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may also occur. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe physician orders I.V. fluid volume replacement with lactated Ringer's solution at a rate of 75 ml/hour. Using an infusion set that provides 15 gtt/ml, the nurse should calculate the flow rate to be:

10 gtt/minute.12 gtt/minute.19 gtt/minute.75 gtt/minute.

RATIONALE: The equation used to calculate the flow rate is: drops/minute = volume (in milliliters) x drip factor (drops/milliliter)/time (in minutes). So, the calculation is: 75 ml x 15 gtt/ml/60 minutes = 18.75 gtt/minute = 19 gtt/minute. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority would be to assess her:

neuromuscular function.bowel sounds.respiratory rate.electrocardiogram (ECG) results.

RATIONALE: Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is helping a client with her meal choices. Which breakfast selection indicates that the client understands her low-potassium diet?

Scrambled eggs and toast with teaBacon, toast, and orange juiceCantaloupe, raisin bran, and skim milkBanana, toast, and whole milk

RATIONALE: Eggs, bread, and tea are foods that have low potassium content. The other foods are high in potassium. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

9%18%27%36%

RATIONALE: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of the total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 52-year-old married man with two adolescent children is beginning rehabilitation following a stroke. As the nurse is planning the client's care, the nurse should recognize that his condition will affect:

only himself.only his wife and children.him and his entire family.no one, if he has a complete recovery.

RATIONALE: According to family theory, any change in a family member, such as illness, produces role changes in all family members and affects the entire family, even if the client eventually recovers completely. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:

turn him frequently.perform passive range-of-motion (ROM) exercises.reduce the client's fluid intake.encourage the client to use a footboard.

RATIONALE: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is conducting a screening for testicular cancer. Which client has the highest risk of developing testicular cancer?

A 7-year-old boyA 28-year-old manA 55-year-old manAn 82-year-old man

RATIONALE: The peak incidence of testicular cancer in men occurs between ages 15 and 40. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA client is receiving chemotherapy for cancer. The nurse reviews his laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Activity intoleranceImpaired tissue integrityImpaired oral mucous membranesIneffective tissue perfusion (cerebral, cardiopulmonary, GI)

RATIONALE: These are all appropriate nursing diagnoses for the client with thrombocytopenia (reduced platelet count). However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the client's physiological integrity. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is teaching breast self-examination (BSE) to a college student. The nurse knows that the client understands the best time to examine her breasts when she says:

"I'll examine my breasts 1 week after my period starts.""I'll perform a BSE just before my period starts.""I must examine my breasts the same time each day.""Every time I shower I'll do a breast examination."

RATIONALE: The breasts are least tender and have fewer nodules 1 week after menstruation starts. Before the onset of menstruation, breasts may be most tender and nodular. Examining the breasts every day or after every shower is excessive and unnecessary. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by:

disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container.wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.draining urine from the drainage bag into a sterile container.clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

RATIONALE: Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there's no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A 78-year-old client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find on physical assessment?Joint pain, crepitus, Heberden's nodesHot, inflamed joints; crepitus; joint painTophi, enlarged joints, Bouchard's nodesSwelling, joint pain, tenderness on palpation

RATIONALE: Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes, Bouchard's nodes, and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Heberden's nodes are bony growths that occur at the distal interphalangeal joints. Bouchard's nodes involve the proximal interphalangeal joints. Tophi are deposits of sodium urate crystals that occur in chronic gout - not osteoarthritis. Hot, inflamed joints rarely occur in osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeA client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?

"I'll need to keep several pillows between my legs at night.""I need to remember not to cross my legs. It's such a habit.""The occupational therapist is showing me how to use a 'sock puller' to help me get dressed.""I don't know if I'll be able to get off that low toilet seat at home by myself."

RATIONALE: To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Encourage coughing and deep breathing.Position the client with his head turned toward the side of the brain tumor.Administer stool softeners.Provide sensory stimulation.

RATIONALE: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP by increasing intrathoracic pressure and reducing venous return. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?

Give the medication on an empty stomach.Warn the client that he'll experience mouth dryness.Schedule the medication before meals.Administer the medication for complaints of muscle weakness or difficulty swallowing.

RATIONALE: Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Encourage the client to close his eyes.Alternately patch one eye every 2 hours.Turn out the lights in the room.Instill artificial tears.

RATIONALE: Patching one eye at a time relieves diplopia. Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat double vision. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client is hospitalized with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in:

vitamin A.vitamin B6.vitamin B12.vitamin C.

RATIONALE: Injury to the gastric mucosa causes gastric atrophy and impaired function of the parietal cells. This results in reduced production of intrinsic factor, which is necessary for the absorption of vitamin B12. Eventually, pernicious anemia occurs. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is conducting a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a:

52-year-old man with a family history of polyposis.32-year-old woman with a history of skin cancer.61-year-old man with a history of gastric ulcers.42-year-old man following a low-fat, 1,800-calorie diet.

RATIONALE: Familial polyposis is a strong risk factor for colorectal cancer. In addition, the risk of developing colorectal cancer increases after age 50. Certain cancers, such as genital or breast cancers, are risk factors for colorectal cancer. Gastric ulcers rarely become malignant and aren't associated with colorectal cancer. A high-fat, high-calorie diet also increases the risk of colorectal cancer. Other risk factors for colorectal cancer include inflammatory bowel disease and a history of colorectal cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 56-year-old male has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Will I need to take medication to reduce it?" Which of the following responses by the nurse would be best?

"Yes. Hypertension is prevalent among males; it's fortunate we caught this during your routine examination.""We'll need to reevaluate your blood pressure because your age places you at high risk for hypertension.""A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made.""You have no need to worry. Your pressure is probably elevated because you're in the doctor's office."

RATIONALE: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. Option A is premature. Option B isn't as specific as option C and also is insensitive to the client's anxiety. Option D gives false reassurance; the client does need to have his blood pressure reevaluated. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?

Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stomaFilling the irrigation bag with 500 to 1,000 ml of lukewarm waterStopping the irrigation for cramps and clamping the tubing until cramps passWashing hands with soap and water when finished

RATIONALE: An irrigation bag should be elevated 18" to 20" (45 to 50 cm) above the stoma. Typically, adults use 500 to 1,000 ml of water at a temperature no higher than 105% F (40.6% C) to irrigate a colostomy. If cramping occurs during irrigation, the irrigation should be stopped and the client told to take deep breaths until the cramping stops. The irrigation can then be resumed. Hand washing reduces the spread of microorganisms. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:

a skin rash.peripheral edema.a dry cough.postural hypotension.

RATIONALE: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a client on the first postoperative day following surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

Risk for infectionDeficient knowledgeIneffective tissue perfusion (peripheral)Activity intolerance

RATIONALE: Ineffective tissue perfusion (peripheral) is a major concern in the postoperative period following abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative client after the nurse has assessed graft patency and peripheral circulation. Generally, wound infections don't occur until 4 to 7 days after surgery. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client is hospitalized with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be:

"You seem angry. Would you like to talk about it?""Calm down. You know that stress will make your symptoms worse.""Would you like to talk about the problem with the nursing supervisor?""I can see you're angry. I'll come back when you've calmed down."

RATIONALE: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said. Offering to get the nursing supervisor also doesn't acknowledge the client's feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

Exposure to sunlight will help control skin rashes.There are no activity limitations between flare-ups.Monitor body temperature.Corticosteroids may be stopped when symptoms are relieved.

RATIONALE: Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

Make inhalation longer than exhalation.Exhale through an open mouth.Use diaphragmatic breathing.Use chest breathing.

RATIONALE: In chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing - not chest breathing - increases lung expansion. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client is being discharged from the hospital after treatment for severe asthma. The nurse is teaching her about her medications. Which point should the nurse include when teaching the client about salmeterol?

Use the inhaler for chest tightness.Take two puffs every 4 hours.It provides relief of nighttime asthma.It's a corticosteroid and shouldn't be abruptly stopped.

RATIONALE: Because salmeterol has a 12-hour duration of action, it's effective in controlling nighttime asthma when taken before bedtime. Salmeterol shouldn't be taken for relief of acute asthma symptoms because it has an onset of action of up to 20 minutes. Because salmeterol has a 12-hour duration of action, it's taken every 12 hours, not every 4 hours. Salmeterol is a sympathomimetic-adrenergic agent. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse administered NPH insulin to a client with diabetes at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

10 a.m.Noon4 p.m.10 p.m.

RATIONALE: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

urine glucose level.fasting blood glucose level.serum fructosamine level.glycosylated hemoglobin level.

RATIONALE: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:

hypotension.thick, coarse skin.deposits of adipose tissue in the trunk and dorsocervical area.weight gain in arms and legs.

RATIONALE: Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionAn 89-year-old client is suffering from Alzheimer's-type dementia. Which intervention would be most useful in managing his dementia?

Provide a safe environment.Provide a stimulating environment.Avoid the use of touch.Use restraints whenever necessary.

RATIONALE: Providing a safe environment ensures safety when a client has poor judgment, memory loss, and an unsteady gait. Overactivity and noise can overstimulate a client with Alzheimer's-type dementia by causing agitation. The use of nonverbal communication techniques, such as touch, conveys acceptance to the client and can be comforting. The use of restraints can increase a client's agitation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse must plan care for a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. Which of the following times would be most appropriate for procedures and care to be completed?

All at one time, to provide a longer rest periodBefore meals, to stimulate her appetiteIn the morning, with frequent rest periodsBefore bedtime, to promote rest

RATIONALE: Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the client may be too exhausted to eat. Procedures should be avoided at bedtime. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, discovered during the history and physical assessment, is typical of MS?

Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexesFlexor spasm, clonus, and negative Babinski's reflexBlurred vision, intention tremor, and urinary hesitancyHyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

RATIONALE: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client is receiving a blood transfusion. If he experiences an acute hemolytic reaction, which nursing intervention is the most important?

Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.Slow the transfusion and monitor the client closely.Stop the transfusion, notify the blood bank, and administer antihistamines.Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.

RATIONALE: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the blood bank and physician should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines may be administered for a mild allergic reaction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

An 86-year-old male is hospitalized with an exacerbation of his heart failure. He's confused and has inadvertently pulled out his I.V. catheters several times while attempting to get out of bed by himself. He was also found lying on the floor unharmed. When all other methods fail to keep the client in bed, the physician orders the use of physical restraints. Which nursing action reflects safe nursing care?

Remove restraints once a shift to check skin and circulation.Cover the restraints with a blanket so that the client can't see them.Apply restraints firmly so that a finger can't be inserted underneath them.Tie the restraint to the bed frame.

RATIONALE: Restraints must be tied to the bed frame. If a restraint is tied to a side rail, the client may be injured when the side rail is lowered. Restraints must be removed at least every 2 hours, not once a shift, to check for skin breakdown, assess circulation, and perform range-of-motion exercises. Restraints should be visible so that they can be removed quickly in an emergency. Apply restraints so that two fingers can be slipped between the restraint and the client. Doing so reduces the risk of circulatory impairment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?

Putting on sterile gloves then opening a container of sterile salineCleaning the wound with a circular motion, moving from outer circles toward the centerChanging the sterile field after sterile water is spilled on itPlacing sterile dressing r" (1.25 cm) from the edge of the sterile field

RATIONALE: A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren't sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area - for example, from the center outward. The outer inch of a sterile field shouldn't be considered sterile. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client has conductive hearing loss caused by otosclerosis and has repeatedly refused surgery. To facilitate communication with the client, the nurse should:

sit or stand in front of the client when speaking.use exaggerated lip and mouth movements when talking.stand in front of a light or window when speaking.say the client's name loudly before starting to talk.

RATIONALE: Standing directly in front of a hearing-impaired client allows him to lip-read and see facial expressions that offer cues to what's being said. Using exaggerated lip and mouth movements can make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for the client to lip-read. To get the attention of a hearing-impaired client, gently touch his shoulder or stand in front of him. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionA client with acute respiratory failure is intubated and placed on mechanical ventilation. Which intervention is most appropriate when suctioning the client?

Insert the suction catheter while applying suction.Apply suction until all the secretions have been removed.Use the same catheter to first suction the mouth, then the endotracheal tube.Preoxygenate with 100% oxygen before suctioning.

RATIONALE: Preoxygenate the client with 100% oxygen before suctioning to prevent the hypoxia that occurs when the client is disconnected from the oxygen source and oxygen is removed from the airway during suctioning. To avoid hypoxia and trauma to the trachea, suction shouldn't be applied when inserting the catheter. To prevent hypoxia, never suction longer than 15 seconds. A suction catheter that has been used to suction the mouth should be considered contaminated and shouldn't be used to suction the endotracheal tube. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is developing a care plan for a client who's at risk for ineffective coping due to the effects of chronic illness. Which factor provides the best evidence that the client is at risk for difficulty in coping with his illness?

Poor sleeping habitsLack of social supportAdverse drug effectsPresence of panic disorder

RATIONALE: Lack of social support most directly indicates that the client is at risk for ineffective coping related to the effects of chronic illness. Sleeping habits and adverse drug effects are physiological responses to illness but don't indicate difficulty coping. Presence of a panic disorder is a problem unrelated to another chronic illness. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrityKeeping the client from sliding to the foot of the bedKeeping the ropes over the center of the pulleyEnsuring that the weights hang free at all times

RATIONALE: Although all measures are correct, assessing neurovascular integrity takes priority. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse administers basic cardiac life support to a client in cardiac arrest. Which action does the nurse perform?

Assessing the patency of the airwayAdministering I.V. medicationsAdministering a countershock of 200 JBreathing for the client after inserting an endotracheal (ET) tube

RATIONALE: A nurse certified in basic cardiac life support can assess airway patency. I.V. medications given to maintain blood pressure, correct acidosis, or restore a cardiac rhythm are administered by a provider of advanced cardiac life support. Administering a countershock of 200 J and breathing for the client after inserting an ET tube are measures carried out during advanced life support. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is caring for an unconscious client. Which nursing intervention takes highest priority?

Inserting an indwelling urinary catheter

Maintaining a patent airwayPutting a nasogastric (NG) tube in placeAdministering an enema daily

RATIONALE: Maintaining a patent airway always takes top priority. An indwelling urinary catheter and NG tube can be inserted after airway patency has been established. Enemas should be avoided because of the danger of increasing intracranial pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is providing care for a postoperative client who has undergone a small bowel resection. The nurse may use an epidural catheter for which of the following?

Antibiotic therapyPain managementBlood transfusionAnticoagulation

RATIONALE: Administration of pain medication through an epidural catheter is recommended if severe pain is anticipated or if the pain doesn't respond to less invasive measures. Epidural catheters can also be used for the administration of regional anesthesia. Epidural catheters may not be used for antibiotic therapy, blood transfusion, or anticoagulation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?

Family history of pressure ulcersPresence of existing pressure ulcersPotential areas of pressure ulcer developmentOverall risk of developing pressure ulcers

RATIONALE: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Polyurethane foam mattressRing or donutGel flotation padWater bed

RATIONALE: Rings or donuts aren't to be used because they restrict circulation. Foam mattresses evenly distribute pressure. Gel pads redistribute with the client's weight. The water bed also distributes pressure over the entire surface. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is preparing to care for a client who was just transferred from the emergency care unit to the medical-surgical floor. What is the most effective means of preventing microbial transmission?

Wearing glovesUsing aseptic techniqueMeticulous hand washingDisinfecting all equipment

RATIONALE: Hand washing is the principal means of preventing the spread of organisms among clients. Wearing gloves when they're indicated, using aseptic technique, and disinfecting equipment between clients are all important; however, none of these techniques substitute for hand washing. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with an endotracheal (ET) tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to avoid:

gastric ulcers.aspiration.abdominal distention.diarrhea.

RATIONALE: Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers aren't a common complication of tube feeding in clients with ET or tracheostomy tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but neither is immediately life-threatening. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationWhich phrase is used to describe the volume of air inspired and expired with a normal breath?

Total lung capacityForced vital capacityTidal volumeResidual volume

RATIONALE: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeWhat is the normal pH range for arterial blood?

7.00 to 7.497.35 to 7.457.50 to 7.607.55 to 7.65

RATIONALE: A pH less than 7.35 is indicative of acidosis; a pH above 7.45 indicates alkalosis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is performing a painless, noninvasive procedure to measure arterial oxygen saturation (SaO2). What procedure is it?

Incentive spirometryArterial blood gas (ABG) measurementPeak flow measurement

Pulse oximetryRATIONALE: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what major complication of ICP monitoring?

ComaInfectionHigh blood pressureApnea

RATIONALE: The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Prone, with the head turned to the rightSupine, with the knees raised toward the chestLateral recumbent, with chin resting on flexed kneesLateral, with right leg flexed

RATIONALE: To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test assesses:

cerebellar function.intellectual function.cerebral function.sensory function.

RATIONALE: The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Intellectual functioning isn't the only cerebral activity. Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a confused, elderly client. What is the nurse's most important consideration?

Protecting the client from injuryDetermining the cause of the confusionEnsuring that the client's neurologic status doesn't deteriorateHelping the client to participate in activities of daily living (ADLs)

RATIONALE: The nurse's first responsibility is always to protect the client from injury. Discovering the cause of the confusion and protecting the client's neurologic status from deterioration are the physician's responsibility. Encouraging the client to participate in ADLs is a nursing intervention but not the top priority. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is interviewing a client who has been raped. Which strategy is most effective?

Listening without asking questionsUsing closed-ended questionsUsing open-ended questions and listening intentlyTalking to the client about rape

RATIONALE: Using open-ended questions encourages the client to express her feelings about the incident. Asking questions helps the client to organize her thoughts. Closed-ended questions can usually be answered with a single word and don't facilitate the expression of feelings. The purpose of the interview is to listen to the client, not to talk to the client; however, it's appropriate to answer questions the client may have about rape. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?

Painful mouth soresFrequent diarrheaNausea and vomitingConstipation

RATIONALE: Nausea and vomiting are the most commonly experienced adverse effects of chemotherapeutic drugs. Nausea and vomiting are more severe with some medications than others. Mouth sores, diarrhea, and constipation are adverse effects of certain chemotherapeutic drugs and are less commonly experienced. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeTo combat the most common adverse effects of chemotherapy, the nurse would administer an:

antiemetic.antimetabolite.tumor antibiotic.anticoagulant.

RATIONALE: Antiemetics are used to treat nausea and vomiting. Antihistamines and certain steroids are also used to treat nausea and vomiting. Antimetabolites and tumor antibiotics are classes of chemotherapeutic medications. Anticoagulants slow blood clotting time, thereby helping to prevent thrombi and emboli. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

Increase in blood pressureIncrease in blood volumeLow serum potassium levelHigh serum sodium level

RATIONALE: Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood volume decreases, blood pressure decreases, and urinary output increases. NURSING PROCESS

STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:

prefers to take insulin orally.has type 2 diabetes.has type 1 diabetes.is a pregnant, type 2 diabetic.

RATIONALE: Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant or lactating women aren't prescribed oral antidiabetic agents because the effect on the fetus is uncertain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?

Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.Store the drug in a cool, well-lit place.Lie down or sit in a chair for 5 to 10 minutes after taking the drug.Restrict alcohol intake to two drinks per day.

RATIONALE: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client very dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of alcohol. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. What is a major complication of TPN?

HyperglycemiaExtreme hungerHypotensionHypoglycemia

RATIONALE: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. Fluid overload may cause hypertension, not hypotension. Extreme hunger occurs with hypoglycemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?

Increase alcohol intake while taking the drug.Avoid foods that are rich in purine.Take aspirin for pain.Take the drug between meals to promote absorption.

RATIONALE: Clients with gout should avoid foods high in purine. Alcohol should be avoided because it increases the uric acid level. Aspirin interferes with the action of allopurinol; therefore, salicylates should be avoided. Allopurinol may irritate the gastric lining and should be taken with food or milk. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Explain to the client what is happening and provide support.Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.Push the protruding organs back into the abdominal cavity.Ask the client to drink as much fluid as possible.

RATIONALE: Immediately covering the wound with moistened gauze will prevent the organs from drying. The gauze and saline solution must be sterile to reduce the risk of infection. Evisceration requires emergency surgery; therefore, the nurse places the client on nothing by mouth status immediately. Evisceration is a frightening situation for any client. While the nurse works quickly to get the client treated, providing support that will reduce the client's anxiety is also important. The organs shouldn't be pushed back into the abdomen because this may tear or damage them. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse provides care for a client receiving oxygen from a nonrebreathing mask. Which nursing intervention has the highest priority?

Posting a no smoking sign over the client's bedApplying an oil-based lubricant to the client's mouth and noseAssessing the client's respiratory status, orientation, and skin colorChanging the mask and tubing daily

RATIONALE: Nonrebreathing masks can deliver high concentrations of oxygen to clients in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. Equipment should be changed daily, but this has a lower priority. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreathing mask. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

Diaphragmatic breathingUse of accessory musclesPursed-lip breathingControlled breathing

RATIONALE: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

InspectionX-rayArterial blood gas (ABG) levelsAuscultation

RATIONALE: Lung sounds should be auscultated before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function, but these tests aren't necessary to determine lung

areas requiring postural drainage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisTo assess a client's cranial nerve function, the nurse should:

assess hand grip.assess orientation to person, time, and place.assess arm drifting.assess gag reflex.

RATIONALE: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhich of the following clinical findings would the nurse look for in a client with chronic renal failure?

HypotensionUremiaMetabolic alkalosisPolycythemia

RATIONALE: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by elevated blood urea, nitrogen, and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans?

Cottage cheese-like dischargeYellow-green dischargeGray-white dischargeDischarge with a fishy odor

RATIONALE: The symptoms of C. albicans include itching and a scant white discharge that has the consistency of cottage cheese. Yellow-green discharge is a sign of Trichomonas vaginalis. Gray-white discharge and a fishy odor are signs of Gardnerella vaginalis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system is functioning normally.The client has a pneumothorax.The system has an air leak.The chest tube is obstructed.

RATIONALE: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:

dysfunction in the cerebrum.the risk of increased intracranial pressure (ICP).dysfunction in the brain stem.dysfunction in the spinal column.

RATIONALE: Decerebrate posturing indicates damage to the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased ICP is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhat mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?

Cardiac pacemakerHypothermia/hyperthermia machineDefibrillatorIntra-aortic balloon pump

RATIONALE: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to initiate and maintain the heartbeat. Hypothermia/hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for conversion of life-threatening ventricular arrhythmias. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeWhile monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT)Platelet count, blood glucose levels, and white blood cell (WBC) countThrombin time, calcium levels, and potassium levelsFibrinogen level, WBC count, and platelet count

RATIONALE: The diagnosis of DIC is based on the results of laboratory studies of PT, platelet count, thrombin time, PTT, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client is being discharged after successful same-day cataract surgery. The nurse instructs the client about permitted activities and those to avoid. Which of the following activities is permitted?

CookingDrivingVacuumingWashing hair in the shower

RATIONALE: Cooking won't cause increased intraocular pressure. The client should avoid driving and vacuuming because they require forward flexion and rapid, jerky movements. The client shouldn't shower and must wash hair with the head tilted back to prevent soap and water from entering the eye, which would predispose the client to infection. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Sit with the client for a few minutes.Administer an analgesic.Inform the nurse-manager.Call the physician immediately.

RATIONALE: The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager isn't necessary. Sitting with the client is appropriate, once the physician has been notified of the change in the client's condition. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisAbout 4 hours after a client who experienced a stroke is hospitalized, the nurse obtains these vital signs: blood pressure, 170/80 mm Hg; apical pulse, 58 beats/minute with a regular rhythm; respiratory rate, 14 breaths/minute; axillary temperature, 101% F (38.3% C). Which nursing action is most appropriate at this time?

Call the physician to report the vital signs.Assess vital signs more frequently.Assess the client for an overdistended bladder.Assess the client for signs of overhydration.

RATIONALE: Brain injury can either elevate or depress blood pressure. A slow pulse, decreased respiratory rate, and increased pulse pressure also are associated with stroke. Although the frequency of assessment will no doubt be increased, the top priority is to report the client's vital signs to the physician. The listed vital signs are associated with increased intracranial pressure and don't result from a distended bladder or fluid overload. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?

Blood relationshipSex and sizeCompatible blood and tissue typesNeed

RATIONALE: The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age. When a living donor is considered, it's preferable to have a relative donate the organ. Need is important, but it can't be the critical factor if a compatible donor isn't available. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe nurse is preparing to teach a client about the significance of a living will. Which of the following principles is incorrect?

The living will must be signed by a competent person.In a living will, the client specifies the steps he does or doesn't want taken.The living will applies to a time when the client is no longer competent.The living will isn't considered a legal document.

RATIONALE: A living will is a legal statement of the client's wishes. All states have laws allowing for the documentation of a living will. The client signs a living will at a time when he's still competent to make decisions about what lifesaving measures he wants carried out when he isn't competent and under what circumstances such measures shall be implemented. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationDrugs to treat acute anxiety are prescribed to a client hospitalized for an acute myocardial infarction. The client is reluctant to take anti-anxiety drugs. The nurse suspects that the client is holding the drugs under his tongue and disposing of them after she has left the room. What should the nurse do first?

Report her suspicions to the client's physician.Talk to the client about his attitude toward the medications.Search the client's room for evidence of the medications.Tell the client that his behavior must stop for his own well-being.

RATIONALE: Before reporting these concerns to the physician, the nurse should discuss the perceived problem about the medications with the client. The nurse will then have more information about the client's attitude toward anti-anxiety medications when she informs the physician of her suspicions. Searching the client's room for the medications is a violation of the client's right to privacy. The nurse and the physician can talk to the client about the benefits of taking the medication prescribed; however, the client has the right to refuse the medication. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA client who has sustained a head injury is to receive mannitol (Osmitrol) by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find:

increased lung expansion.decreased cerebral edema.decreased cardiac workload.increased cerebral circulation.

RATIONALE: Mannitol, an osmotic diuretic, is used to decrease cerebral edema in clients with head injuries. Increased lung expansion, decreased cardiac workload, and increased cerebral circulation aren't effects of mannitol. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationWhich of the following statements is true?

Standard precautions should be implemented at the nurse's discretion, as the need arises.Performing routine care activities may cause transmission of human immunodeficiency virus (HIV) regardless of precautions.The Centers for Disease Control and Prevention (CDC) has issued guidelines called standard precautions.Standard precautions encompass all isolation categories.

RATIONALE: The CDC requires the use of standard precautions for all client care. All health care providers who come in contact with the client's blood and body fluids must use standard precautions. Routine care activities don't facilitate transmission of HIV. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationWhich of the following measures should a nurse take when following standard precautions?

Wear a mask and gown when starting an I.V. line.Wash hands immediately after removing gloves.

Recap all needles after use to prevent accidental sticks.Wear a protective hair cover when caring for a client who has tuberculosis (TB).

RATIONALE: Standard precautions are used to prevent contamination from blood and body fluids. Gloves are worn whenever exposure is possible, and hands should be washed after removing gloves. Needles are never recapped after use because this increases the risk of accidental needle sticks. Under ordinary circumstances, masks and gowns aren't necessary for starting an I.V. line. Clients with active TB require droplet precautions and don't require a hair cover. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationIn the course of providing care, the nurse discovers a possible error in the physician's order. How should the nurse respond?

Carry out the order without question.Carry out the order and inform the physician about the concern.Refuse to carry out the order under any circumstances.Confer with the physician, and then decide whether or not to carry out the order.

RATIONALE: Ambiguous orders must be clarified with the physician. If the nurse believes the physician's order is incorrect, she should refuse to carry it out. The nurse's decision and all communication with the physician about the order must be documented. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA client with a neurogenic bladder is beginning bladder training. Which of the following nursing actions is most important?

Set up specific times to empty the bladder.Force fluids.Provide adequate roughage.Encourage the use of an indwelling urinary catheter.

RATIONALE: Clients are taught to write down their voiding pattern and to empty the bladder at the same times each day. Forcing fluids (more than 2 L/day) increases urine production and complicates the initial bladder-training process. Roughage is unnecessary for bladder training. An indwelling urinary catheter is used only when other methods of control don't work. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhich intervention will best help to prevent a client from falling?

Monitor the client regularly or continually if his condition warrants it.Keep the bed at a level where the nurse can easily provide care.Make sure the side rails of the client's bed are down.Restrain the client to prevent him from getting out of bed and falling.

RATIONALE: Monitoring the client regularly, especially if the client is elderly or confused, will help to prevent falls. The bed should be kept in its lowest position unless a member of the health care team is present and providing care. Side rails may be used judiciously to prevent the client from falling out of bed, but the client can crawl over side-rails. The nurse should refer to facility policy for information about side rails. Restraints are used with a physician's order and only after other means have failed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

A positive reaction indicates that the client has active tuberculosis (TB).A positive reaction indicates that the client has been exposed to the disease.A negative reaction always excludes the diagnosis of TB.The PPD can be read within 12 hours after the injection.

RATIONALE: A positive reaction means the client has been exposed; it isn't conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA nurse working in a senior center encounters a client who recently lost his spouse as well as several friends and family members. What is the best way for the nurse to assist the client?

Recommend that the client get over the loss and move on with his life.Encourage the client to participate in grief counseling.Suggest that the client move into a senior residence to avoid places that remind him of his wife.Ignore the client's grief because it's only temporary.

RATIONALE: In most instances, the grieving spouse will benefit from grief counseling. Some clients do better in group counseling; others prefer individual counseling. Recommending that the client move on with his life ignores the reality that the client must move through the stages of grief at his own pace. If moving into a senior residence is the best option for a grieving spouse, he should be advised to do so only after a period of counseling. Ignoring the client's grieving doesn't validate his feelings or help him progress through the stages of grief. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a reactive purified protein derivative (PPD) test. What should the nurse anticipate as the next step of treatment?

Immediately begin administration of prophylactic medications to eradicate the disease.Immediately isolate the client (for at least 1 week) to contain the disease.Perform more definitive testing to determine whether the client has active disease.Explain to the client that a positive PPD only indicates exposure to the disease and that he must be retested in 6 months.

RATIONALE: The diagnosis of tuberculosis can never be confirmed without bacteriologic studies. Freshly expectorated sputum is obtained and examined microscopically for the presence of acid-fast bacilli. Drug therapy is initiated on the basis of a positive acid-fast bacilli smear. After the diagnosis has been established, the client may be isolated in a negative-pressure room until treatment is started and three negative cultures are obtained. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is developing a teaching plan for a client with asthma. Which of the following teaching points has the highest priority?

Avoid contact with fur-bearing animals.Change filters on heating and air conditioning units frequently.Take prescribed medications, as scheduled.Avoid goose down pillows.

RATIONALE: Although all the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse want to include?

Limit fluid intake to reduce the need to urinate.

Take medication prescribed for a UTI until the symptoms subside.Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.Wear only nylon underwear to reduce the chance of irritation.

RATIONALE: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. The client should notify her physician so that a microscopic urinalysis can be done and appropriate treatment can be initiated. Women should be instructed to drink 2 to 3 L of fluid a day to dilute the urine and reduce irritation on the bladder mucosa. The full amount of antibiotics prescribed for UTIs must be taken despite the fact that the symptoms may have subsided. This will help to prevent recurrences. Women are told to avoid scented toilet tissue and bubble baths and to wear cotton - not nylon - underwear to reduce the chance of irritation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who relates well to others but displays the following behavior: failure to adhere to tasks, failure to learn new skills, unwillingness to set goals, and inaccurate follow-through of instructions. Which nursing diagnosis is most appropriate?

Deficient knowledge related to cognitive impairmentDefensive coping related to perceived threat to positive self-regardIneffective denial related to fear or anxietyDeficient knowledge related to lack of motivation

RATIONALE: The client's behavior most closely match the defining characteristics of deficient knowledge related to lack of motivation. There's nothing that indicates that the client has a cognitive impairment. Clients with a diagnosis of Defensive coping have similar defining characteristics, but there's evidence that the client also has problems with relationships. The client with a diagnosis of Ineffective denial can't admit that a problem even exists. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is teaching a class about breast self-examinations. A client asks if she should have an annual mammogram. According to the American Cancer Society (ACS), how should the nurse respond?

All women over age 30 should have an annual mammogram.All women over age 40 should have an annual mammogram.Any woman over age 20 whose mother had breast cancer should have an annual mammogram.Any woman who feels she's at risk for breast cancer should have an annual mammogram.

RATIONALE: The ACS has adopted the recommendation that all women over age 40 should have annual mammograms. Decisions about mammography for women in all other age categories and circumstances are made by the physician and the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?

Testicular cancer is a highly curable type of cancer.Testicular cancer is very difficult to diagnose.Testicular cancer is the number one cause of cancer deaths in males.Testicular cancer is more common in older men.

RATIONALE: Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is teaching a client about maintaining a healthy heart. The nurse should include which recommendations?

Smoke in moderation.Use alcohol in moderation.Consume a diet high in saturated fats and low in cholesterol.Exercise one or two times per week.

RATIONALE: Alcohol may be used in moderation, as long as there are no other contraindications for its use. Smoking, a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise 3 to 4 times per week, and consume a diet low in cholesterol and saturated fat. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.To avoid fractures, the client should avoid strenuous exercise.The recommended daily allowance of calcium may be found in a wide variety of foods.Obtaining the recommended daily allowance requires taking a calcium supplement.

RATIONALE: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's usually, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over age 35 who are at risk. Strenuous exercise won't cause fractures. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is preparing a client with a malignant tumor for colorectal surgery and subsequent colostomy. The client tells the nurse that he's anxious. What would the nurse's initial step be in working with this client?

Determining what the client already knows about colostomiesShowing the client pictures of colostomiesArranging for someone who has had a colostomy to visit the clientProviding the client with written materials about colostomy care

RATIONALE: Initially, the nurse should assess the client's perceptions of how a colostomy will affect his lifestyle. The nurse should determine not only what the client already knows, but also what he wants to know. Giving written materials and pictures to the client and arranging for a visit by an ostomate are all appropriate interventions when the client is ready to receive more detailed information. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA home health care nurse is working with the family of a client who has Alzheimer's disease. The client's spouse is too exhausted to continue providing care on her own. The adult children live too far away to provide relief on a weekly basis. Which nursing intervention would be most helpful?

Calling a family meeting to tell the absent children that they must participate in helping the clientSuggesting that the spouse seek psychological counseling to help her cope with exhaustionInvestigating community resources for adult day care and other servicesInsisting that the client be placed in a long-term care facility for the good of his spouse and children

RATIONALE: Many community services exist for clients with Alzheimer's disease and their families. Making use of these resources may make it possible for the client to stay at home and to alleviate the spouse's exhaustion. A family meeting to tell children to participate more would probably be ineffective and may evoke anger or guilt. Counseling may be helpful, but it wouldn't help the caregiver's physical exhaustion nor would it address the client's immediate needs. A long-term care facility is used as a last resort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 42-year-old client, the mother of two children, has just been told that her ovarian cancer is terminal. The client, usually religiously observant, is expressing rage at God and the clergy. The nurse makes the diagnosis of Spiritual distress related to a situational crisis. Which intervention is appropriate for this client?

Engage the client in diversional activities to distract her from the present situation.Help the client use effective coping strategies to ease spiritual discomfort.Encourage the client to read everything possible about the treatment of ovarian cancer.Allow the client time and space to bargain with God for a cure.

RATIONALE: As the client calls forth her ability to cope or learns new coping strategies, she may be able to ease her spiritual distress and possibly return to religious practice. Developing effective coping strategies helps the client cope with spiritual distress more effectively than diversional activities or reading about treatment for ovarian cancer. Bargaining with God for a cure is an element of the grieving process. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is about to lose her second child to sickle cell anemia. She has been unable to eat or sleep and can talk only about her pending loss and the guilt she feels about the child's pain and suffering. Which of the following interventions has the highest priority?

Allowing the client to express her feelings without judging herHelping the client to understand the phases of the grieving processReassuring the client that the child's death isn't her faultArranging for genetic counseling to inform the client of her chances of having another child with the disease

RATIONALE: Listening to the client express her feelings openly without judging her is the highest priority. The nurse shouldn't impose her own values on the client. The nurse should also help the client to understand the grieving process and use all the support systems that are available to assist her in coping with this situation. Genetic counseling may be appropriate at a later time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which of the following interventions should the nurse perform to assist the client?

Assure the client that everything will be all right and that he shouldn't become upset.Ask a family member to interpret what the client is trying to communicate.Ask the physician to wean the client off of the mechanical ventilator to allow the client to talk.Ask the client to write, use a picture board, or spell words with an alphabet board.

RATIONALE: If the client uses an alternative method of communication, he'll feel in better control and be less frustrated. Assuring the client that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. In a client with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the client's wishes. Making them responsible for interpreting the client's gestures may frustrate the family. The client may be weaned off of a mechanical ventilator only when the physiologic parameters for weaning have been met. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationBased on an assessment of a client's health and home environment, the nurse determines the need for assistive devices, such as hearing aids, cane, walker, wheelchair, or shower chair. What is the purpose of providing assistive devices?

To help the client to remain independent and thereby improve self-confidenceTo counter premature efforts to achieve independence by fostering the client's need for assistive devicesTo determine whether the caregiver understands concepts of home safety by introducing more safety hazards into the homeTo relieve the caregiver of responsibility for the client

RATIONALE: The use of assistive devices can support coping of both the client and the caregiver. They allow the client greater independence. Clients need to be taught how to use assistive devices properly and where to store them, so that they don't pose safety hazards, and they don't relieve the caregiver of all responsibility. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisFollowing hospitalization for a fractured hip, a client is transferred to a nursing care center. The client is upset about not being able to return home immediately. The nurse makes the diagnosis of Relocation stress syndrome. Which of these interventions would most benefit this client?

Inviting the family to tour the facility and meet the new staffEducating the family about relocation stress syndrome and the support that the client needsRecommending that the family visit regularlyEncouraging the client to express emotions associated with relocation

RATIONALE: Allowing the client to express his feelings, without expressing judgment, may reduce the client's anxiety. The other measures are also important but have a lower priority at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationWhich of the following statements describing urinary incontinence in the elderly is true?

Urinary incontinence is a normal part of aging.Urinary incontinence isn't a disease.Urinary incontinence in the elderly can't be treated.Urinary incontinence is a disease.

RATIONALE: Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisThe nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching is required?

"I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread.""I need to use laxatives regularly to prevent constipation.""I need to drink 2 to 3 L of fluid every day.""I should exercise 4 times per week."

RATIONALE: The elderly client should be taught to gradually eliminate the use of laxatives. Point out that using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise all promote good bowel

health. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client is having difficulty sleeping. Which of the following should the nurse suggest to the client?

Take a warm bath in the early morning, just after rising.Maintain the same schedule for waking and sleeping.Exercise after dinner each night, to bring on fatigue.Take frequent naps, especially in the afternoon.

RATIONALE: Keeping the same schedule each day helps to maximize the client's ability to sleep without disturbance. The client should take a warm bath in the evening, before going to bed. It's better not to exercise in the evening. Naps should be limited to 1 or 2 hours and taken at the same time each day. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is changing a dressing and providing wound care. Which activity should she perform first?

Assess the drainage in the dressing.Slowly remove the soiled dressing.Wash hands thoroughly.Put on latex gloves.

RATIONALE: Whenever going to care for a client, the first thing the nurse must do is wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is teaching the client how to use a cane. Which of the following statements is most inaccurate?

The client should hold the cane on the involved side.The client should hold the cane close to his body.The stride length and the timing of each step should be equal.The nurse should stand behind the client to prevent falls.

RATIONALE: The client is instructed to hold the cane on the uninvolved side, 24" to 26" (61 to 66 cm) from the base of the little toe. This is done to promote a reciprocal gait pattern. The nurse should instruct the client to hold the cane close to his body to prevent leaning. The stride length and timing of each step should be equal. To prevent falls, the nurse stands behind the client as he's learning to use the cane. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is giving instructions to family members of a client who can't feed himself. Which of the following should the nurse recommend?

Keep the client on a soft food or liquid diet.Ask the physician to order total parenteral nutrition (TPN) for the client.Determine foods best handled by the client and feed these foods to him.Have the physician order a gastrostomy tube for feeding the client.

RATIONALE: Tell the family to determine the foods the client can chew and swallow and to prepare meals using these foods. Give the family a list of the foods that the client ate well during hospitalization. The major issue is to ensure that the client receives the necessary amount of nutrients. With assistance, the client may be able to eat regular food cut in very small pieces. A liquid or soft diet may not be necessary. Gastrostomy tubes and TPN are invasive procedures used only when other methods of feeding have failed. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisAn elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates the presence of a thromboembolism?

RhombergPhalen'sRinneHomans'

RATIONALE: A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. The Rhomberg test assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do?

Consider this to be a normal finding for his age and race.Recommend he have his blood pressure rechecked in 1 year.Recommend he have his blood pressure rechecked within 2 months.Recommend he see his physician immediately for further evaluation.

RATIONALE: While hypertension is more prevalent in blacks, a blood pressure of 150/90 mm Hg isn't considered normal. He should have his blood pressure rechecked within 2 months. One year is too long to wait. He need not see his physician yet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she's taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?

HypertensionOsteoporosisMuscle wastingTruncal obesity

RATIONALE: All of the options listed above are adverse effects of long-term corticosteroid therapy; however, osteoporosis frequently causes compression fractures of the spine. The other adverse effects wouldn't likely have caused severe back pain. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?

Client teaching about the cause of TBReviewing the risk factors for TBDeveloping a list of people with whom the client has had contactClient teaching about the importance of TB testing

RATIONALE: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help to determine if the client infected anyone else. The remaining options are important areas to address when educating high-risk populations about TB

before its development. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA quadriplegic client is in spinal shock. What should the nurse expect?

Absence of reflexes along with flaccid extremitiesPositive Babinski's reflex along with spastic extremitiesHyperreflexia along with spastic extremitiesSpasticity of all four extremities

RATIONALE: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client demonstrates positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionA client develops a pulmonary embolism after total knee surgery and must be converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse tell the client?

Coumadin will continue to break up the clot over a period of weeks.His prothrombin time (PT) and international normalized ratio (INR) will be periodically checked for dose adjustment.Anticoagulant therapy usually lasts 4 to 6 weeks.He should take a vitamin supplement containing vitamin K.

RATIONALE: The client's PT and INR should be periodically checked to make sure that they're in the therapeutic range. Overanticoagulation predisposes the client to hemorrhage. Anticoagulant therapy prevents further clot formation but can't be used to dissolve a clot. The therapy continues for approximately 6 months. Vitamin K reverses the effect of anticoagulant therapy and shouldn't be taken in large amounts. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?

Anticipate the client will exhibit some degree of expressive or receptive aphasia.When transferring the client into a wheelchair, place the wheelchair on his left side.Provide close supervision due to the client's impulsiveness and poor judgment.Support the right arm with a sling or pillow to prevent subluxation.

RATIONALE: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisThe nurse is caring for an L1-L2 paraplegic undergoing rehabilitation. Which of the following goals is appropriate?

Establishing an intermittent catheterization routine every 4 hoursManaging spasticity with range-of-motion exercises and medicationsEstablishing an ambulation program using short leg bracesPreventing autonomic dysreflexia by preventing bowel impactions

RATIONALE: The paraplegic client with an L1-L2 injury will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is giving home care instructions to a client who just had a cataract removed and an intraocular lens implanted. What should the nurse tell the client?

Don't sleep on the operated side.Wear the eye shield continuously for 2 weeks.Aspirin may be taken for mild pain.Straining during bowel movements is allowed.

RATIONALE: Postoperative cataract clients should avoid sleeping on the operated side as well as lifting heavy objects or straining, all of which could cause bleeding in the eye. Aspirin, due to its anticoagulant properties, should be avoided for the same reason. An eye shield is worn continuously for the first 24 hours postoperatively. Straining during a bowel movement should be avoided because it increases intraocular pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of falling?

Arranging pieces of furniture close together so the client can use them for guidance and supportEncouraging the client to wear a medical identification bracelet that describes the client's visual deficitInstalling a flashing light to indicate when the phone or doorbell is ringingInstalling handrails in hallways, in bathrooms, and on steps

RATIONALE: Handrails help to guide the client in his environment as well as provide physical support to enhance stability. Close arrangement of furniture provides dangerous obstacles that could precipitate falls and sharp, hard objects upon which to fall. A medical identification bracelet provides no protection in the event of a fall. Blinking lights that indicate a ringing doorbell or phone are useful for the hearing impaired. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA client underwent a retinal detachment repair. The nurse receives the following order from the client's physician: Keep client in upright sitting position, with head over the bed table, until first dressing change. What should the nurse do?

Call the physician and tell him the order is in error and must be reviewed.Follow the order because this position will help keep the retinal repair intact.Instruct the client to do this while awake but sleep lying flat on the unoperated side.Assume she should change the dressing at bedtime then allow the client to lie flat.

RATIONALE: During retinal detachment repair, an air bubble is often injected into the eye to provide added pressure. Postoperative positioning is dependent on where the air bubble needs to apply pressure. This position should be maintained until the physician removes the dressing and assesses how well the retina is adhering to the choroid. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhich of the following statements about external otitis is true?

External otitis is characterized by pain when the pinna of the ear is pulled.External otitis is usually accompanied by a high fever in children.External otitis is usually related to an upper respiratory infection.

External otitis can be prevented by using cotton-tipped applicators to clean the ear.RATIONALE: External otitis is an infection of the external ear. Pain can be elicited when the pinna of the ear is pulled. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeDuring a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve, or humpback. What is this condition called?

LordosisKyphosisScoliosisGenus varum

RATIONALE: Kyphosis refers to an increased thoracic curvature of the spine. Lordosis is an increase in the lumbar curve, or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeA 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weight-bearing joints.OA affects joints on both sides of the body. RA is usually unilateral.OA is more common in women. RA is more common in men.

RATIONALE: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women, while OA affects both sexes equally. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Keep the affected leg in a position of adduction.Use measures other than turning to prevent pressure ulcers.Prevent internal rotation of the affected leg.Keep the hip flexed by placing pillows under the client's knee.

RATIONALE: External rotation and abduction of the hip helps to prevent dislocation of a new hip joint. Internal rotation and adduction should be avoided. Postoperative total hip replacement clients may be turned onto the unaffected side. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal?

More back pain than the first postoperative dayParesthesia in the dermatomes near the woundsUrinary retention or incontinenceTemperature of 99.2% F (37.3% C)

RATIONALE: Urinary retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in pain on the second postoperative day is common because the long-acting local anesthetic, which may have been injected during surgery, will wear off. While paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if it reaches 101% F (38.3% C). NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhich symptoms indicate that a client probably has a sinus infection?

Sore throat, fever, malaise, and no drainage in the oropharynxEnlarged tonsils, clear drainage in the oropharynx, and a dry, hacking coughProductive cough, hoarseness, and shortness of breathPain in the upper molars and tan or green drainage in the oropharynx

RATIONALE: The client is likely to experience pain in the molars during a sinus infection because the roots of the molars are close to the maxillary sinuses. Green drainage in the oropharynx would indicate infection whereas clear drainage wouldn't. While a sore throat, fever, and malaise may accompany a sinus infection, these symptoms aren't specific to sinus infections and may indicate another type of upper respiratory infection. A productive cough, hoarseness, and shortness of breath indicate an infection of respiratory origin rather than a sinus infection. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?

Increased intestinal motilityDecreased abdominal strengthIncreased intestinal bacteriaDecreased production of hydrochloric acid

RATIONALE: Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron, and an increase in intestinal bacteria actually causes diarrhea. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeWhat laboratory finding is the primary diagnostic indicator for pancreatitis?

Elevated blood urea nitrogen (BUN)Elevated serum lipaseElevated aspartate aminotransferase (AST)Increased lactate dehydrogenase (LD)

RATIONALE: Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is coordinating an immunization program for health care workers and clients. What information should be included as part of the program?

Health care workers are at high risk for hepatitis B because of its airborne transmission.

Immunization against hepatitis B involves a series of two injections given 6 months apart.The hepatitis B virus can't exist outside the body for more than a few minutes.Hepatitis B immunization should be given to neonates before they leave the hospital.

RATIONALE: Immunization against hepatitis B is a series of 3 injections. Neonates are given their first hepatitis B immunization before they leave the hospital and again at 1 and 6 months of age. Hepatitis B is transmitted through body fluids and can survive on environmental surfaces for more than 1 week. It can't be transmitted by air. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?

Maintenance of blood glucose levels between 180 and 200 mg/dlSmoking reduction but not complete cessationAn eye examination every 2 years, until age 50Exercise and a weight-reduction diet

RATIONALE: Type 2 diabetes is often obesity-related; therefore, weight reduction may enhance the normalization of blood sugar. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained within normal limits to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes shouldn't smoke because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeLaboratory studies indicate a client's blood sugar level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose utilization?

A fasting blood sugarA 6-hour glucose tolerance testA test of serum glycosylated hemoglobin (Hb A1c)A test for urine ketones

RATIONALE: Hb A1c is the most reliable indicator of glucose utilization because it reflects blood sugar levels for the previous 3 months. While a fasting blood sugar and 6-hour glucose tolerance test yield information about a client's utilization of glucose, the results will be influenced by other factors such as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose utilization but is limited in its diagnostic significance. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionEvery morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?

70 units of NPH insulin and 30 units of regular insulin70 units of regular insulin and 30 units of NPH insulin70% NPH insulin and 30% regular insulin70% regular insulin and 30% NPH insulin

RATIONALE: Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is caring for a postthyroidectomy client at risk for hypocalcemia. What should the nurse do?

Monitor laboratory values daily for an elevated thyroid-stimulating hormone.Observe for swelling of the neck, tracheal deviation, and severe pain.Evaluate the quality of the client's voice postoperatively, noting any drastic changes.Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

RATIONALE: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisTo verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method?

Aspiration of gastric contents and testing for a pH less than 6.0Instillation of 30 ml of water while listening with a stethoscopeCessation of reflex gaggingEnsuring proper measurement of the tube before insertion

RATIONALE: Aspiration of gastric secretions with a pH less than 6.0 indicates placement in the stomach. A pH greater than 6.0 would indicate placement in the intestine. Instillation of 30 ml of water is dangerous without prior assurance of proper placement. The cessation of gagging that occurs during placement indicates the oropharynx is no longer being stimulated. Exact measurement of the distance between the nares and the stomach is impossible before insertion but should be estimated and marked. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA 25-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She's placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which of the following is the most likely medication prescribed?

Nitrofurantoin (Macrodantin)Ibuprofen (Motrin)Acetaminophen with codeinePhenazopyridine (Pyridium)

RATIONALE: Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on urinary mucosa, phenazopyridine is specifically used for the relief of bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. While ibuprofen and acetaminophen with codeine are analgesics, they don't exert a direct effect on the urinary mucosa. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.

RATIONALE: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap tests are important for early detection. Because condylomata acuminata is a virus, there's no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. NURSING PROCESS STEP:

Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client?

She should have had a baseline mammogram before age 30.She should eat a low-fat diet to further decrease her risk of breast cancer.She should perform breast self-examinations (BSEs) during the first 5 days of each menstrual cycle.When she begins having yearly mammograms, BSEs are no longer necessary.

RATIONALE: A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman's risk of breast cancer. A baseline mammogram should be done between ages 30 and 40. Monthly BSEs should be done between days 7 and 10 of the menstrual cycle. The client should continue to perform monthly BSEs even when receiving yearly mammograms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

ActinicAsymmetryArcusAssessment

RATIONALE: When following the ABCD method for assessing skin lesions, the A stands for asymmetry, the B for border irregularity, the C for color variation, and the D for diameter. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionWhat should a male client over age 50 do to help ensure early identification of prostate cancer?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.Have a transrectal ultrasound every 5 years.Perform monthly testicular self-examinations, especially after age 50.Have a complete blood count (CBC) yearly (including blood urea nitrogen [BUN] and creatinine assessment).

RATIONALE: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and the PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound and CBC with BUN and creatinine assessment are usually done after diagnosis to identify the extent of disease and potential metastases. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?

IIIIIIIV

RATIONALE: Stage II (out of III) is exhibited by the above listed symptoms as well as communication difficulties, motor disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is characterized by memory loss, poor judgment and problem-solving, difficulty adapting to new environments and challenges, and agitation or apathy. Stage III is characterized by loss of all mental abilities and the ability to care for self. Although there are different staging systems (one characterizes the disease as mild, moderate, and severe), none includes stage IV. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA family member is caring for a client diagnosed with Alzheimer's disease. Which of the following is most likely to cause the caregiver depression and role strain?

The caregiver had a close relationship with the client before diagnosis of the illness.The caregiver has no formal support, such as a visiting nurse or day care worker.The caregiver understands the full reality of the disease and its inevitable progression.The caregiver feels unable to control the client and unable to cope with caregiving.

RATIONALE: The caregiver who feels unable to control the client's behavior and unable to cope with the responsibility of caregiving is at the greatest risk for depression and role strain. A close relationship with the client who has Alzheimer's disease doesn't place the caregiver at greater risk for role strain and depression. Absence of formal support may cause role strain and depression, but the effect may be mitigated by the caregiver's coping mechanisms and skills. A deeper understanding of the disease is unlikely to increase role strain or depression. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisClients diagnosed with a chronic illness exhibit a general pattern of adaptation, which consists of three stages. What is the sequence of these stages?

Disbelief, integration, developing awarenessDeveloping awareness, disbelief, integrationIntegration, disbelief, developing awarenessDisbelief, developing awareness, integration

RATIONALE: Disbelief is the first stage. It includes denial, withdrawal, and depression. Anger and feelings of guilt may also occur. Developing awareness, the second stage, is manifested by feelings of anger and resistance. Integration, the third stage, is characterized by a rational acceptance of the chronic illness. Reestablishment of a sense of identity with meaning and purpose occurs during this stage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe 1990 Americans with Disabilities Act (ADA) has increased employment and social independence for people with disabilities. What did this Act mandate?

Facilities receiving federal funds must make those facilities accessible to individuals with disabilities.All streets and sidewalks used by private sector businesses must contain curb cuts.Municipal and private parking lots must use the disability symbol to identify parking spaces for persons with disabilities.Discrimination against persons with disabilities, regarding employment or environmental accessibility, is illegal.

RATIONALE: The ADA states that employers of more than 15 people can't discriminate against a person with disabilities who can perform the same job with reasonable accommodation. Distribution of federal funds contingent upon providing accessibility to persons with disabilities was part of the Rehabilitation Act of 1973. Curb cuts weren't a part of the ADA. The disability symbol was common before 1990. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client is hospitalized with a possible electrolyte imbalance. The client is disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. The client most likely suffers from:

hypernatremia.hyponatremia.hyperkalemia.hypokalemia.

RATIONALE: The symptoms of hypokalemia include GI, cardiac, renal, respiratory, and neurologic disturbances. The use of potassium-wasting diuretics, such as hydrochlorothiazide, without potassium replacement therapy is a primary cause of hypokalemia. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAn elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a mild laxative, such as magnesium citrate, when necessary.Take a stool softener, such as docusate sodium (Colace), daily.Administer a tap water enema weekly.Administer a phospho-soda (Fleets) enema when necessary.

RATIONALE: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that the client is obtaining adequate pain relief?

Awakening several times during the night to redoseRespiratory rate of 10 breaths/minutePain rating of 2 or 3 on a scale of 0 to 10Complaint of itching as an adverse effect of the analgesia

RATIONALE: A rating of 2 or 3 on a scale of 0 to 10 is considered mild pain, which is to be expected after abdominal surgery. Redosing during the night, which disrupts sleep, is a disadvantage of this method and doesn't indicate adequate or inadequate pain relief. A depressed respiratory rate of 10 breaths/minute is an adverse effect of an opiate analgesic rather than indication of comfort. Itching is a common adverse effect and bears no relationship to pain relief. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA peripherally placed needle for intermittent infusion of antibiotics is a potential site for infection. When assessing the infusion site, the nurse should look for what signs?

Puffiness of the tissue below the tip of the needle and absence of blood returnA painful red line running down the arm along the course of the veinA tender lump within the vein located close to the tip of the needleRedness and drainage around the needle insertion site

RATIONALE: Redness and drainage around the needle's insertion site are cardinal signs of infection. Puffiness below the tip of the needle indicates infiltration of the I.V. A painful red line running down the arm along the course of the vein indicates phlebitis. A lump located close to the tip of the needle may indicate a thrombus. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client who experienced a stroke and developed left-sided paralysis is learning how to dress independently. What is the proper technique for upper extremity dressing?

Buttoning the shirt first then flipping it on over the headPlacing the unaffected arm in the shirt before the affected armRequesting help because this activity is impossible to do independentlyPlacing the affected arm in the shirt before the unaffected arm

RATIONALE: By placing the affected arm in the shirt first, the unaffected arm is free to pull the shirt around to the other side and put the other sleeve on. Pulling a shirt on over the head is difficult to do with only one arm. If the client uses proper techniques, becoming independent in upper extremity dressing is possible. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client taking aspirin for arthritis reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?

TinnitusMild gastric irritationMild bleeding of the gums when brushing teethDecrease in arthritic pain

RATIONALE: Tinnitus is a sign of ototoxicity, which can occur when a client's dose is too high. Mild gastric irritation is common and should initially be dealt with by taking the aspirin with food or by taking enteric-coated aspirin. Mild bleeding of the gums is another common adverse effect; therefore, clients should be instructed to use a soft-bristled toothbrush. Achieving a decrease in arthritic pain is the goal of therapy, not an adverse effect. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA 64-year-old female is found on the floor of her apartment. She had apparently fallen and hit her head on the bathtub. On admission to the neurologic unit, she has a decreased level of consciousness. The physician orders positioning as follows: elevate the head of the bed; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion. Which of the following is the best rationale for this positioning?

To decrease cerebral arterial pressureTo avoid impeding venous outflowTo prevent flexion contracturesTo prevent aspiration of stomach contents

RATIONALE: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase intracranial pressure. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures aren't a priority at this time. Stomach contents could still be aspirated in this position. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 58-year-old male is hospitalized for a wedge resection of the left lower lung lobe. A routine chest X-ray shows carcinoma. The client is anxious and asks if he can smoke. Which of the following statements by the nurse would be most therapeutic?

"Smoking is the reason you're here.""The doctor left orders for you not to smoke.""You're anxious about the surgery. Do you see smoking as helping?""Smoking is OK right now, but after your surgery it's contraindicated."

RATIONALE: This acknowledges the client's feelings and encourages him to assess his previous behavior. Option A belittles the client. Option B doesn't address the client's anxiety. Option D would be highly detrimental to this client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA female client is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and frequently feels her heart "flutter." What action should the nurse take?

Tell the client to rest more often.Tell the client to stop taking the digoxin, and call the physician.Call the physician, report the symptoms, and request to draw a blood sample to determine the client's potassium level.Tell the client to avoid foods that contain caffeine.

RATIONALE: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the client to rest more often won't help the client if she's hypokalemic. Digoxin isn't causing the client's symptoms, so she doesn't need to stop taking it. The client should probably avoid caffeine, but this wouldn't resolve potassium depletion. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take?

Assume he's anxious about discharge, and administer pain medication.Assess the surgical site and affected extremity.Reassure the client that pain is a direct result of increased activity.Suspect a wound infection, and monitor the client's temperature and vital signs.

RATIONALE: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication don't address the cause of the pain. Sudden severe pain isn't normal after hip replacement. Wound infections are usually distinguished by purulent drainage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhen should a nurse use surgical aseptic technique?

When hand washing before performing a dressing changeWhen inserting an indwelling urinary catheterWhen disposing of contaminated syringes in a puncture-proof containerWhen performing suctioning of the oral cavity

RATIONALE: Insertion of an indwelling urinary catheter is done using aseptic technique to prevent introduction of bacteria into the bladder. Hand washing decreases the number of bacteria but doesn't render the environment sterile. Disposal of contaminated syringes is done to prevent accidents and environmental contamination. Suctioning of the oral cavity is done using clean technique. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationWhile packing a client's abdominal wound with sterile, half-inch Iodoform gauze, the nurse drops some of the gauze onto the client's abdomen 2" (5 cm) away from the wound. What should the nurse do?

Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound.Pick up the gauze and continue packing the wound.Continue packing the wound and irrigate the wound with Betadine.Discard the gauze packing and repack the wound with new Iodoform gauze.

RATIONALE: The sterile gauze became contaminated when it was dropped on the client's abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine shouldn't be used in the wound unless ordered. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is coordinating an exercise group for older adults who live in a retirement community. Which statement is appropriate for the nurse to make to this group of clients?

"If your muscles are sore tomorrow, you should probably discontinue this program.""If you have arthritis, exercise your affected joints to the point of discomfort.""You should all begin walking 2 miles every day as a part of this program.""If you're taking blood pressure medication, don't perform these exercises."

RATIONALE: Exercising arthritic joints allows clients to maintain as much mobility as possible. If clients haven't recently exercised, sore muscles are to be expected and aren't a reason for discontinuing the program. Two miles of walking may be the ultimate goal for some clients, but it isn't a realistic goal at the beginning of an exercise program. Exercise is helpful in reducing blood pressure and isn't contraindicated for clients taking blood pressure medication as long as the program is only mildly intensive. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levelsLow levels of urine constituents normally excreted in the urineAbnormally low hematocrit and hemoglobin levelsElectrolyte imbalance that could affect blood's ability to coagulate properly

RATIONALE: Low preoperative hematocrit and hemoglobin levels indicate the client may require a blood transfusion before surgery. If the hematocrit and hemoglobin levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who just had surgery. What is the nurse's highest priority?

Assessing for hemorrhageMaintaining a patent airwayManaging the client's painAssessing vital signs every 15 minutes

RATIONALE: The priority concern is the client's airway, as demonstrated by the ABC principle: A = Airway, B = Breathing, C = Circulation. Assessing for hemorrhage and vital sign assessment are also important but constitute second and third priorities. Pain management is important but only after the client has been stabilized. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client receives fentanyl through an epidural catheter for control of postoperative pain. The nurse should observe for which common adverse effect?

PruritusIncontinenceTachycardiaHypertension

RATIONALE: Pruritus is the most common adverse effect when fentanyl is administered through an epidural catheter. Other adverse effects include urinary retention, respiratory depression, hypotension, and bradycardia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe nurse provides fluid replacement for a client with burns on 35% of his body. It has been 12 hours since the burns occurred. His blood pressure is 85/60 mm Hg. His pulse is 124 beats/minute. Urine output was 25 ml during the past hour. What orders should the nurse expect to receive from the physician?

Maintain I.V. fluids at the present rate, and continue to reassess vital signs and urine output hourly.Increase the I.V. rate, and continue to reassess vital signs and urine output hourly.Decrease the I.V. rate, and continue to reassess vital signs and urine output hourly.Administer a vasoconstrictor, and reassess vital signs and urine output hourly.

RATIONALE: During the first 24 hours after a burn, interstitial and intracellular fluid shifts occur and intravascular fluid volume decreases. Hypovolemia calls for fluid replacement therapy to maintain vital organ perfusion. Keeping I.V. fluids at the current rate wouldn't correct the client's fluid deficit. A vasoconstrictor would be inappropriate because it doesn't correct fluid volume deficits. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client is to undergo a hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment would best indicate informed consent on the part of the client?

"I know I'll be fine because the physician said he has done this procedure hundreds of times.""I know I'll have pain after the surgery.""The physician is going to remove my uterus and told me about the risk of hemorrhage.""Because the physician isn't taking my ovaries, I'll still be able to have children."

RATIONALE: The nurse witnessing informed consent should evaluate the client's understanding of the surgical procedure by having her repeat what the physician told her. In option C, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. Options A, B, and D don't indicate client understanding of the procedure. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisWhich one of the following clients is at the greatest risk for aspiration?

A stroke client with dysarthriaAn ambulatory client with Alzheimer's diseaseA 92-year-old client who needs help with activities of daily living (ADLs)A client with severe, deforming rheumatoid arthritis

RATIONALE: The muscles that become paralyzed in dysarthria are the same ones used for swallowing. This increases the client's risk of aspiration. Clients with Alzheimer's disease that are still ambulatory probably don't have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis shouldn't have difficulty swallowing unless it exists secondary to another problem. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisSeveral conditions may cause sexual dysfunction in men. Which condition represents one of the most common causes?

Coronary artery diseasePeptic ulcer diseaseDiabetes mellitusOsteoarthritis

RATIONALE: A variety of vascular, neurologic, respiratory, endocrine, and genitourinary conditions can cause sexual dysfunction in men. Diabetes mellitus is one of the most common due to the deleterious effects of diabetes on blood vessels. The other conditions don't necessarily cause sexual dysfunction. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeHospice care is primarily geared toward which population?

Clients with chronic conditionsClients going home to recover after surgeryClients in the terminal stage of an illnessFamilies who are recovering from a tragedy

RATIONALE: Hospice is a program that offers services and resources for clients and their families when the client is in the terminal stage of an illness. Only clients with chronic conditions in the terminal phase require hospice care. Hospice care doesn't concern recovery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client recovering from a spinal cord injury that left him paraplegic. He comments, "I hate what this injury has done to my life, but I have to go on and make a new life for myself." This comment indicates what psychological stage of adaptation?

DenialAngerGuiltAcceptance

RATIONALE: Though the client is unhappy that he'll most probably be a paraplegic for the rest of his life, his willingness to make a new life for himself indicates he has passed through the stages of denial, anger, and guilt. He's ready to accept and adapt to his new state of health. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionClients taking certain drugs should be cautioned against using them with alcohol. What are some of these drugs?

Aspirin, antihistamines, and sedativesPenicillin-class antibiotics and decongestantsBirth control pills and caffeine-based weight-reduction medicationsHistamine-2 receptor blockers and antacids

RATIONALE: Combining alcohol with antihistamines or sedatives potentiates the sedative effect. Taking aspirin with alcohol is dangerous because gastric irritation may cause GI bleeding. The other drugs listed don't cause dangerous interactions when combined with alcohol. Be aware, however,

that alcohol may reduce the effectiveness of a variety of drugs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client undergoing I.V. antibiotic therapy with gentamicin sulfate. Which of the following interventions is most important?

Infuse the medication quickly to minimize its irritating effect on the walls of blood vessels.Obtain renal function tests, such as blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy.Assess for pulmonary and peripheral edema.Obtain an order for an antiemetic to counteract the common adverse effect of nausea.

RATIONALE: Gentamicin sulfate is toxic to the kidneys. Monitoring BUN and creatinine levels during the course of therapy can identify nephrotoxicity before severe damage occurs. Be aware that gentamicin sulfate is also toxic to ears. Assessing for tinnitus, dizziness, vertigo, and hearing loss can prevent damage from ototoxicity. Gentamicin sulfate should be infused slowly. Nausea isn't an adverse effect of I.V. gentamicin sulfate. Pulmonary and peripheral edema aren't common adverse effects. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionDuring the assessment of a geriatric client, a nurse would expect which findings?

Eye structure and visual acuity changesFacial hair decreasing in a female clientFacial hair increasing in a male clientWounds healing more quickly

RATIONALE: Multiple structural changes occur in the eyes of aging clients. Vision is often diminished, particularly night vision. Healing is slowed from nitrogen loss. Women have increased facial hair, while men have decreased facial hair. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program?

Establishing a predetermined fluid intake pattern for the clientEncouraging the client to increase the time between voidingsRestricting fluid intake to reduce the need to voidAssessing present elimination patterns

RATIONALE: The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1r to 2 qt (1.5 to 2 L) of water per day. A voiding schedule should be established after assessment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhich intervention has the highest priority when providing skin care to a bedridden client?

Changing the bed linens frequently for an incontinent clientKeeping the skin clean and dry without using harsh soapsGently massaging the skin around the pressure areasRubbing moisturizing lotion over the pressure areas

RATIONALE: Keeping the skin clean is always the highest priority. The other measures are also important but only after the skin is cleaned. Rub around, not directly over, pressure areas to avoid skin breakdown. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with impaired gas exchange. Which of the following outcomes is most appropriate based upon this nursing diagnosis?

The client maintains a reduced cough effort to lessen fatigue.The client restricts fluid intake to prevent overhydration.The client reduces daily activities to a minimum.The client has normal breath sounds in all lung fields.

RATIONALE: If the interventions are effective, breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluid intake should thin secretions. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan?

Make an effort to read the client's lips to foster communication.Encourage the client's communication attempts by allowing him time to select or write words.Answer questions for the client to reduce his frustration.Avoid using a tracheostomy plug because it blocks the airway.

RATIONALE: The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. The other options are inappropriate. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisWhich of the following nutritional deficiencies may delay wound healing?

Lack of thiamineLack of vitamin CLack of folateLack of vitamin A

RATIONALE: Vitamins C, B6, and B12 are necessary for collagen synthesis that takes place during wound healing. Folate enables oxygen transport. Vitamin A is needed for reversal of effects of the glucocorticoids. Thiamine is required for carbohydrate metabolism. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities.Move the client's fingers or toes to test movement.Compare capillary refill of both extremities, making sure it's the same bilaterally.Be aware that edema and pulse checks aren't part of the neurovascular assessment.

RATIONALE: During the complete neurovascular check, extremities should be compared; for example, compare capillary refill of both extremities. Capillary refill should be the same bilaterally. Extremities should be equally warm. Movement should be checked by having the client move his own fingers and toes. Edema and pulse checks are part of a neurovascular assessment. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client is hospitalized with a diagnosis of acute renal failure. The nurse should monitor closely for:

enuresis.drug toxicity.lethargy.insomnia.

RATIONALE: Acute renal failure is characterized by oliguria and rapid accumulation of nitrogen waste in the blood. Kidneys excrete medications, so the nurse should monitor the client closely for drug toxicity. With decreased urinary output or no output, enuresis shouldn't occur. The client will most likely feel lethargic, but this isn't as serious a problem as drug toxicity. The client isn't likely to have insomnia but instead may want to sleep most of the time. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA client sustains a C5 spinal cord injury that results in quadriplegia. Several days after being moved out of the intensive care unit, he complains of a severe throbbing headache. What should the nurse do next?

Check the client's indwelling urinary catheter for kinks to ensure patency.Lower the head of the bed to improve perfusion.Call the physician immediately for a pain medication order.Reassure the client that headaches are normal after spinal cord injuries.

RATIONALE: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the head of the bed can increase intracranial pressure. Before calling the physician, the nurse should check the client's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this client; it isn't normal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse and assistant must put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that doesn't have removable arms. What is the best way to return the client to bed?

Use a mechanical lift.Lift him manually with assistance from other staff members.Use a transfer belt to lift him up and transfer him to the bed.Use a plastic slider to move the client from the chair to the bed.

RATIONALE: A mechanical lift should be used to promote client safety and avoid staff injury. Nurses and assistant personnel risk injury by using their bodies to lift a comatose client. A transfer belt is to help support conscious clients when walking with assistance. A plastic slider can't be used to transfer a comatose client from the chair to the bed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit level in this client?

Hypoalbuminemia with hemoconcentrationVolume overload with hemodilutionMetabolic acidosisLack of erythropoietin factor

RATIONALE: Reduced hematocrit is caused by hemodilution, when the concentration of erythrocytes and other blood elements is lowered by volume overload. This is a result of interstitial-to-plasma fluid shift. Hypoalbuminemia causes the movement of fluid from the vascular component to the interstitial space and results in hemoconcentration. Metabolic acidosis does cause the red blood cell components to be fragile, but isn't applicable in this situation. Erythropoietin factor would only be reduced if kidney failure occurred. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse provides care for a client who experienced an extensive myocardial infarction (MI). The client exhibits behavior characteristic of the denial stage of the grieving process. What should the nurse do?

Reinforce and support the client's denial.Let the client know that the nurse is available to talk.Point out other clients with MI who are doing well.Explain to the client that he needs to accept his diagnosis.

RATIONALE: Letting the client know that the nurse is available to talk acknowledges the client's feelings. It may help the client cope until he's ready to move on to the next stage of the grieving process. Pointing out other clients with MI who are doing well offers false reassurance to this client and disregards his feelings. The client shouldn't be forced to face reality either. Denial is a protective mechanism that enables the client to cope with crisis until he can use more effective coping behaviors. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which of the following nursing interventions is appropriate?

Tell the client to try to urinate around the catheter to remove blood clots.Restrict fluids to prevent the client's bladder from becoming distended.Prepare to remove the catheter.Use aseptic technique when irrigating the catheter.

RATIONALE: If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urinary output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician's order. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?

"Be careful after taking nitroglycerin because it may cause dizziness.""Make sure you replace your nitroglycerin tablets every 6 months to ensure potency.""A burning sensation after taking nitroglycerin indicates medication potency.""When you experience chest pain, take one tablet every 30 minutes until the pain is relieved."

RATIONALE: Clients should use caution when taking nitroglycerin because it commonly causes orthostatic hypotension and dizziness. The client should rise slowly and lie down at the first sign of dizziness. To ensure potency, store nitroglycerin in a tightly closed container in a cool, dark place and replace the tablets every 3 months. Many brands of nitroglycerin no longer cause a burning sensation. The client should take a sublingual nitroglycerin tablet at the onset of chest pain and repeat the dose every 5 to 10 minutes, for up to 3 doses. If this doesn't relieve chest pain, the client should seek immediate medical attention. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationWhen should the client with type 2 diabetes take the oral antidiabetic agent glipizide?

With mealsAfter meals

30 minutes before bedtime30 minutes before breakfast

RATIONALE: The client with type 2 diabetes should take glipizide 30 minutes before breakfast to minimize wide fluctuations in blood glucose levels. The other options aren't as effective. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is giving dexamethasone by otic administration. The nurse should inform the client that he may experience what adverse reaction?

TinnitusTemporary hearing lossDizzinessStinging or burning sensations

RATIONALE: Transient local stinging or burning sensations are a common adverse reaction to otic dexamethasone. The other options don't apply. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionDuring a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease?

Antidiabetic agents, administered orallyNonsteroidal anti-inflammatory drugs (NSAIDs)Beta-adrenergic blockersContraceptive agents, administered orally

RATIONALE: Concomitant use of NSAIDs may increase the risk of a peptic ulcer; therefore, they should be administered 2 hours before or 2 hours after prednisone. Oral antidiabetic agents, beta-adrenergic blockers, and oral contraceptive agents don't increase the risk of peptic ulcer disease when administered with prednisone. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationWhen preparing to administer insulin, the nurse disinfects the injection site with a sterile alcohol swab. How long should the nurse allow the disinfected area to dry before injecting insulin?

10 seconds30 seconds1 minute2 minutes

RATIONALE: Before administering an injection, the nurse should allow the disinfected area to dry for about 1 minute. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionOn a routine visit, the client asks the nurse if he can cut his large enteric-coated tablets in half. The nurse tells the client no because dividing the medication will:

alter the medication's absorption.make the medication less effective.cause severe adverse reactions.cause interactions with other medications.

RATIONALE: Dividing an enteric-coated tablet destroys the enteric barrier, allowing stomach secretions to act on the medication and alter its absorption. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse brings a client his prescribed antibiotic. The client tells the nurse that he usually takes a white tablet, not the yellow tablet in the medication cup. What should the nurse do?

Tell the client that the yellow tablet is probably from a different manufacturer.Reassure the client that it's the correct medication.Withhold the medication and notify the physician.Recheck the medication name and strength.

RATIONALE: Any time a client says the medication seems unusual, the nurse should recheck the medication name and strength. Telling him the medication is from a different manufacturer gives the client false information. Reassuring him without checking the medication name and strength could lead to a serious medication error. Withholding the medication and notifying the physician isn't necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client comes to the emergency department with an acute myocardial infarction. An electrocardiogram shows a heart rate of 116 beats/minute with frequent premature ventricular contractions. The client experiences ventricular tachycardia and becomes unresponsive. After resuscitation, the client moves to the intensive care unit. Which nursing diagnosis is top priority?

Impaired physical mobility related to complete bed restDeficient knowledge related to emergency interventionsSocial isolation related to restricted family visitsAnxiety related to the threat of death

RATIONALE: Anxiety related to the threat of death is an appropriate nursing diagnosis. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other options are valid, but their priority is less urgent. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 57-year-old client reports experiencing leg pain whenever he walks several blocks. The client has type 1 diabetes and has smoked two packs of cigarettes per day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client?

Practice meticulous foot care.Consider cutting down on your smoking.Reduce your exercise level.See the physician if the symptoms bother you.

RATIONALE: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water, dry them thoroughly, cut his toenails straight across, wear well-fitting shoes, and avoid taking medication unless cleared by the physician. The client should stop smoking - not just cut down - because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. The client should see the physician regularly, not just when he's bothered by symptoms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

The nurse is caring for a client with adult respiratory distress syndrome (ARDS). What is the most likely laboratory finding in the early stages of this disease?

Increased carboxyhemoglobinDecreased partial pressure of arterial oxygen (PaO2)Increased partial pressure of arterial carbon dioxide (PaCO2)Decreased bicarbonate (HCO3-)

RATIONALE: Decreased PaCO2 indicates hypoxemia, which is a universal finding in ARDS. The PaCO2 level is low early in the disease due to hyperventilation and then elevates later in the disease due to fatigue and worsening clinical status. The HCO3- level may be low in ARDS and is related to reduced tissue oxygenation. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. This isn't a common cause of ARDS. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse provides care for a client with chronic obstructive pulmonary disease (COPD). Administering high doses of oxygen may produce what result?

Increased respiratory driveDiminished respiratory driveA mismatch between ventilation and perfusionA profound decrease in partial pressure of arterial carbon dioxide (PaCO2)

RATIONALE: A client with COPD who has had an elevated PaCO2 level for a prolonged time no longer depends on changes in carbon dioxide level to regulate the respiratory drive. The client with COPD depends on hypoxia or lower partial pressure of arterial oxygen level changes to regulate respirations. If high levels of oxygen are administered, the client will lose his hypoxic respiratory drive, causing respirations to decrease or even stop. As the respirations decrease, the PaCO2 levels elevate. COPD leads to a mismatch between ventilation and perfusion. The alveoli enlarge and overdistend, decreasing the surface area of alveoli to capillary ratio. Increasing the oxygen level won't increase the ventilation-perfusion mismatch. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationRight-sided heart failure may develop as a result of pulmonary embolus. What is a hallmark sign of right-sided heart failure?

A physiologic second heart sound (S2) splitP pulmonaleExpiratory wheezingPericardial friction rub

RATIONALE: The elevated pulmonary pressures present with pulmonary embolus can lead to right-sided heart failure, leading to an increase in right atrial volume. This increased atrial volume will appear as an altered P wave (known as P pulmonale) on the electrocardiogram. The P wave will be taller and more peaked than a normal P wave. A physiologic S2 split is normal. When pulmonary pressures become severely elevated, the split becomes pathologic. Lung sounds are generally clear in a client with pulmonary emboli. In extreme cases, there may be crackles in the bases. A pleural friction rub may be heard in clients with pulmonary emboli and must be differentiated from pericardial friction rub. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationConjunctivitis may be caused by bacteria, viruses, allergens, or irritants. What signs and symptoms differentiate bacterial conjunctivitis from other types?

Subacute onset, severe pain, and preauricular adenopathyRecurrent onset, no pain, and clear dischargeAcute onset, moderate pain, and purulent dischargeAcute onset, mild pain, and clear discharge

RATIONALE: Bacterial conjunctivitis has an acute onset, moderate pain, preauricular adenopathy, and a copious and purulent discharge. Viral conjunctivitis has an acute or subacute onset, mild to moderate pain, preauricular adenopathy, and moderate and seropurulent discharge. Allergic conjunctivitis has a recurrent onset, no pain, no preauricular adenopathy, and moderate and clear discharge. Irritant conjunctivitis has an acute onset, mild pain or no pain, rare preauricular adenopathy, and minimal and clear discharge. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionWhat finding would lead the nurse to conclude that treatment for conjunctivitis wasn't effective?

The client's eye pain is relieved.Preauricular adenopathy is decreased.Purulent discharge is resolved.Both eyes have purulent discharge.

RATIONALE: After effective treatment for conjunctivitis, the client's eye pain should be relieved, preauricular adenopathy should be decreased or completely resolved, and purulent discharge resolved. Further therapy is needed for the client who has purulent drainage in both eyes. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhich of the following medications shouldn't be given via an endotracheal (ET) tube?

Atropine sulfateSodium bicarbonateEpinephrine (Adrenalin)Lidocaine hydrochloride (Xylocaine)

RATIONALE: Sodium bicarbonate shouldn't be given via an ET tube because it's prepared in a large volume of fluid and the medication is alkaline in nature. Atropine, epinephrine, and lidocaine are absorbed rapidly by the lungs and may be given safely via the ET tube. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Pulmonary embolismHeart failureCardiac tamponadeTension pneumothorax

RATIONALE: A client with heart failure has a decreased cardiac output, caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. Clients with pulmonary embolism experience acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. Clients with cardiac tamponade experience muffled heart sounds, hypotension, and elevated central venous pressure. Clients with tension pneumothorax have a deviated trachea and absent breath sounds on the affected side as well as dyspnea

and jugular vein distention. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client arrives in the emergency department complaining of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs.Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician.Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team.Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

RATIONALE: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen will increase the myocardial oxygen supply. Cardiac monitoring will help detect life-threatening arrhythmias. Ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial assessment is premature. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationWhat is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volumeExcess fluid volumeDecreased cardiac outputIneffective tissue perfusion (GI)

RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock will cause a decrease in cardiac output. Tissue perfusion will be altered if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisPeritoneal lavage is a diagnostic tool used to detect abdominal injuries. Which of the following is a contraindication for peritoneal lavage?

An unconscious clientA history of abdominal surgeryA distended bladderAn allergy to radiopaque dye

RATIONALE: A distended bladder is an absolute contraindication for peritoneal lavage. An indwelling urinary catheter should be inserted before the procedure. Peritoneal lavage may be especially useful in an unconscious client with suspected abdominal injuries because the client is unable to report pain. History of abdominal surgery isn't a contraindication to this procedure. Peritoneal lavage involves the instillation and withdrawal of fluid from the abdominal cavity and doesn't require radiopaque dye. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse instructs a client on diuretic therapy to eat foods high in potassium. The selection of which food would indicate the need for further teaching?

PotatoesHoneyBeansCheese

RATIONALE: Sources of potassium include cheese, beans, potatoes, broccoli, milk, and beef. Honey has a moderate amount of iron but has unappreciable amounts of potassium. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionWhat does a positive Chvostek's sign indicate?

HypocalcemiaHyponatremiaHypokalemiaHypermagnesemia

RATIONALE: Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. If the client's facial muscles twitch, it indicates hypocalcemia. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is about to begin teaching a client how to perform tracheostomy care. What's the most important principle in client teaching that the nurse needs to utilize?

Providing the most up-to-date information availableAlleviating the client's guilt associated with not knowing appropriate self-careDetermining the client's readiness to learn new informationBuilding on previous information

RATIONALE: Client readiness is critical to accepting and integrating new information. Unless the client is ready to accept new information, client teaching will be ineffective. Giving up-to-date information won't matter if the client isn't ready to accept new information. Client guilt can't be alleviated until the client understands the intricacies of the condition and his physiological response to the disease. If the client isn't ready to learn, it will be impossible to build on previous information because the client won't be receptive to that information and won't learn. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationWhich of the following teaching methods is most effective?

A list of instructions written at a sixth-grade levelA short videotape providing useful information and demonstrationsAn audiotaped version of discharge instructionsA discussion and demonstration between the nurse and the client

RATIONALE: The discussion and demonstration method, which provides direct contact and the opportunity to ask questions, is the most effective teaching method. A list of instructions, a videotape, and an audiotape are effective methods of reinforcing teaching after the discussion and demonstration have taken place. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA 49-year-old client is diagnosed with hypercholesterolemia. The client is obese. The nurse needs to determine if the client has other major risk factors for coronary artery disease (CAD). Which factor would indicate an increased risk for CAD?

A history of diabetes mellitusElevated high-density lipoprotein (HDL) levelsA history of ischemic heart disease

A history of alcoholismRATIONALE: Diabetes mellitus is a major risk factor for CAD. Elevated HDL levels aren't a risk factor for CAD. Ischemic heart disease is another term for CAD - not a risk factor. Alcoholism hasn't been identified as a major risk factor for CAD. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is planning care for a client with Menicre's disease. Which nursing diagnosis takes highest priority?

Acute pain related to Menicre's diseaseImbalanced nutrition: Less than body requirements related to nausea and vomitingRisk for deficient fluid volume related to vomitingRisk for injury related to vertigo

RATIONALE: Vertigo, the hallmark finding in Menicre's disease, is a severe rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of risk for injury related to vertigo takes priority. Menicre's disease doesn't cause pain. Although nausea and vomiting may lead to imbalanced nutrition and fluid loss, these problems aren't as important as client safety. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisTetany results when pathogenic organisms are introduced into human tissue. Which bacterium causes tetany?

Pasteurella multocidaClostridiumEnterobacterStreptococcus

RATIONALE: Clostridium tetani inhabits the intestinal tracts of humans and animals, enters the bloodstream, and travels to the central nervous system. Clostridium has the ability to survive in soil for years. P. multocida is the etiologic agent in hemorrhagic septicemia. Enterobacter occurs in the intestines of humans and animals and is a common cause of nosocomial infections. The streptococcus group encompasses a wide variety of gram-negative bacteria found in a range of hosts, including humans, horses, pigs, and cows. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ComprehensionThe nurse is moving a client in bed. What should the nurse do to ensure that she maintains proper body mechanics?

Straighten her knees and back.Stand with her feet apart.Lift the client to the proper position.Stand several feet from the client.

RATIONALE: When moving a client in bed, the nurse should stand with her feet apart to establish a wide base of support. The nurse should flex her knees and use her arm and leg muscles instead of the back. To reduce the energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull, rather than lift the client. To minimize stress, the nurse should stand as close to the client as possible. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeWhich procedure or practice is associated with surgical asepsis?

Hand washingNasogastric (NG) tube irrigationColostomy irrigationI.V. catheter insertion

RATIONALE: Caregivers must use surgical asepsis when performing any procedure in which skin integrity is broken or a sterile body cavity is entered. Because it disrupts skin integrity and involves entry into a sterile cavity (a vein), inserting an I.V. catheter requires surgical asepsis. The other options require the use of clean technique to prevent the spread of infection. Hand washing cleans the hands; it doesn't sterilize them. The GI tract isn't sterile; therefore, irrigating an NG tube or a colostomy requires only clean technique. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is transferring a client from the bed to a chair. What action should the nurse take during client transfer?

Help the client dangle his legs.Position the head of the bed flat.Stand behind the client.Place the chair facing away from the bed.

RATIONALE: After placing the client in high Fowler's position and moving him to the side of the bed, the nurse should help the client sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeA client is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutrition teaching plan has been effective?

"I chose a ham and cheese sandwich with potato chips for lunch.""I chose a baked potato with broiled chicken for dinner.""I chose a tossed salad with sardines and oil and vinegar dressing.""I chose chicken bouillon soup."

RATIONALE: The client's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionWhen following standard precautions, the nurse should perform which of the following measures?

Recap needles after use.Wear a gown when bathing a client.Wear gloves when administering oral medication.Change gloves after each client contact.

RATIONALE: When following standard precautions, the nurse must change gloves after each client contact. Used, uncapped needles and syringes should be placed in a puncture-resistant container; they should never be recapped. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client or administering oral medication because these activities aren't likely to cause contact with blood or body fluids. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is performing wound care. Which of the following practices violates surgical asepsis?

Holding sterile objects above the waistConsidering a 1" (2.5 cm) edge around the sterile field as being contaminatedPouring solution onto a sterile field clothOpening the outermost flap of a sterile package away from the body

RATIONALE: Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse places a client in isolation. Isolation techniques attempt to break the chain of infection by interfering with:

transmission mode.agent.susceptible host.portal of entry.

RATIONALE: Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques don't affect the agent, host, or portal of entry. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA 55-year-old male client has been diagnosed with open-angle glaucoma. The physician's orders include one drop of pilocarpine (Pilocar) 1% in each eye every 6 hours. The client states that he doesn't understand the need for medication because he doesn't have symptoms of an eye problem. Which of the following nursing diagnoses would be most appropriate?

Noncompliance related to refusal to use eyedropsDeficient knowledge related to the diseaseAnxiety related to a new health problemDisturbed body image related to the need for medication

RATIONALE: Deficient knowledge is the nursing diagnosis used for an individual who lacks the knowledge to manage a condition. Noncompliance doesn't apply to clients who refuse treatment but to those who fail to follow an agreed-upon treatment plan. Assessment data don't support diagnoses of anxiety or disturbed body image. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is demonstrating how to clean dentures to a client who is wearing them for the first time. What should the nurse teach the client to do?

Rinse the dentures under hot running water.Inspect the dentures for rough or sharp areas.Clean the dentures over the sink with the drain closed.Scrub the dentures with a cleaning agent and cold water.

RATIONALE: When cleaning dentures, the client should inspect them for rough or sharp areas that could lacerate the gums and subsequently lead to infection. The client should rinse dentures under tepid (rather than hot) running water because hot water could change their shape. When cleaning dentures over a sink, the client should place a paper towel or washcloth in the sink to prevent damage if the dentures are dropped. The client should scrub dentures with a cleaning agent and tepid (not cold) water for ease in cleaning and denture reinsertion. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeThe nurse is about to give a back rub to a client after a complete bed bath. How should the nurse proceed?

Help the client move to the middle of the bed.Massage gently in areas directly over pressure points.Pour a small amount of lotion on the center of the client's back.Remove excess lotion by rubbing the client's skin briskly with a towel.

RATIONALE: Vigorous massage could damage tissues; therefore, the nurse should massage gently in areas directly over pressure points. The client should be moved near the side of the bed, within the nurse's reach, rather than in the middle of the bed. The nurse should pour lotion onto the palms of her hands to warm it before it touches the client's back. To remove excess lotion, the nurse should pat the area dry with a towel; brisk rubbing could damage tissues. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionThe nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates that teaching has been effective?

"I'll limit my intake of protein.""I'll make sure that the bandage is wrapped tightly.""My foot should feel cold."" I'll eat plenty of fruits and vegetables."

RATIONALE: For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. To provide these nutrients, the client should eat a high-protein diet with plenty of fruits and vegetables. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the client's foot feels cold, circulation is impaired which inhibits wound healing. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?

Keeping the client well-hydratedAvoiding bathing the client with mild soapRemoving adhesive tape quickly from the skinRecommending tight-fitting clothes in hot weather

RATIONALE: Keeping the client well-hydrated helps to prevent skin cracking and infection. To help a client maintain healthy skin, the nurse should use mild soap and avoid strong or harsh detergents. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. To promote heat loss by evaporation, the nurse should recommend wearing loose-fitting clothes in hot weather. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splintsElevating the foot of the bedHyperextending the client's palmsPerforming shoulder range-of-motion (ROM) exercises

RATIONALE: Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; it can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

Encouraging the client to suppress his feelings regarding obesityReinforcing the client's concerns over physical appearanceUsing an abrupt, forceful manner to communicate with the clientTeaching the client alternative ways to lose weight

RATIONALE: Teaching the client alternative ways to lose weight is the appropriate intervention. Instead of encouraging the client to suppress his feelings, the nurse should encourage him to express his feelings, especially those related to obesity. Reinforcing the client's concerns about physical appearance may make the client's anxiety worse and lead to more self-destructive behavior. Using an abrupt, forceful manner discourages therapeutic communication with the client. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with allergies how to prevent anaphylaxis. Which recommendation is most appropriate?

Dry mop all hardwood floors.Wear medical identification.Have carpeting installed in every room of the house.Advise family and friends not to visit during the winter.

RATIONALE: If the client became unconscious or couldn't report allergies, medical identification could provide information that health care providers would need to know to avoid anaphylaxis. The client should wet mop hardwood floors because dry mopping scatters dust that can trigger allergies. The client should minimize the amount of carpeting in the home because carpets trap allergens such as dust and dirt. Unless the client is ill, the nurse should encourage visits by family and friends to promote healthy social interaction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionWhen assessing a geriatric client, which finding indicates a normal age-related change?

Reduced intelligenceElectrolyte imbalancesDecreased reaction timeIncreased vein elasticity

RATIONALE: Decreased reaction time is a normal age-related change in a geriatric client. Although the client's intelligence should remain intact, the client may learn at a slower rate. Electrolyte imbalances are an abnormal finding in any client regardless of age. Vein elasticity usually decreases with age. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?

Encouraging intake of at least 2 qt (2 L) of fluid dailyGiving the client a glass of soda before bedtimeTaking the client to the bathroom twice per dayConsulting with a dietitian

RATIONALE: By encouraging a daily fluid intake of at least 2 qt, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client who just underwent a colectomy. What should the nurse do to prevent postoperative thrombus formation in the legs?

Encourage the client to dorsiflex and plantar flex the feet.Instruct the client to turn from side to side every hour.Have the client use a trapeze bar to move in bed.Keep the client flat and warm.

RATIONALE: Dorsiflexion and plantar flexion of the feet promote venous return to the heart, thus reducing the risk of thrombus formation. Having the client turn from side to side helps prevent pressure ulcers but won't prevent a leg thrombus. Using a trapeze bar to move in bed may help the client move independently but won't enhance blood flow to the legs or prevent thrombus formation. Keeping the client flat and warm doesn't promote blood flow or venous return and, therefore, won't reduce the risk of thrombus formation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client is scheduled for an appendectomy. The nurse must teach the client about incision splinting and leg exercises. When is the best time for the nurse to provide teaching?

Upon the client's admission to the postanesthesia care unit (PACU)When the client returns from the PACUDuring the intraoperative periodBefore the surgical procedure

RATIONALE: Teaching is most effective when provided before surgery. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is providing postoperative care for a client who has had spinal anesthesia. The nurse should place the client in which position?

On the right side with two pillows under the headOn the left side in Sims' positionSupine with a pillow for comfortProne with no pillows

RATIONALE: The nurse should place the client on the left side in Sims' position to facilitate breathing and to help maintain a patent airway if the client vomits. The first option is inappropriate; the client's head should be kept flat for several hours after surgery to prevent spinal headaches and promote cerebrospinal fluid equilibration. The supine position increases the risk of postoperative aspiration. The prone position is usually contraindicated; it impedes assessment of the client's airway, breathing, and circulation - key postoperative parameters. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client injured during a car accident is brought to the emergency department by ambulance. Which finding indicates that the client sustained a head injury?

TachycardiaWidening pulse pressureHypotensionRapid respiratory rate

RATIONALE: As intracranial pressure increases following a head injury, the systolic blood pressure rises. Widening of pulse pressure occurs as the difference between systolic and diastolic blood pressure increases. As the systolic blood pressure rises, the client develops hypertension (not hypotension). The client develops bradycardia (not tachycardia). Respiration slows down and may progress to Cheyne-Stokes respiration (alternating periods of shallow and deep breathing). NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with an acute head injury. Which nursing diagnosis has the highest priority?

Deficient fluid volumeIneffective tissue perfusion: CerebralRisk for infectionIneffective airway clearance

RATIONALE: Establishing a patent airway always takes priority. Without an open airway, interventions aimed at the other nursing diagnoses will be in vain. The other nursing diagnoses would be addressed after a patent airway has been established. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with an acute head injury. How should the nurse position the client?

On his side, with the head of the bed elevatedFlat on his back, with his head turned to the sideProne, with his knees sharply flexedTrendelenburg's position, with his body in straight alignment

RATIONALE: Positioning the client on his side, with the head of the bed elevated, reduces the risk of airway occlusion by the tongue and aids in the drainage of secretions. Elevating the head of the bed may also reduce intracranial pressure. Positioning the client flat on his back increases the risk of aspiration. The client's head should be maintained in a neutral position, and not turned to the side, to promote venous return. The nurse should avoid sharp flexion of the client's knees and the Trendelenburg position because these positions reduce venous return from the client's head and may increase intracranial pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with an acute head injury. The client is stabilized and ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?

Raise the side rails on both sides of the bedPosition the chair approximately 2' (0.6 m) from the bedLock the brakes on the bedPlace socks on the client's feet

RATIONALE: Locking the wheels of the bed (and wheelchair, if one is used) will prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail (on the side of the bed where the nurse is standing) should be lowered, to facilitate the transfer. Positioning the chair along the side of the bed will help the client to pivot into the chair. Placing shoes, or slippers with nonskid soles, on the client's feet will help to prevent slipping during the transfer. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhich nursing action takes priority when admitting a client with right lower lobe pneumonia?

Elevating the head of the bed 45 to 90 degreesAuscultating the chest for adventitious soundsObtaining a sputum specimen for cultureNotifying the physician of the client's admission

RATIONALE: Clients with pneumonia breathe easier in Fowler's or semi-Fowler's position because gravity facilitates diaphragmatic movement. The other nursing actions are important but don't take first priority. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA male client who had a segmental left lung resection for treatment of a lung carcinoma returns from surgery with a left posterior-lateral chest tube attached to a disposable water-seal chest drainage system. Which of the following signs would indicate that the drainage system is working properly?

Air is bubbling in the water-seal chamber.The fluid level in the drainage chamber remains constant.The fluid level in the water-seal chamber fluctuates.A pneumothorax is present.

RATIONALE: Fluctuation of the fluid level (upward on inspiration and downward on exhalation) in the water-seal chamber indicates a patent tube. Bubbling in the water-seal chamber indicates an air leak. A constant fluid level in the drainage chamber may indicate an obstructed drainage tube. A pneumothorax wouldn't indicate whether the drainage equipment was functioning properly. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a woman with phenylketonuria who wants to start a family. Which of the following guidelines should the nurse provide the woman?

Follow a low-phenylalanine diet before trying to conceive.A low-phenylalanine diet is necessary only during the first trimester.Begin a low-phenylalanine diet when pregnancy is confirmed.Dietary restrictions won't be necessary.

RATIONALE: A woman with phenylketonuria should begin a low-phenylalanine diet before she tries to conceive. This will reduce the risk of giving birth to a baby with microcephaly, mental retardation, and low birth weight. The low-phenylalanine diet must be continued throughout pregnancy and during breast-feeding. Starting a low-phenylalanine diet after conception increases the risk of physical and mental disabilities to the fetus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is assessing a client for signs of hypoxemia. Which of the following should the nurse interpret as a late sign of hypoxemia?

Increased respiratory rateIncreased heart rateDiaphoresisAgitation

RATIONALE: Initially, the respiratory rate increases to obtain more oxygen, the heart rate increases in response to increased energy demands, and the client experiences agitation from early cerebral hypoxia. Later, as the client continues to work to obtain oxygen, the skin becomes diaphoretic and cool from vasoconstriction. Increased respiratory rate, increased heart rate, and agitation are early signs of hypoxemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment?

Flashing lights in the visual fieldSudden eye painLoss of color visionColored halos around lights

RATIONALE: Flashing lights in the visual field are a common symptom of retinal detachment. Clients may also report spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment isn't associated with eye pain, loss of color vision, or colored halos around lights. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?

Applying a restraining vest to keep the client from getting out of bedOrienting the client to the room so he can find his way to the bathroom by himselfLowering the side rails so the client can get out of bed more easilyPlacing the call bell within the client's reach and making sure he knows how to use it

RATIONALE: To reduce the risk of injury and falls, the nurse should place the call bell within the client's reach and instruct him in its use. Because the client is alert and oriented, applying a restraint to keep him in bed is inappropriate. If activity orders allow limited ambulation, such as to the bathroom, the nurse should explain the importance of calling for assistance when getting out of bed. When the client is in bed, the side rails should be raised for safety. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse provides care for a client with a detached retina who has both eyes patched. When communicating with the client, the nurse should:

avoid touching the client because it may startle him.speak in a loud tone of voice so the client can hear her.identify herself every time she enters the room.leave the room quietly so the client isn't disturbed.

RATIONALE: Each time the nurse enters the client's room, she should identify herself. She shouldn't assume the client will be able to identify her voice. The use of touch can be very comforting to the client who has a visual alteration. There's no need to speak loudly to a visually impaired client, unless he's also hearing impaired. The nurse should tell the client when she's leaving the room so the client doesn't continue talking to a person who is no longer present. This also allows the client to ask for anything he may need before the nurse leaves. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with a detached retina who underwent a scleral buckling procedure on the left eye. The procedure included gas injection into the vitreous. Which of the following statements indicates that the client understands the nurse's instructions?

"I should lie on my abdomen with my head turned to the right.""I'll lie facedown with my head turned to the left.""I'll lie faceup with my head turned to the right.""I should lie on my back with my head turned to the left."

RATIONALE: In a scleral buckling, the sclera is flattened against the retina. A piece of silicone is attached to the sclera with a band that encircles the eye to keep the retina in contact with the choroid and sclera. Air or other gasses may be injected into the vitreous to float up against the retina and promote retinal reattachment. When a gas is used, the client is positioned on his abdomen with the head turned to the affected eye (in this situation, the left side), so that the gas will float up against the retina and aid in reattachment. The other positions won't allow the gas to float up against the retina. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisWhich client is most at risk for developing otosclerosis?

A 54-year-old manA premenstrual girlA child with chronic otitis mediaA 24-year-old pregnant woman

RATIONALE: Otosclerosis is more common in women than in men. The onset is usually in late adolescence or the early twenties. Otosclerosis often begins during or after pregnancy. A 54-year-old man is less at risk for the development of otosclerosis. Because the disease typically begins in the late teens, a premenstrual girl is less at risk for otosclerosis. A history of otitis media doesn't increase the risk of otosclerosis. Other risk factors for otosclerosis include a family history of the disease and a childhood history of osteogenesis imperfecta. Whites are more commonly affected than Blacks. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a 32-year-old client with otosclerosis. The nurse should be aware that the client's hearing loss:

affects one ear only.affects both ears.occurred suddenly.is associated with ear pain.

RATIONALE: The hearing loss associated with otosclerosis is bilateral, although one ear may show a greater impairment. Otosclerosis develops slowly over time. The client isn't usually aware of a problem until communication is affected. Otosclerosis doesn't cause ear pain. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate?

Your hearing may not improve but you'll no longer be bothered by tinnitus.Your hearing may be dramatically improved right after surgery.You may notice improved hearing within 1 to 2 weeks.Your hearing may improve 3 to 6 weeks after surgery.

RATIONALE: After stapedectomy, it can take as long as 6 weeks for hearing to improve. The client may not notice any improvement in the first 2 weeks after surgery. After surgery, hearing may initially worsen because of swelling and fluid accumulation in the ear. Tinnitus may not resolve. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, the nurse should instruct the client to:

sneeze with her mouth open.blow her nose frequently.clean her operated ear with a cotton-tipped applicator twice per day.resume bending and straining when she's no longer experiencing ear pain.

RATIONALE: If sneezing can't be avoided, the client should sneeze with her mouth open. This will prevent changes of air pressure in the middle ear, which can dislodge the prosthesis and graft. Blowing the nose and coughing should be avoided. Small objects, such as cotton-tipped applicators, shouldn't be inserted into the ear. Straining during a bowel movement and bending should be avoided for at least 2 to 3 weeks, or as instructed by the physician. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?

Rashes on his palms and solesCauliflower-like warts on his penisPainful red papules on the shaft of his penisFoul-smelling discharge from his penis

RATIONALE: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms and soles are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a male client with gonorrhea who is receiving ceftriaxone and doxycycline. The client asks the nurse why he's receiving two antibiotics. How should the nurse respond?

Because there are many resistant strains of gonorrhea, more than one antibiotic may be required for successful treatment.The combination of these two antibiotics reduces the risk of reinfection.Many people infected with gonorrhea are infected with chlamydia as well.This combination of medications will eradicate the infection faster than a single antibiotic.

RATIONALE: Treatment of gonorrhea includes the antibiotic ceftriaxone. Because many people with gonorrhea have a coexisting chlamydial infection, doxycycline or azithromycin is prescribed as well. There has been an increase in the number of resistant strains of gonorrhea, but that isn't the reason for this dual therapy. This combination of antibiotics doesn't reduce the risk of reinfection or provide a faster cure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to:

ask all potential sexual partners if they have a sexually transmitted disease.wear a condom every time he has intercourse.consider intercourse safer if his partner has no visible discharge, lesions, or rashes.expect to limit the number of sexual partners to fewer than five over his lifetime.

RATIONALE: Wearing a condom during intercourse considerably reduces the risk of contracting STDs. The other options may help reduce the risk for contracting an STD but not to the extent wearing a condom will. A monogamous relationship reduces the risk of contracting STDs. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is planning care for a 52-year-old male client experiencing an acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Risk for infectionDecreased cardiac outputImpaired physical mobilityImbalanced nutrition: Less than body requirements

RATIONALE: 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 appropriate nursing diagnoses for the client with Addison's disease, but aren't priorities in a crisis. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client experiencing acute addisonian crisis. Which laboratory data would the nurse expect to find?

HyperkalemiaReduced blood urea nitrogen (BUN)HypernatremiaHyperglycemia

RATIONALE: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases, as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nursing care for the client in addisonian crisis should include which of the following interventions?

Encouraging independence with activities of daily living (ADLs)Allowing ambulation as toleratedOffering extra blankets and raising the heat in the room to keep the client warmPlacing the client in a private room

RATIONALE: The client in an addisonian crisis has a reduced ability to cope with stress due to an inability to produce corticosteroids. Compared to a multibed room, a private room is easier to keep quiet, dimly lit, and temperature controlled. What's more, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs because ambulation isn't allowed. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with Addison's disease about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

"I'll take my hydrocortisone in the late afternoon, before dinner.""I'll take all of my hydrocortisone in the morning, right after I wake up.""I'll take two-thirds of the dose when I wake up and one-third in the late afternoon.""I'll take the entire dose at bedtime."

RATIONALE: Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:

elevate the client's head to 90 degrees.press the right upper abdomen.press the left upper abdomen.lie the client flat in bed.

RATIONALE: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is administering captopril to a client with heart failure. Which assessment finding would prompt the nurse to withhold the next dose and notify the physician?

HypertensionThird (S3) heart soundDyspnea and cracklesHyperkalemia

RATIONALE: Captopril is an angiotensin-converting enzyme (ACE) inhibitor administered to clients with heart failure to improve functional capacity. Hyperkalemia is an adverse effect of ACE inhibiting medications, which inhibit potassium excretion. If the client is hyperkalemic, the nurse should notify the physician before administering the next dose. Hypertension is an indication for the use of captopril, not an adverse effect. If captopril causes hypotension, the physician should be notified. An S3, dyspnea, and crackles are signs of heart failure and indications for the use of ACE inhibiting medications, not adverse effects. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?

Bend over the object you're lifting.Narrow the stance when lifting.Push or pull an object using your arms.Stand close to the object you're lifting.

RATIONALE: Standing close to an object being lifted moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with lower back pain scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degreesProneSupine with his feet raisedSupine with his head lower than his trunk

RATIONALE: After a myelogram, positioning will depend on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The other positions are contraindicated when a water-soluble contrast dye is used. If an air-contrast study was performed, the client should be positioned supine with his head lower than his trunk. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe nurse is planning care for a female client diagnosed with acute hepatitis A virus (HAV). What's the primary mode of transmission for HAV?

Fecal contamination and oral ingestionExposure to contaminated bloodSexual activity with an infected partnerSharing a contaminated needle or syringe

RATIONALE: HAV is predominantly transmitted by the ingestion of fecally contaminated food. Transmission is more likely to occur with poor hygiene, crowded conditions, and poor sanitation. Hepatitis B and C may be transmitted through exposure to contaminated blood and blood products. Sexual activity with an infected partner and sharing contaminated needles or syringes may also transmit hepatitides B and C. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeThe nurse is teaching family members of a client with hepatitis A virus (HAV). Family members were exposed to the client and, therefore, should receive immunoglobulin. The nurse should tell the family members that immunoglobulin:

prevents hepatitis infection in all people.provides immunity for life.must be administered within 2 weeks of exposure.should be administered even if the person has anti-HAV antibodies.

RATIONALE: If immunoglobulin is administered within 2 weeks of exposure it usually prevents HAV. If family members do contract HAV, the course of the disease may be reduced to a subclinical infection after receiving immunoglobulin. Immunoglobulin provides passive immunity for 6 to 8 weeks only - not for life. If a person with anti-HAV antibodies is exposed to HAV, it isn't necessary to administer immunoglobulin. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is teaching a client with acute hepatitis about to be discharged to her home. Which activity guideline is most appropriate?

Ambulate for increasing distances at least three times per day.Maintain bed rest except for trips to the bathroom.Perform active range-of-motion exercises three times per day.Perform mild housework as tolerated.

RATIONALE: There's no specific therapy for viral hepatitis. Treatment is usually supportive and can be managed at home in many cases. During the acute phase of viral hepatitis, complete bed rest (with bathroom privileges) is necessary. This will reduce the metabolic demands on the liver, thereby increasing hepatic blood flow and promoting regeneration of liver cells. The other activities are too strenuous during the acute phase of hepatitis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Pallor, bradycardia, reduced pulse pressurePallor, tachycardia, sore tongueSore tongue, dyspnea, weight gain

Angina, double vision, anorexiaRATIONALE: Pallor, tachycardia, and a sore tongue are characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesias of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is teaching a client with pernicious anemia who requires vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program?

"I'll swallow one vitamin B12 pill every morning for 2 weeks.""I'll take a vitamin B12 pill once each month for life.""I'll need an injection of vitamin B12 every month for life.""I'll need daily injections of vitamin B12 only until my blood count improves."

RATIONALE: In pernicious anemia, the gastric mucosa doesn't secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally won't be absorbed; therefore, vitamin B12 must be administered through the I.M. or deep subcutaneous routes. Clients must have vitamin B12 injections each day for up to 2 weeks initially, then weekly for up to several months, and then once each month for life. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is assessing a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

Vision changesAbsent deep tendon reflexesTremors at restFlaccid muscles

RATIONALE: Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive - not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Affected muscles are spastic, rather than flaccid. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

take a hot bath.rest in an air-conditioned room.increase the dose of muscle relaxants.avoid naps during the day.

RATIONALE: Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli?

Increased partial pressure of arterial oxygen (PaO2), reduced sensation in left leg or footLeft leg pain, dyspneaBradycardia, skin bruisesCyanosis, decreased PaO2

RATIONALE: Fat emboli may occur with fractures of the long bones and pelvis and may be fatal. Clinical manifestations include cyanosis, dyspnea, tachycardia, chest pain, tachypnea, apprehension, restlessness, confusion, petechiae, and decreased PaO2. Increased PaO2 reduced sensation in left leg or foot, pain in the affected extremity, skin bruises, and bradycardia aren't associated with fat emboli. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with a fractured humerus in a long arm cast. Twelve hours after the cast is applied, the client begins to complain of arm pain, which is unrelieved by analgesics. Which nursing action is most appropriate?

Preparing the client for cast removal or bivalving of the castObtaining an order for a different pain medicationEncouraging the client to wiggle and move his fingersPetaling the edges of his cast

RATIONALE: Pain distal to the fracture and not relieved with analgesics is an early sign of compartment syndrome. This syndrome occurs when pressure, caused by swelling and hematoma formation, is contained within a compartment of the extremity. A cast could create such a closed compartment. Venous and arterial circulation become impaired, resulting in ischemia. Irreversible nerve and muscle damage and tissue necrosis can occur. Removing or bivalving the cast relieves pressure. Ordering different analgesics doesn't address the underlying problem. Encouraging the client to move his fingers or perform range-of-motion exercises won't treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown - not compartment syndrome. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a postoperative client. What intervention should the nurse perform to prevent thrombophlebitis?

Encouraging the client to perform coughing and deep-breathing exercisesApplying elastic stockingsMassaging legs gentlyEncouraging the client to turn frequently

RATIONALE: Elastic stockings prevent thrombophlebitis by keeping pressure on the muscles, thereby promoting venous return. Coughing and deep-breathing exercises promote lung expansion and remove retained secretions, reducing the risk of atelectasis and pneumonia; however, they don't prevent thrombophlebitis. Legs shouldn't be massaged; massage may dislodge any preexisting clots. Frequent turning prevents skin breakdown and enhances lung function but doesn't prevent thrombophlebitis. Other nursing measures to reduce the risk of thrombophlebitis include early ambulation, leg exercises while on bed rest, subcutaneous heparin, and encouraging adequate hydration as well as avoiding pressure on the back of the knees and deep veins of the legs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is administering warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory value indicates warfarin is at therapeutic levels?

Partial thromboplastin time (PTT) 1r to 2 times the controlProthrombin time (PT) 1r to 2 times the controlInternational normalized ratio (INR) of 3 to 4Hematocrit of 32%

RATIONALE: Warfarin is at therapeutic levels when the client's PT is 1r to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage; whereas lower values indicate increased risk of blood clot formation. Heparin - not warfarin - prolongs PTT. The INR may also be used to determine if warfarin is at a therapeutic level. An INR of 2 to 3 is considered therapeutic. Hematocrit doesn't provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with a C7 spinal cord injury who develops hypertension, bradycardia, and sweating. Which intervention should the nurse perform first?

Palpating the client's bladderLying the client flat in bedCovering the client with a blanketPerforming a rectal examination

RATIONALE: Hypertension, bradycardia, and sweating are signs of autonomic dysreflexia, a complication that may occur with a spinal cord injury at or above T6. Because a distended bladder is one of the most common causes of autonomic dysreflexia, the nurse should palpate the client's bladder for fullness. If the client has an indwelling urinary catheter, the nurse should check it for patency and kinks. The nurse should elevate the head of the bed, to promote cerebral venous return; dangle the feet over the side of the bed, if possible, to promote an orthostatic reduction in blood pressure; and keep the client from lying flat. Anything that may stimulate the skin, such as a blanket or shoes, should be removed. Although a distended rectum is another common cause of autonomic dysreflexia, the nurse shouldn't check for fecal impaction until an anesthetic has been applied to reduce stimulation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is preparing a treatment plan for a client taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands his treatment plan?

"I should take corticosteroids on an empty stomach.""I need to take corticosteroids to help build up my immune system.""I should stop taking corticosteroids if I haven't had an asthma attack for 1 week.""I'll tell my other health care providers that I'm taking a corticosteroid."

RATIONALE: The client's other health care providers need to know that the client is taking a corticosteroid because these drugs can suppress inflammatory and immune responses. To reduce GI symptoms, clients should take corticosteroids with food or milk, never on an empty stomach. Corticosteroids suppress, rather than build up, the immune system. Clients should never take corticosteroids without consulting with a physician. To prevent an adrenal crisis, corticosteroid use must be discontinued by gradually reducing drug dosage, especially when the client has been on long-term corticosteroid therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

Serve the client his usual diet.Order a high-fiber diet.Encourage plenty of fluids.Serve dairy products.

RATIONALE: Adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Only clear liquids are allowed the evening before the test. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionWhich client has the highest risk of ovarian cancer?

30-year-old woman taking oral contraceptive pills45-year-old woman who has never been pregnant40-year-old woman with three children36-year-old woman who had her first child at age 22

RATIONALE: The incidence of ovarian cancer increases in women who have never been pregnant, are infertile, or have menstrual irregularities and after menopause. Other risk factors include a personal or family history of ovarian, breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken oral contraceptives, have had multiple births, or have had a first child at a young age. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse in the emergency department is assessing a 64-year-old client experiencing substernal chest pain. The client's electrocardiogram shows evidence of myocardial ischemia. Which statement should indicate to the nurse that the client may be a candidate for thrombolytic therapy?

"I have had chest pain for 2 days.""My chest pain started 3 hours ago.""My chest pain stops when I take a nitroglycerin pill.""I have had chest pain on and off all week."

RATIONALE: Because it takes 4 to 6 hours for myocardial cells to die, thrombolytic therapy should be given within 6 hours of the onset of chest pain to achieve the best results in an acute myocardial infarction. The client who has waited 2 days to be treated for chest pain won't benefit from thrombolytic therapy. Chest pain that's relieved by nitroglycerin is most likely due to angina and not an indication for thrombolytic therapy. Chest pain for 1 week is also beyond the 6-hour time limit. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing intervention should be included in the care plan for the next 8 hours?

Maintaining pressure over the femoral access siteAllowing the client to sit up in bed for mealsChecking the dressing and access site for yellow drainageChecking vital signs every 4 hours

RATIONALE: Pressure is applied at the access site to control bleeding and allow a clot to form. When the femoral access site is used, the client is kept on flat bed rest with his leg extended for up to 8 hours to reduce bleeding. The dressing and access site must be observed frequently for bleeding and hematoma formation. Drainage, redness, warmth, and tenderness are signs of infection but not an immediate concern during the first 8 hours following cardiac catheterization. Following this procedure, vital signs and pedal pulses should be checked every 15 minutes for the first hour, every 30 minutes

for 2 hours, and then every 4 hours until stable. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching a client about the use of sublingual nitroglycerin. Which statement indicates understanding of the teaching plan?

"I must swallow the tablet whole without chewing.""I should take a tablet about 45 minutes before initiating a strenuous activity that causes angina.""I'll keep the nitroglycerin in its original dark, airtight container.""I'll take a tablet every 5 minutes until my chest pain stops."

RATIONALE: To maintain potency, nitroglycerin should be kept in its original dark, airtight container. Sublingual nitroglycerin tablets should be placed under the tongue and allowed to dissolve; they shouldn't be chewed or swallowed. Tablets may be placed under the tongue about 5 to 10 minutes before an activity known to cause angina. If angina occurs, one tablet should be placed under the tongue every 5 minutes until pain is relieved, up to a total of three tablets in 15 minutes. If the angina still isn't relieved, the client should seek immediate treatment. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to:

advance both legs first.advance the unaffected leg first.advance the affected leg first.advance both crutches first.

RATIONALE: To walk down a flight of stairs, body weight is first transferred to the unaffected leg. Both crutches are then advanced to the stair below. Body weight is transferred to the crutches as the affected leg descends. The unaffected leg is then brought down to the next step, so that both legs and crutches are all on the same step. The procedure is repeated for each step. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is caring for a 74-year-old client with chronic open-angle glaucoma. After the nurse administers pilocarpine, the client reports blurred vision. Which nursing action is most appropriate?

Holding the next dose and notifying the physicianTreating the client for an allergic reactionSuggesting that the client put on his glassesExplaining that this is an expected adverse effect

RATIONALE: Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eyedrops is an expected adverse effect. The client may also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug doesn't need to be withheld nor does the physician need to be notified. Likewise, the client doesn't need to be treated for an allergic reaction. Wearing glasses won't alter this temporary adverse effect. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with glaucoma who has gradually lost his eyesight. When assisting the client with ambulation, the nurse should walk:

slightly in front of the client offering an elbow for the client to hold.slightly in front of the client grasping the client's elbow.next to the client offering an elbow for the client to hold.next to the client grasping the client's elbow.

RATIONALE: In the sighted-guide technique, the nurse walks slightly ahead of the blind client and offers an elbow for the client to lightly grasp. The nurse doesn't grasp the client's elbow or walk beside him because these interventions wouldn't be as effective. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ComprehensionThe nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find?

Rigid abdomen, Levine's sign, pain relief leaning forwardRebound tenderness, McBurney's sign, low-grade feverRight lower quadrant pain, Chvostek's sign, muscle guardingPeriumbilical pain, Trousseau's sign, pain relief with pressure

RATIONALE: Rebound tenderness, McBurney's sign (pain midway between umbilicus and right iliac crest), and a low-grade fever are all signs of appendicitis. Other clinical findings include a rigid abdomen, a preference to lie still with right leg flexed, right lower quadrant pain, muscle guarding, periumbilical pain, anorexia, nausea, and vomiting. The other findings aren't signs of appendicitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing pain in a client with appendicitis. Which initial statement or question will be most effective in eliciting information?

"Tell me how you feel.""Point to where you're feeling pain.""Does your pain medication relieve your pain?""Coughing makes your pain worse, doesn't it?"

RATIONALE: Asking the client to describe what he's feeling is an open-ended question, allowing for the widest range of responses. Asking the client to point to his pain may be an important follow-up question but is too limiting to be the nurse's first question. Asking if pain medication relieves his pain is a closed question (requiring only a yes-or-no response) and should be avoided. A better follow-up question may be what makes your pain feel better? The last choice is leading as well as closed. It suggests to the client that coughing should make his pain worse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate?

"There's no need to ask for pain medication, you'll receive it on a schedule.""Take your pain medication after walking so that you won't feel dizzy.""Take your pain medication before your pain becomes intense.""Use as little pain medication as possible to avoid addiction."

RATIONALE: When an analgesic is taken before pain becomes severe, less medication is required to control the pain, thus minimizing the risk of adverse effects. Clients shouldn't be told to wait for the nurse to ask about pain or offer an analgesic. Pain medication should be taken before walking or other activities that are expected to cause pain. The client shouldn't be discouraged from using pain medication because of possible addiction. A client with no history of substance abuse has a very minimal risk of addiction when using pain medication for postoperative pain relief. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is admitting a client with tuberculosis who is coughing. To minimize the transmission of tuberculosis, which nursing measure is most appropriate?

Wearing a high-efficiency particulate air (HEPA) mask when entering the client's roomWearing gloves and a mask when entering the client's roomRestricting visitors until the client has taken antitubercular medications for 2 weeksPlacing the client in a room with open windows

RATIONALE: Because the client is coughing and tubercle bacilli are transmitted via airborne droplets, a HEPA mask is necessary to prevent transmission. Gloves aren't necessary unless the nurse is touching contaminated items such as respiratory equipment. There's no need to restrict visitors, as long as they comply with isolation procedures. A room with reverse flow ventilation also reduces transmission. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with tuberculosis. The client's wife has a positive reaction to purified protein derivative (PPD) skin testing but doesn't have active tuberculosis. What treatment would the nurse expect to administer?

Bacille Calmette-Guerin vaccineIsoniazid (INH) for six monthsYearly skin testing until negativeA combination of at least three drugs for 18 months

RATIONALE: Prophylactic therapy with isoniazid, administered once each day for 6 months, is recommended to prevent active disease. Bacille Calmette-Guerin vaccine is rarely used in the United States, where the incidence of tuberculosis is low; however, it may be given to clients with negative skin tests who have had intimate or prolonged exposure to people with tuberculosis. Because this client already has a positive skin test, Bacille Calmette-Guerin wouldn't be administered. Yearly testing isn't useful; when a client develops a positive reaction to a skin test, it remains positive for life. This client doesn't require a combination of at least three drugs given over 18 to 24 months; such treatment is recommended for clients with active tuberculosis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. What's appropriate for the nurse to say to the client?

"Don't you realize that resistance can develop if you don't take your medications properly?""You need to take your medication as you were instructed. Do you need supervision?""Why aren't you taking your medications? Don't you want to get better?""Taking many medications can be difficult. Tell me about the difficulties you're having."

RATIONALE: Acknowledging that a multidrug regimen can be difficult conveys empathy. Asking the client to discuss difficulties promotes active participation. The nurse can then provide more education and help remove potential obstacles to compliance such as lack of finances. The other responses are closed questions that require only a yes-or-no answer. They also have an adversarial tone and are judgmental, blocking further therapeutic communication. "Why" questions should be avoided because they can be interpreted as accusations, making the client defensive. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is performing a dressing change for a client with a red, granulating foot ulcer. Which of the following actions is part of this procedure?

Cleaning the wound with normal saline solutionFully cleaning the ulcer vigorouslyApplying a dry gauze dressingPerforming wet-to-dry dressing changes

RATIONALE: A red, granulating foot ulcer is healing well and should be cleaned with normal saline solution or a nontoxic wound cleaner. Minimal force should be used to prevent disrupting healthy granulation tissue. A dry gauze dressing will adhere to the wound and disrupt the granulation tissue when removed. When used in a healthy, healing wound, a wet-to-dry dressing can traumatize healing tissue during removal. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide?

Examine feet once per week for redness, blisters, and abrasions.Apply lotion to dry feet, especially between the toes.Avoid hot-water bottles and heating pads.Dry feet vigorously after each bath.

RATIONALE: Hot-water bottles and heating pads should never be used to warm cold feet. Because many clients with diabetes mellitus have neuropathy and can't feel temperature changes, serious injuries or burns may occur. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the client should gently - not vigorously - pat feet dry to avoid injury. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

Weight gain, constipation, lethargyWeight loss, nervousness, tachycardiaExophthalmos, diarrhea, cold intoleranceDiaphoresis, fever, decreased sweating

RATIONALE: Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, cold intolerance, and decreased sweating are signs of hypothyroidism. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect what complication?

TetanyHemorrhageThyroid stormLaryngeal nerve damage

RATIONALE: Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feeling of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism - not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with cholecystitis receiving 1,000 ml of I.V. fluids infused over 12 hours. The administration set delivers 15 gtt/ml. What should the drip rate be?

15 gtt/minute21 gtt/minute67 gtt/minute84 gtt/minutes

RATIONALE: When administering I.V. fluids, the nurse should use the following formula to calculate flow rate: (total volume)/(infusion time in minutes) x (drop factor). In this example, the equation would be: (1,000 ml)/(720 minutes) x (15 gtt/ml) = 1.39 ml/minute x 15 gtt/ml = 20.8 gtt/minute, which is rounded to 21 gtt/minute. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Straw-colored urineReduced hematocritClay-colored stoolsElevated urobilinogen in the urine

RATIONALE: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored), as a result of soluble bilirubin in the urine. Hematocrit isn't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client receiving spironolactone to treat hypertension. Which instruction should the nurse give the client?

Choose foods high in potassium.Take potassium supplements each day.Discontinue sodium restrictions.Avoid salt substitutes.

RATIONALE: Because spironolactone is a potassium-sparing diuretic, the client should be taught to avoid salt substitutes because they have high potassium content. Foods high in potassium and potassium supplements should be avoided. Sodium restrictions should continue to reduce fluid volume overload. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication?

Chills and tachycardiaUrinary frequency and burning on urinationDizziness and faintingPink-tinged urine and bladder spasms

RATIONALE: Chills and tachycardia may indicate bladder infection and should be reported to the physician immediately. Clients commonly feel burning on urination and urinary frequency after cystoscopy as a result of irritation from the cystoscope. Orthostatic dizziness and fainting may occur after the legs have been removed from stirrups, which are used to maintain the client in a lithotomy position. Pink-tinged urine and bladder spasms may be expected after cystoscopy. Note, however, that the occurrence of bright red blood may be an indication of hemorrhage. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client with bladder cancer undergoes a total cystectomy and ileal conduit. Postoperatively, the nurse notes mucus in the client's urine. Which nursing intervention is most appropriate?

Informing the physician that the client has a urinary tract infectionObtaining a urine specimen for culture and sensitivityMonitoring for other signs and symptoms of infectionExplaining to the client that this is normal after this type of surgery

RATIONALE: In an ileal conduit, the ureters are attached to a portion of the ileum that has been removed from the intestine and brought out through the abdominal wall, creating a stoma. The resected portion of the ileum is irritated by urine and secretes mucus. Because mucus secretion isn't a sign of infection, the physician doesn't need to be notified nor does urine need to be collected for culture and sensitivity. Note that, although mucus in the urine from an ileal conduit doesn't indicate infection, the client should be observed for other signs and symptoms of infection postoperatively. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client with hyperthyroidism is started on propylthiouracil. When should the nurse expect noticeable improvement in the client's condition?

In 24 to 48 hoursIn 6 to 7 daysIn 2 to 4 weeksIn 6 months

RATIONALE: Propylthiouracil is slow-acting, taking 2 to 4 weeks to produce noticeable improvement. The other options are incorrect. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 78-year-old male client has been newly diagnosed with hypothyroidism. He lives in his own apartment in a community development designed for the elderly. He asks the nurse assigned to this complex for advice about his condition. What would be the best advice the nurse could give the client?

"Stop taking your self-prescribed daily aspirin.""Stop attending group activities.""Keep the temperature in your apartment cooler than usual.""Increase fiber and fluids in your diet."

RATIONALE: Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. Taking aspirin isn't related to hypothyroidism management. The client doesn't need to discontinue all group activities, although he may need to limit them until his condition improves. Clients with hypothyroidism have an intolerance of cold and need an environment warmer than average. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is performing an otoscopic examination of a client with ear pain. The nurse notes that the tympanic membrane is bulging and red. Identify the structure that the nurse is assessing.RATIONALE: The tympanic membrane separates the external and middle ear and may appear red and bulging in a client with otitis media. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is performing a cardiac assessment. Identify where the nurse places the stethoscope to best auscultate the pulmonic valve.

RATIONALE: The pulmonic area is best heard at the second intercostal space, just left of the sternum. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA septic client with hypotension is being treated with dopamine hydrochloride (Inotropin). The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine hydrochloride in 250 ml, the infusion pump is running at 23 ml/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving?7.71RATIONALE: First, calculate how many micrograms per milliliter of dopamine hydrochloride are in the bag: 400 mg/250 ml = 1.6 mg/ml Next, convert milligrams to micrograms: 1.6 mg/ml x 1,000 mcg/mg = 1,600 mcg/ml Lastly, calculate the dose: 1,600 mcg/ml x 23 ml/hour/79.5 kg 79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client with deep vein thrombosis has an I.V. infusion of heparin sodium infusing at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters of solution should the nurse document as intake from this infusion for an 8-hour shift?240RATIONALE: First, calculate how many units are in each milliliter of the medication: 25,000 units/500 ml = 50 units/ml Next, calculate how many milliliters the client receives each hour: 1 ml/50 units x 1,500 units/hour = 30 ml/hour Lastly, multiply by 8 hours: 30 ml/hour x 8 hours = 240 ml NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse suspects that her client is in cardiac arrest. According to the American Heart Association, the nurse should perform the actions listed below. Order these actions in the sequence that the nurse should perform them. 1. Activate the emergency medical system. 2. Assess responsiveness. 3. Call for a defibrillator. 4. Provide two slow breaths. 5. Assess pulse. 6. Assess breathing.213645RATIONALE: According to the American Heart Association, the nurse should first assess responsiveness. If the client is unresponsive, the nurse should activate the emergency medical system, and then call for a defibrillator. Next, the nurse should assess breathing by opening the airway and then looking, listening, and feeling for respirations. If respirations aren't present, the nurse should administer two slow breaths, then assess the pulse. If no pulse is present, the nurse should start chest compressions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationAn adult client with Hodgkin's disease who weighs 143 lb is to receive vincristine (Oncovin) 25 mcg/kg I.V. What is the correct dose in micrograms that the client should receive?1625RATIONALE: First, convert the client's weight from pounds to kilograms: 1 lb = 2.2 kg; 143 lb = X kg 143 lb/2.2 kg = 65 kg. Next, multiply the weight in kilograms by the number of micrograms desired per kilogram: 65 kg x 25 mcg = 1,625 mcg NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply:

Avoid people who have recently received attenuated vaccines.Avoid activities that may cause bleeding.Wash hands frequently.Increase intake of fresh fruits and vegetables.Avoid crowded places such as shopping malls.Treat a sore throat with over-the-counter products.

RATIONALE: Chemotherapy can cause myelosuppression, which is reduced numbers of red blood cells, white blood cells, and platelets. A client receiving chemotherapy needs to avoid people who have been vaccinated recently because an exaggerated reaction may occur. Because platelet counts are reduced, the client also needs to avoid activities that could cause trauma and bleeding. The client should wash her hands frequently because hand washing is the best way to prevent the spread of infection. A client receiving chemotherapy should avoid crowded places, as well as people with colds during the flu season because she has a reduced ability to fight infection. Fresh fruits and vegetables should be avoided because they can harbor bacteria that can't be removed easily by washing. Signs and symptoms of infection, such as a sore throat, fever, and a cough, should be reported immediately to the physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is reviewing the causes of gastroesophageal reflux disease (GERD) with a client. What area of the GI tract should the nurse identify as the cause of reduced pressure associated with GERD?RATIONALE: Normally, there is enough pressure around the lower esophageal sphincter (LES) to close it. Reflux occurs when LES pressure is deficient or when pressure in the stomach exceeds LES pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is being treated for hypothyroidism. The nurse knows that thyroid replacement therapy has been inadequate when she notes which findings? Select all that apply:

Prolonged QT interval on electrocardiogramTachycardiaLow body temperatureNervousnessBradycardiaDry mouth

RATIONALE: In hypothyroidism, the body is in a hypometabolic state. Therefore, a prolonged QT interval with bradycardia and subnormal body temperature would indicate that replacement therapy was inadequate. Tachycardia, nervousness, and dry mouth are symptoms of an excessive level of thyroid hormone; these findings would indicate that the client has received an excessive dose of thyroid hormone. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA client is experiencing problems with balance, as well as fine and gross motor function. Which area of the brain is malfunctioning?RATIONALE: The cerebellum is the portion of the brain that controls balance and fine and gross motor function. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? Select all that apply:

Trousseau's signCardiac arrhythmias

ConstipationDecreased clotting timeDrowsiness and lethargyFractures

RATIONALE: Hypocalcemia is a calcium deficit that causes nerve fiber irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is performing a head and neck assessment on a client who reports fatigue. Identify the area that the nurse palpates to assess the occipital lymph nodes of the head.RATIONALE: Using the pads of the fingers, the nurse bilaterally palpates the area behind the ears to assess the occipital lymph nodes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationAfter assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?

Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact)Parents' active participation in child's physical or emotional careParents' failure to use available support systems or agencies to assist in copingEvidence of adaptation to parental role changes

RATIONALE: A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisAn 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?

Ask the parents not to visit the child until he has adjusted to the new environment.Ask the physician to explain to the child why he needs to stay in the health care facility.Explain to the child that he must act like an adult while he's in the facility.Have the parents stay with the child and participate in his care.

RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 13 year old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:

send the child home to recover.inspect the child for uneven shoulder height or uneven hip height.arrange for the child to have spinal X-rays as soon as possible.ask the child's parent to take him to a physician immediately.

RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report:

pain at the injection site.generalized urticaria.mild temperature elevation.local swelling at the injection site.

RATIONALE: Generalized urticaria can herald the onset of a life-threatening episode and medical assistance should be sought immediately. A child may experience some pain, redness at the sight, mild temperature elevation, or localized swelling. These reactions can be treated symptomatically and aren't life-threatening. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action wouldn't be appropriate for the nurse to take?

Helping the child and family obtain necessary equipment, supplies, and medicationPointing out to the parents ways in which they might have done things differentlyProviding referrals to local community agencies and the Cystic Fibrosis FoundationEncouraging the parents to allow their child to follow as normal a childhood as possible

RATIONALE: The nurse should avoid being critical when talking with parents about how they have handled their child's disease or condition. The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support. Providing referrals to local community agencies and the Cystic Fibrosis Foundation is also an appropriate intervention. The child should be treated as much like a normal child as possible. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who was involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

reintroduce the tube and attach it to water seal drainage.call the physician and obtain a chest tray.cover the opening with petroleum gauze.clean the wound with povidone-iodine and apply a gauze dressing.

RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is providing cardiopulmonary resuscitation (CPR) to a child age 4. The nurse should:

compress the sternum with both hands at a depth of 1r" to 2" (4 to 5 cm).

deliver 12 breaths/minute.perform only two-person CPR.use the heel of one hand for sternal compressions.

RATIONALE: The nurse should use the heel of one hand and compress 1" to 1r". The nurse should use the heels of both hands clasped together and compress the sternum 1r" to 2" for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeA mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by:

decreasing respiratory tract edema.lowering anxiety.drying secretions.increasing fluid intake.

RATIONALE: The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them and it doesn't increase the child's fluid intake. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAn otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:

cerebral edema.dehydration.heart failure.hypovolemic shock.

RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:

"Yes, you should have a Pap test after the onset of menstruation.""No, you aren't sexually active.""Yes, you're 16 years old.""No, you aren't 21 years old."

RATIONALE: A 16-year-old female client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:

"This is very abnormal, your child must be sick.""Let's see about further developmental testing.""Don't worry, this is normal for her age.""Maybe you just haven't seen her do it."

RATIONALE: At age 12 months, a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options A and D aren't therapeutic and can cut off communication with the mother. Option C misleads the mother with false reassurance. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisAn emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:

slapping, kicking, and punching others.poor hygiene and weight loss.loud crying and screaming.pulling hair and hitting.

RATIONALE: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, punching, pulling hair, and hitting are examples of forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old child. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?

"I told my husband to give my son aspirin for his fever.""I'll ask the physician about giving the baby an immunization shot.""I don't have to worry because I've had the measles.""I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son."

RATIONALE: Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until age 12 to 15 months. Measles is rubeola and won't provide immunity for rubella. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ComprehensionThe nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1r"22G, 1"20G, 1r"20G, 1"

RATIONALE: The nurse should first evaluate the muscle mass and amount of subcutaneous fat and then select the correct size needle. Without more information, the nurse would select the 22G, 1" needle, appropriate for an average-sized school-age child. The 20G, 1" needle would be unnecessarily large. The 22G, 1r" needle would be too long. The 20G, 1r" needle

would be too long and unnecessarily large. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:

resolve conflict with parents.develop an identity and independence.develop trust.plan for the future.

RATIONALE: The adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures along with development. Adolescents rarely finalize plans for the future; this usually happens later in adulthood. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhat's the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums?

Move the toddler to a different setting.Allow the toddler more choices.Ignore the behavior when it happens.Give in to the toddler's demands.

RATIONALE: Ignore tantrum behavior because attention to the behavior can reinforce the undesirable behavior. Changing settings can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. It's ill-advised to give in to the toddler's demands because doing so only promotes tantrum behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:

developmental readiness of the child.consistency in approach.the mother's positive attitude.developmental level of the child's peers.

RATIONALE: If the child isn't developmentally ready, the child and parent will become frustrated. Consistency is important when toilet training is started. The mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response?

Let the child know that he'll be punished for lying.Ask him why he isn't telling the truth.It's probably due to his vivid imagination and creativity.Acknowledge him by saying, "That's a pretend story."

RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Imagination and creativity need to be acknowledged. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA mother is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?

6 months4 months8 months10 months

RATIONALE: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. At 4 to 6 months of age, children can't sit securely alone. At 8 months of age, children can sit securely alone but can't understand the permanence of objects. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is assessing whether the client has received all recommended immunizations for his age. Which immunizations should he have received between ages 4 and 6?

Hepatitis AMeasles, mumps, and rubella (MMR)Haemophilus influenzae BDiphtheria, pertussis, and tetanus (DPT), MMR, and oral poliovirus (OPV)

RATIONALE: Between ages 4 and 6, the child should receive DPT, MMR, and OPV. Hepatitis A isn't a required immunization. MMR alone is incomplete. H. influenzae B immunization is completed by age 15 months. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake?

Allow the child to feed herself.Use specially designed dishes for children - for example, a plate with the child's favorite cartoon character.Only serve the child's favorite foods.Allow the child to eat at a small table and chair by herself.

RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with:

diabetes.leukemia.asthma.cystic fibrosis.

RATIONALE: Leukemia causes immunosuppression, so inactivated - rather than live - viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they

aren't immunosuppressed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should:

perform chest physiotherapy every 4 hours.give pancreatic enzymes as ordered.place the child in an oxygen tent and have oxygen administered continuously.serve a high-calorie diet.

RATIONALE: Chest physiotherapy aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients - not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition related to impaired physical mobility. Which of the following is most likely to occur with this condition?

Decreased protein catabolismIncreased calorie intakeIncreased digestive enzymesIncreased carbohydrate need

RATIONALE: Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased - not decreased - protein catabolism is present. Decreased appetite - not increased - is a problem. Digestive enzymes are decreased - not increased. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have:

dysuria and urine retention.perineal ulcers and erosions.bilateral inguinal lymphadenopathy.burning or tingling on vulva, perineum, or vagina.

RATIONALE: Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeA 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:

a barking cough.a high fever.sudden onset.dysphagia.

RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low-grade. Croup has a gradual onset, and dysphagia isn't a symptom. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeA 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to:

expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible.ask the mother to wait briefly outside until the assessment is over.tell the child the nurse is going to listen to his chest with the stethoscope.allow the child to handle the stethoscope before listening to his lungs.

RATIONALE: Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should expose only one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?" NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 2-year-old child is brought to the emergency department with suspected croup. Which of the following assessment findings reflects increasing respiratory distress?

Intercostal retractionsBradycardiaDecreased level of consciousnessFlushed skin

RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAn emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is:

albuterol (Ventolin).metaproterenol (Alupent).racepinephrine.ipratropium (Atrovent).

RATIONALE: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta2-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for:

respiratory distress.profound tachycardia.signs of improved oxygenation.diminished cyanosis.

RATIONALE: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisAn 8-month-old male is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of:

increased myelination.intracranial hypotension.cerebral hyperemia.a slightly thicker cranium.

RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension - not hypotension - places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include:

a depressed fontanel.slurred speech.tachycardia.an altered level of consciousness.

RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child can't speak at this age, but a change in cry may be noted. Bradycardia - not tachycardia - is a sign of increased ICP. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for:

cerebrospinal fluid otorrhea.deafness.raccoon eyes.Battle's sign.

RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull - frontal, ethmoid, sphenoid, temporal, or occipital. Otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Raccoon eyes and Battle's sign occur primarily in orbital fractures. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect:

subdural hematoma.epidural hematoma.subarachnoid hemorrhage.concussion.

RATIONALE: An initial loss of consciousness followed by transient consciousness leading to unconsciousness is caused by epidural hematoma. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. Concussion may result in a brief loss of consciousness. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA visibly upset mother carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:

take the infant from the mother and offer to help.take the infant and mother to a treatment room.call the resuscitation team and the supervisor.call security and the hospital administration.

RATIONALE: Taking the infant and mother into a treatment room for assessment provides privacy and a controlled environment. The mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisWhile assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should:

attempt rescue breaths.attempt to reposition the airway a third time.administer five back blows.attempt to ventilate with a handheld resuscitation bag.

RATIONALE: The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds that he still isn't breathing and that he has no pulse. The nurse should then:

resume CPR beginning with breaths.declare her efforts futile.resume CPR beginning with chest compressions.call for assistance.

RATIONALE: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA neonate arrives at the emergency department in full cardiopulmonary arrest. Resuscitation efforts fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which of the following is true regarding the etiology of SIDS?

It occurs in suspected child abuse cases.It occurs primarily in neonates with congenital lung problems.

It occurs primarily in black neonates.It occurs more commonly in neonates who sleep in the prone position.

RATIONALE: SIDS occurs in seemingly healthy neonates. However, more neonates who sleep in the prone position are affected. Because of the pooling of blood that occurs in the child with SIDS, child abuse is sometimes suspected. No correlation to race or lung disease exists. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is providing care for a mother whose child has died. The mother tells the nurse that she's angry with God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate?

Ineffective copingSpiritual distressPowerlessnessIneffective denial

RATIONALE: The mother's expression of anger toward God is an indication of spiritual distress. Expressions of anger are a normal part of the grieving process and don't indicate ineffective coping. Although the mother may indeed be experiencing feelings of powerlessness, this isn't the most accurate diagnosis of her feelings as indicated by the assessment data. There's no evidence of denial on the mother's part. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA 2-year-old client is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should:

question the mother about the child's allergies.initiate standard precautions.evaluate the child's neurologic status.examine the child's throat and ears.

RATIONALE: These are signs of meningitis and the priority is to evaluate neurologic status. Petechiae aren't allergic reactions. Standard precautions should be used when there's the risk of contacting body fluids (contact precautions should be instituted for the client diagnosed with meningitis). Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:

express negativism.have reliable verbal responses to pain.have a good concept of danger.have little fear.

RATIONALE: Toddlers' increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain - they respond just as strongly to painless procedures as they do to painful ones. They have little concept of danger and have common fears. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds on to furniture when he walks. The nurse should ask the mother:

how long the child has been like this.if the child can walk without holding on to furniture.how the child's condition today differs from his normal condition.if the child always drools.

RATIONALE: Identify the chief complaint from how the child was previously behaving at home. Asking how long the child has been like this may be interpreted poorly by the caregiver. Focus on what the child can do - and not on what he can't do - to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncuffed tube because the:

vocal cords provide a natural seal.trachea is shorter.larynx is anterior and cephalad.cricoid cartilage is the narrowest part of the larynx.

RATIONALE: The cricoid cartilage in the toddler is the narrowest part of larynx and provides a natural seal. This keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. The trachea is shorter and the larynx is anterior and cephalad, but these aren't reasons to choose an uncuffed tube. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:

prepare the child by positive self-talk.establish a time limit to get ready for the procedure.hold and rock him and give him a security object.count and sing with the child.

RATIONALE: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; but the success of these tactics depends on the child. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?

Adolescents can't follow detailed instructions.Adolescents are worried about appearing different from their peers.Adolescents' fine motor coordination isn't sufficiently developed to administer treatments.Adolescents have a well-developed sense of self-identity.

RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents can follow detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a

sense of identity. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?

Severe sore throat, drooling, leaning forward to breatheLow-grade fever, stridor, barking coughPulmonary congestion, productive cough, feverSore throat, fever, general malaise

RATIONALE: A child with acute epiglottiditis appears acutely ill, and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, leaning forward with the neck hyperextended, high fever, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles are indicative of pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionWhen caring for a child with epiglottiditis, the nurse should first:

examine his throat.prepare him for tracheotomy.administer I.V. fluids.administer antibiotics.

RATIONALE: Acute epiglottiditis is an emergency situation that may require tracheotomy or endotracheal intubation. Inflammation of the epiglottis can cause the airway to swell so that it can't rise and totally obstructs the airway. Never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottiditis are present. This maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are a priority. After a patent airway is secured, antibiotics may be given to treat Haemophilus influenzae, a common cause of acute epiglottiditis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 4-month-old infant is brought to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that:

the baby will need to fast before the test.a sample of blood will be necessary.a low-sodium diet is necessary for 24 hours before the test.a low-intensity, painless electrical current is applied to the skin.

RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. After pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is taking a history from the parents of a child admitted with Reye's syndrome. Which illness would the nurse expect the parents to report their child having the previous week?

ChickenpoxBacterial meningitisStrep throatLyme disease

RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionA 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to:

place ice packs on the client's painful joints.administer antibiotics.provide oral and I.V. fluids.administer folic acid supplements.

RATIONALE: Priority care for the child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial. Daily supplements of folic acid will help counteract anemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA 2-year-old male is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The child's mother asks about treatment of the disease. The nurse's response should be based on which of the following facts?

He'll have a permanent colostomy; as he matures, he can learn the required care.He'll have a temporary colostomy; "pull-through" surgery will be done in the future.He'll require many reconstructive colostomy surgeries over a lifetime.He'll require chemotherapy and radiation to treat his disease.

RATIONALE: Repair of aganglionic megacolon requires dissection of the aganglionic segment and anastomosis with the unaffected intestine. It's usually done in a two-stage operation. The first surgery creates a colostomy to evacuate the bowel of stool and rest the distended portion of the bowel. The second surgery, done several months later, involves colostomy closure and a rectal "pull-through." The colostomy isn't permanent, and only a two-stage operation is required. Chemotherapy and radiation are never required for this condition. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe mother of a child with sickle cell anemia confides in the nurse that she feels guilty about letting the child run and play with the neighborhood children and that if she had been a better mother, the child wouldn't have suffered a sickle cell crisis. Which response would be most appropriate?

"She's just fine now; don't worry.""Tell me more about how you feel.""But you know that children with sickle cell anemia often have crises.""You shouldn't be so protective of her."

RATIONALE: Many parents feel guilty when their child is sick. Encouraging parents to talk more about their feelings provides support and helps to develop a therapeutic relationship. Giving a stock answer, such as "Don't worry," shows a lack of interest in what the parent is feeling. Commenting on the course of the disease doesn't address the parent's feelings. Being judgmental or offering an opinion can also block therapeutic communication by inhibiting the parent from discussing her feelings and developing solutions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media. Which statement by the parent indicates that teaching has been successful?

"I'll give the antibiotics for the full 10-day course of treatment.""I'll give the antibiotics until my child's ear pain is gone.""Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics.""If the ear pain is gone, there's no need to see the physician for another examination of the ears."

RATIONALE: Antibiotics must be given for the full course of therapy, even if the child feels well, otherwise the infection won't be eradicated. Antibiotics should be taken at prescribed intervals to maintain blood levels and not as needed for pain. A reexamination at the end of the course of antibiotics is necessary to confirm that the infection is resolved. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationWhen planning care for a 7-year-old boy with Down syndrome, the nurse should:

plan interventions at the developmental level of a 7-year-old child because that's the child's age.plan interventions at the developmental level of a 5-year-old child because the child will have developmental delays.assess the child's current developmental level and plan care accordingly.direct all teaching to the parents because the child can't understand.

RATIONALE: Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome, especially one with mild limitations, can learn. Gear teaching toward the appropriate developmental age. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA baby boy has just had surgery to repair his cleft lip. Which nursing intervention is the most important during the immediate postoperative period?

Clean the suture line carefully with a sterile solution after every feeding.Lay the infant on his abdomen to help drain fluids from his mouth.Allow the infant to cry to promote lung reexpansion.Give the baby a pacifier to suck for comfort.

RATIONALE: To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on his abdomen after a cleft lip repair will put pressure on the suture line, causing damage. The infant can be positioned on his side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the baby's needs, such as holding and cuddling him. Hard objects, such as pacifiers, should be kept away from the suture line because they can cause damage. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisSeveral children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should:

tell the children not to bite their fingernails.not let children share hairbrushes.tell the children to cover their mouths and noses when they cough or sneeze.have their children immunized.

RATIONALE: Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching. The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if the child chews on his nails, and the pinworm's life cycle continues. In addition to teaching children not to bite their fingernails, parents should keep the nails short and encourage hand washing before food preparation and eating. Sharing hairbrushes contributes to the spread of head lice, not pinworms. Although covering the mouth and nose are hygienic practices to reduce the spread of infections from respiratory droplets, doing so doesn't affect the spread of pinworms. There are no immunizations to protect against pinworms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA 4-year-old male is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention shouldn't be included in the nursing care plan?

Provide preoperative teaching to the child and his parents.Palpate the child's abdomen to monitor tumor growth.Assess vital signs and report hypertension.Monitor urine for hematuria.

RATIONALE: The abdomen of a child with Wilms' tumor should never be palpated because it may increase the risk of metastasis. All children and their parents require preoperative teaching when surgery is planned. The child with Wilms' tumor may be hypertensive as a result of excessive renin production and may have hematuria. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA neonate undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively?

Ineffective airway clearanceImbalanced nutrition: Less than body requirementsInterrupted breast-feedingHypothermia

RATIONALE: Ineffective airway clearance is the priority nursing diagnosis in the immediate postoperative period. The neonate's airway must be carefully assessed, and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. Assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. Imbalanced nutrition, interrupted breast-feeding, and hypothermia are also important during the postoperative period but only after a patent airway is assured. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse practicing in a nurse-managed clinic suspects that an 8-year-old client's chronic sinusitis and upper respiratory infections may be due to allergies. She orders an immunoglobulin assay. Which of the following would the nurse expect to find elevated?

Immunoglobulin (Ig) EIgDIgGIgM

RATIONALE: IgE is predominantly found in saliva and tears as well as intestinal and bronchial secretions. Increased levels of IgE may be found in allergic disorders. The physiological function of IgD is unknown and constitutes only 1% of the total number of circulating immunoglobulins. IgG is

elevated in the presence of viral and bacterial infections. IgM is the first antibody activated after an antigen enters the body and is especially effective against gram-negative organisms. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that:

these students are too young to screen; instead, older students should be screened.these students are too old to screen and will no longer benefit from screening for scoliosis.scoliosis screening requires sophisticated equipment and can't be done in school.this is an appropriate request and arrangements will be made as soon as possible.

RATIONALE: Screening for scoliosis should begin at age 10 and be performed yearly until at least age 16. Screening for scoliosis involves inspection of the spine and use of a scoliometer, both of which can be done in a school setting. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationAt what age should boys be taught how to do a monthly testicular self-examination?

Age 8Age 12Age 16When they become sexually active

RATIONALE: Testicular cancer typically occurs between ages 15 and 40; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA mother brings to the clinic her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

barely visible outside the tonsillar pillar.halfway between the tonsillar pillar and the uvula.touching the uvula.touching each other.

RATIONALE: Tonsils that touch the uvula are 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are given a 4+ rating. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe mother of a 16-year-old girl calls the emergency department, suspecting her daughter's abdominal pain may be appendicitis. In addition to pain, her daughter has a fever of 100% F (37.8% C) and has vomited twice. What should the nurse tell the mother?

Give the daughter a laxative to rule out the possibility that constipation is causing the pain.Gently press on the left lower quadrant of her daughter's abdomen to test for rebound tenderness.It's most likely the flu because her daughter is too young to have appendicitis.Immediately bring her daughter into the emergency department before the appendix has a chance to rupture.

RATIONALE: Abdominal pain, low-grade fever, and vomiting are cardinal signs of appendicitis. Administration of a laxative during appendicitis is dangerous because it may cause the appendix to rupture. Rebound tenderness is also a symptom but would be found in the right lower quadrant. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA child is sent to the school nurse because, according to his teacher, he's constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did she probably see?

Flaking of the scalp with pink, irritated skin exposedSmall white spots that adhere to the hair shaft, close to the scalpScaly, circumscribed patches on the scalp, with mild alopecia in these areasMultiple tiny pustules on the scalp with no abnormal findings on the hair shafts

RATIONALE: The small white spots that adhere to the hair shafts are the eggs, or nits, of lice. These are easy to see and can't be brushed off like dandruff. Flaking of the scalp may indicate dandruff or a dry scalp. Scaly patches and pustules, due to the scratching, may accompany a lice infestation, but nits would also be found on the hair shafts. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is calculating the proper dosage of medication for a child. What parameters should this calculation be based on?

AgeBody weightDevelopmental stage in relation to ageBody surface area in relation to weight

RATIONALE: Body surface area in relation to weight is the most reliable method for estimating proper medication dosage for a child. Body surface area is more accurate for dosage calculation than height or weight alone because height and weight vary widely. Developmental stage doesn't enter into dosage calculation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is conducting a well-baby examination of a 4-month-old. During the examination, the nurse shouldn't be able to elicit which reflex?

SteppingMoroPlantar graspPalmar grasp

RATIONALE: The stepping reflex is present only until age 3 months so it shouldn't be present in a 4-month-old. The Moro reflex is present until approximately age 5 months. The plantar grasp reflex is present until approximately age 9 months. The palmar grasp is present until age 3 or 4 months. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?

"It's common for a child to exhibit regressive behavior when anxious or stressed.""Your child is probably angry about being hospitalized. This is her way of acting out.""Don't worry. It's common for a 3-year-old child to not be fully toilet-trained.""The nurses probably haven't been answering the call light soon enough. They will try to respond more quickly."

RATIONALE: Young children commonly demonstrate regressive behavior when anxious, under stress, or in a strange environment. Although the child could be deliberately wetting the bed out of anger, her behavior is most likely not under voluntary control. It's appropriate to expect a 3-year-old child to be toilet-trained, but it isn't appropriate to expect that child to be able to utilize a call light to summon the nurse. NURSING PROCESS STEP:

Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 15-year-old girl visits the neighborhood clinic seeking information on how to keep from becoming pregnant. What should the nurse say in response to her request?

"What would you like to know?""Let's discuss what your friends are doing to keep from getting pregnant.""Can you tell me if you've told your parents you're having sex?""Can you tell me about the precautions you're taking now?"

RATIONALE: An attitude that requests only the information the girl is willing to give is nonthreatening and nonjudgmental. This may enhance the girl's willingness to talk about her experiences, thus enabling the nurse to better assess her needs. The first response assumes the girl knows what she needs to know. The precautions her friends are taking are irrelevant at this time. Reference to the girl's parents may make her defensive and fearful of help. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 10-year-old girl visits the clinic for a checkup before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is most appropriate?

"Her physical development will be rapid at this stage, and rapid development will continue from now on.""She'll become more independent and won't require parental supervision.""Don't anticipate any changes at this stage in her growth and development.""Friends will be very important to her, and she'll develop an interest in the opposite sex."

RATIONALE: Friends become very important at this age. Children usually begin having an interest in the opposite sex around this age, although they aren't always willing to admit it. Her physical development towards maturity continues, but it isn't as rapid at this stage as in previous years. Although independence increases at this stage, children continue to need parental supervision. Growth and development slow down, but gradual changes continue to occur. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first?

Apply a warm compress to the injured shoulder.Ask him to demonstrate full range of motion of his left arm.Keep him in a comfortable position, and apply ice to the injured shoulder.Give him a nonnarcotic analgesic for pain.

RATIONALE: Ice would be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. Warm compresses may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA 14-year-old client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the last 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what would the nurse suspect?

AppendicitisPancreatitisCholecystitisConstipation

RATIONALE: Right lower quadrant pain, rebound tenderness, nausea, vomiting, a positive psoas sign, and a low-grade fever are findings consistent with acute appendicitis. The other disorders may mimic appendicitis; however, the pain of pancreatitis is usually localized in the left upper quadrant. Cholecystitis is associated with right upper quadrant pain. Constipation wouldn't cause a fever. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is giving instructions to parents of a child diagnosed with sickle cell disease. The instructions should include which of the following?

Apply cold to affected areas to reduce the child's discomfort.Restrict the child's fluids during crisis situations.Avoid areas of low oxygen concentration such as high altitudes.Encourage the child to exercise to reduce the likelihood of crisis.

RATIONALE: The child should avoid areas of low oxygen, such as high altitudes, because they may precipitate sickle cell crisis. Applying warm compresses will reduce discomfort to the affected area; cold compresses, however, may add to discomfort by impairing circulation. The child should be encouraged to drink fluids to rehydrate cells. Strenuous exercise may induce sickle cell crisis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe nurse is speaking to grieving parents after a sudden infant death syndrome (SIDS) death. What should the nurse emphasize to the parents?

The death couldn't have been prevented and isn't the parents' fault.The parents must allow an autopsy to confirm the diagnosis.The parents are still young and can have more children.The parents should place other infants on their backs to sleep.

RATIONALE: The nurse can best help the parents by countering the false belief that the death is their fault or that they could have prevented it. Informing the parents that an autopsy needs to be performed is a secondary concern. Stressing that they're still young and can have more children minimizes their feelings of grief. Instructing the parents to place other infants on their backs to sleep implies that the parents did something to cause the death. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is teaching accident prevention to the parents of a toddler. Which of the following is appropriate for the nurse to tell the parents?

The toddler should wear a helmet when rollerblading.Place locks on cabinets containing toxic substances.Teach the toddler water safety.Don't allow the toddler to use pillows when sleeping.

RATIONALE: All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age group. Rollerblading isn't an appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. (Note that rollerblading and teaching water safety are appropriate for school-age children). Pillows shouldn't be placed in the crib of an infant, to avoid suffocation; however, toddlers may use them. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

An obese 14-year-old girl states that she wants to lose weight. Besides her dietary intake and physical activity, which of the following would be the most important to assess?

Her metabolic rateWho prepares the mealsHow food is used in her homeHer educational interests

RATIONALE: Food habits and eating behaviors are largely related to cultural patterns and family preferences. Although the client's metabolic rate and educational interests might be useful in motivation, they don't add to the dietary history. Rather than assessing who prepares the meals, it would be better to assess the complete nutritional environment, including such factors as the school cafeteria. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching the parents of a 5-year-old child how to respond in case of poisoning. If poisoning occurs, what should the parents' first response be?

Administer syrup of ipecac.Call the poison control center.Take the child to the physician's office.Monitor the child for adverse effects.

RATIONALE: If parents believe that their child has ingested a poison, they should first call the poison control center. The poison control center will tell the parents whether to administer syrup of ipecac. If the child ingests a caustic or corrosive material, administering syrup of ipecac isn't appropriate. The parents should call the poison control center before transporting the child to a physician. The poison control center may recommend monitoring the child for adverse effects, but parents shouldn't make this decision on their own. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is assessing a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect?

Reddish-colored skinEdematous lipsHypertensionLower abdominal pain

RATIONALE: The child who has ingested a caustic poison, such as lye (found in toilet bowl cleaners), may develop edema, ulcers of the lips and mouth, pain in the mouth and throat, excessive salivation, dysphagia, and burns of the mouth, lips, esophagus, and stomach. Bleeding from burns in the GI tract can lead to pallor, hypotension, tachypnea, and tachycardia. Reddish-colored skin, hypertension, and lower abdominal pain don't commonly occur in caustic poisoning. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionA child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's mother tells the nurse she feels guilty. What should the nurse say to the mother?

"You shouldn't feel guilty. You didn't know their cleaners weren't locked up.""Don't worry. She's going to be fine.""Why didn't you watch your child more closely?""Tell me about your guilty feelings."

RATIONALE: Asking the mother about her feelings of guilt acknowledges those feelings and demonstrates the nurse's willingness to listen. Telling the mother that she shouldn't feel guilty dismisses her feelings and discourages further discussion. Giving false reassurances sends the message that the nurse isn't really interested in the mother's feelings. Asking the mother why she didn't watch her child more closely will make her feel defensive. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse administers an I.M. injection. Afterward, the nurse should:

recap the needle and discard it in any medical waste container.recap the needle and discard it in a puncture-proof container.discard the uncapped needle in a puncture-proof container.break the needle and discard the needle and syringe in any medical waste container.

RATIONALE: Discarding uncapped needles in a puncture-proof, leakproof container is the appropriate procedure. To reduce the risk of accidental needle sticks, the nurse should never recap a needle. A used needle should never be placed in a garbage can or medical waste container that isn't puncture-proof and leakproof. A needle should never be broken or bent before it's discarded because this increases the risk of a needle stick. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationThe nurse is teaching about proper nutrition to the parents of a child with cystic fibrosis. Which of the following instructions should the nurse include?

Encourage a high-calorie, high-protein diet.Restrict fluids to 1,500 ml per day.Limit salt intake to 2 g per day.Encourage foods high in vitamin B.

RATIONALE: The child should eat a high-calorie, high-protein diet. In cystic fibrosis, the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged. Without these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. Because fats aren't easily tolerated, they may need to be restricted. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are necessary. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her?

"The baby's eustachian tubes are shorter and lie more horizontally.""The baby is too young to blow his nose when he has a cold.""The baby spends more time lying down than his older brother; therefore, more dirt gets in the baby's ear.""The baby puts dirty toys in his mouth."

RATIONALE: Infants and young children are more prone to otitis media because their eustachian tubes are shorter and lie more horizontally. Pathogens from the nasopharynx can more readily enter the eustachian tube of the middle ear. The inability to clear nasal passages by blowing the nose, lying down on the floor, and putting dirty toys in the mouth don't increase the tendency toward otitis media. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is developing a plan to teach a mother how to reduce her baby's risk of developing otitis media. Which of the following directions should the nurse include in the teaching plan?

Administer antibiotics whenever the baby has a cold.Place the baby in an upright position when giving a bottle.

Avoid getting the ears wet while bathing or swimming.Clean the external ear canal daily.

RATIONALE: Feeding a baby in an upright position reduces the pooling of formula in the nasopharynx. Formula provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. The other interventions don't reduce the risk of a baby developing otitis media. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a 10-year-old child with rheumatic fever. While obtaining the child's health history from the mother, the nurse should ask if the child recently had which illness?

Strep throatInfluenzaChickenpoxMononucleosis

RATIONALE: Rheumatic fever typically follows an infection with group A beta-hemolytic streptococcus, as in strep throat, impetigo, scarlet fever, or pharyngitis. Influenza, chickenpox, and mononucleosis are caused by viruses and don't lead to rheumatic fever. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionThe nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan?

Playing ping-pongReading booksClimbing on play equipment in the playroomUnrestricted ambulation

RATIONALE: During the acute phase of rheumatic fever, the child should be placed on bed rest to reduce the heart's workload and prevent heart failure. An appropriate activity for this child would be reading books. The other activities are too strenuous during the acute phase. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

To obtain a heart rate that isn't affected by medicationTo eliminate interference from the jerky movements of choreaTo ensure that the child can't consciously raise or lower the heart rateTo compensate for the effects of activity on the heart rate

RATIONALE: Tachycardia may be a sign of heart failure. Mild tachycardia is more easily detected during sleep than during the day when activity can cause an increase in heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin, exert their influence day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. However, it doesn't affect pulse because the child would be sitting quietly and not involved in purposeful movement. A ten-year-old child is unlikely to be able to consciously raise or lower his heart rate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?

Performing gentle passive range-of-motion (ROM) exercisesGently massaging the painful jointsUsing a bed cradle to keep linens off the jointsEncouraging position changes in bed every 2 hours

RATIONALE: 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 ROM 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. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationThe nurse is preparing to discharge a child who has rheumatic fever. Which of the following medications is prescribed to prevent recurrence of rheumatic fever?

GlucocorticoidsDigoxinAntibioticsAnti-inflammatory medications

RATIONALE: Because the child with rheumatic fever is at risk for a recurrence, especially if the condition is complicated by carditis, long-term antibiotic therapy is necessary into adulthood, maybe even for life. Digoxin may be prescribed to treat heart failure, but it doesn't prevent the recurrence of rheumatic fever. Corticosteroids and anti-inflammatory medications reduce inflammation in rheumatic fever but won't prevent a recurrence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionAn 18-month-old male child is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child?

A concave abdomenBulges in the groin areaA protuberant abdomenA palpable abdominal mass

RATIONALE: A child with celiac disease has a protuberant abdomen due to the presence of fat, bulky stools, undigested food, and flatus. A concave abdomen, bulges in the groin area, and a palpable abdominal mass aren't associated with celiac disease. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother would indicate understanding?

"My son can't eat wheat, rye, oats, or barley.""My son needs a diet rich in gluten.""My son must avoid potatoes, rice, flour, and cornstarch.""My son can safely eat frozen and packaged foods."

RATIONALE: A child with celiac disease must eat a gluten-free diet. If foods containing gluten are eaten, changes occur in the intestinal mucosa that prevent the absorption of foods, especially fats. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, flour, and cornstarch are allowed in a gluten-free diet. Frozen and packaged foods may contain gluten fillers; therefore, they should be avoided. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionThe nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?

Monitor vital signs every 4 hours.Monitor the appearance, size, and number of stools.Measure blood urea nitrogen (BUN) and serum creatinine levels.Measure intake and output.

RATIONALE: When a child with celiac disease is placed on a gluten-free diet, fat, bulky, foul-smelling stools should be eliminated. This indicates that the disease is controlled and the child is utilizing nutrients effectively. Taking vital signs, measuring BUN and serum creatinine levels, and measuring intake and output don't provide an indication of the effectiveness of diet therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA 15-year-old girl with bulimia nervosa complains to the nurse that all the other girls on the ward are nerds. What's the best action for the nurse to take?

Explain how the client's attitude affects the other girls.Sit her down and ask her why she doesn't like the other girls.Include boys and girls in her age-group when planning activities.Help her select activities that include the nurse and other teenagers.

RATIONALE: Having her participate in activity selection gives her some control over her life while in the hospital. Clients with an eating disorder have difficulty with issues of control, so an opportunity to participate in the therapeutic program helps. Explaining how her attitude affects the other girls and asking her why she doesn't like the other girls may provoke a defensive response by the client. Including boys and girls in her age-group when planning activities isn't as therapeutic as allowing her to help choose activities. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe school nurse is examining a student at an elementary school. Which of the following findings would lead the nurse to suspect impetigo?

Small, red lesions on the trunk and in the skin foldsA discrete pink-red maculopapular rash that starts on the head and progresses down the bodyRed spots with a blue base found on the buccal membranesVesicular lesions that ooze, forming crusts on the face and extremities

RATIONALE: Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most often on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik's spots, are characteristic of measles (rubeola). NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:

teach children to cover mouths and noses when they sneeze.have their children immunized against impetigo.teach children the importance of proper hand washing.isolate the child with impetigo from other members of the family.

RATIONALE: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing won't prevent its spread. Currently, there's no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo is unnecessary. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA 2-month-old baby hasn't received any immunizations. Which immunizations should the nurse prepare to administer?

Measles, mumps, rubella (MMR); diphtheria, tetanus, pertussis (DTP); and Hepatitis B (HepB)Polio (IPV); DTP; and MMRVaricella; Haemophilus influenzae B (HIB); IPV; and DTPHIB, DTP, HepB, and IPV

RATIONALE: The current immunizations recommended for a 2-month-old who hasn't received any immunizations are HIB, DTP, HepB, and IPV. The first immunizations for MMR and varicella are recommended when a child is 12 months old. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following instructions should the nurse emphasize in her talk?

Stay out of the sun between 1 p.m. and 3 p.m.Tanning booths are a safe alternative for those who wish to tan.Sun exposure is safe, provided the client wears protective clothing.Examine skin once per month, looking for suspicious lesions or changes in moles.

RATIONALE: To detect skin cancer in its early stages, the nurse should emphasize the importance of monthly skin self-examinations and yearly examinations by a physician. To reduce the risk of skin cancer, the nurse should teach clients to avoid the sun's ultraviolet rays between 10 a.m. and 3 p.m. Repeated exposure to artificial sources of ultraviolet radiation, such as tanning booths, increases the risk of skin cancer. Although protective clothing offers some protection, some of the sun's harmful rays can penetrate clothing. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is caring for a 2r-year-old male client with tetralogy of Fallot. Which assessment findings should the nurse expect?

Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophyPulmonary artery stenosis, intraventricular septal defect, overriding aorta, right ventricular hypertrophyPulmonary artery stenosis, patent ductus arteriosus, overriding aorta, right ventricular hypertrophyTransposition of the great vessels, intraventricular septal defect, right ventricular hypertrophy, patent ductus arteriosus

RATIONALE: Tetralogy of Fallot consists of four congenital anomalies: pulmonary artery stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. The other combinations of defects aren't characteristic of tetralogy of Fallot. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is caring for a young child with tetralogy of Fallot. The child is upset and crying. The nurse observes that he's dyspneic and cyanotic. Which position would help relieve the child's dyspnea and cyanosis?

Sitting in bed with the head of the bed at a 45-degree angleSquatting positionLying flat in bedLying on his right side

RATIONALE: Placing the child in a squatting position sequesters a large amount of blood to the legs, reducing venous return. The other positions don't reduce venous return; therefore, they won't relieve the child's dyspnea and cyanosis. Note that a child with tetralogy of Fallot may also assume a

knee-chest position to reduce venous return to the heart. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is caring for a child with tetralogy of Fallot. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate?

The child is depressed.The child is in pain.The child wants attention.The child is responding to stress.

RATIONALE: Regression (reverting back to previously outgrown behaviors) is a common response to stressful situations. The nurse should reassure the parents that thumb sucking and other regressive behaviors should disappear when the stressful situation is resolved. Thumb sucking isn't a sign of depression or pain nor is it an attention-seeking behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse observes a 2r-year-old client playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the client to engage in?

Associative playParallel playCooperative playTherapeutic play

RATIONALE: Two-year-old children engage in parallel play, in which they play side by side but rarely interact. Preschoolers engage in associative play, in which they are all involved in a similar activity but there's little organization. School-age children engage in cooperative play, which is organized and goal directed. Therapeutic play is a technique that can be used to help understand a child's feelings. Therapeutic play consists of energy release, dramatic play, and creative play. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is interviewing the mother of a 7-year-old child. Which of the following symptoms reported by the mother would most lead the nurse to suspect that the child has type 1 diabetes?

Recent bed wettingPoor appetiteWeight gainBoundless energy

RATIONALE: Polyuria is a hallmark sign of type 1 diabetes mellitus. Parents often notice this symptom as bed wetting in a child previously toilet trained. Polyphagia is also a hallmark sign of type 1 diabetes mellitus. A parent is likely to report that a child eats excessively but seems to be losing weight. The child with type 1 diabetes mellitus may also complain of fatigue. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child?

HypercalcemiaHyperphosphatemiaHypokalemiaHypernatremia

RATIONALE: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. Calcium levels aren't directly affected by insulin administration. Hypophosphatemia, not hyperphosphatemia, may occur with insulin administration because phosphorus also enters the cells with insulin and potassium. Sodium levels aren't directly affected by insulin administration. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?

100 U of regular insulin in normal saline solution100 U of NPH insulin in normal saline solution100 U of regular insulin in dextrose 5% in water100 U of NPH insulin in dextrose 5% in water

RATIONALE: Only short-acting regular insulin is used in continuous insulin infusions. Insulin is added to normal saline solution and administered until blood glucose levels fall. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a male neonate who has hypospadias. His parents are planning to have the baby circumcised before discharge. When teaching the parents about their child's condition, the nurse should tell them:

the baby can still be circumcised as planned.the foreskin will be needed at the time of surgical correction.circumcision is necessary because the foreskin obstructs the urethral meatus.circumcision will correct the hypospadias.

RATIONALE: Circumcision is the surgical removal of the foreskin of the penis. In hypospadias, the urethral meatus is on the underside of the penis. A neonate with hypospadias shouldn't be circumcised because the surgeon may use the foreskin for surgical repair. The foreskin doesn't block the urethral meatus, which may be located near the glans, along the underside of the penis, or at the base. Circumcision doesn't correct hypospadias because the location of the urethral meatus isn't changed during circumcision. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?

"This is only a minor problem. Many other babies are born with worse defects.""Don't worry. After surgical repair you'll hardly remember there was anything wrong with your baby.""I'll ask the physician to explain to you how this defect occurs.""You seem upset. Tell me about it."

RATIONALE: By verbalizing observations of the client's behavior, the nurse acknowledges the client's feelings. By listening, the nurse can help the client understand her feelings and begin to deal with them. Telling the client that there are babies with worse defects doesn't acknowledge - and may even belittle - her feelings. Providing a stock answer, such as "Don't worry," shows a lack of interest in the client's feelings. Offering to ask the physician also doesn't address the client's feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

"The cast will be removed in 6 weeks.""A new cast is needed every 1 to 2 weeks.""A short leg cast is applied when the baby is ready to walk.""The cast will be removed when the baby begins to crawl."

RATIONALE: Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time a baby is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he's 1 year old. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a neonate with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the neonate with leg and ankle exercises and provide his parents with a home exercise regimen?

Occupational therapistPhysical therapistRecreational therapistSpeech therapist

RATIONALE: After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. An occupational therapist, who helps the chronically ill or disabled perform activities of daily living and adapt to limitations, isn't necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also isn't required. A speech therapist isn't necessary; clubfoot isn't accompanied by speech problems. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse in a well-child clinic is assessing children for scoliosis. Which of the following children is most at risk for scoliosis?

8-year-old boyTeenage boy6-year-old girl10-year-old girl

RATIONALE: The 10-year-old girl is most likely to have scoliosis. Scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis, but it's more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers syrup of ipecac followed by acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy?

Alanine aminotransferase and aspartate aminotransferaseCreatine kinase (CK)-MBBlood urea nitrogen (BUN) and serum creatinineComplete blood count

RATIONALE: Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. CK-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. BUN and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?

Always make the toddler wear a seat belt when riding in a car.Make sure medications are kept in containers with childproof safety caps.Never leave a toddler unattended on a bed.Teach rules of the road for bicycle safety.

RATIONALE: All over-the-counter and prescription medications should have childproof safety caps. Poisoning accidents are common in toddlers, due to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat. Wearing a seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb onto and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers shouldn't be allowed in the road unsupervised. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ComprehensionA neonate is assessed by the nursery nurse for congenital dislocated hip. Which of the following is the most reliable assessment for this condition?

Trendelenburg's testCurvature of the lower spineMacewen's signOrtolani's click

RATIONALE: Ortolani's click is a reliable sign of hip dislocation in the neonate. Trendelenburg's test is used to assess the valves of the leg veins. Curvature of the spine is more directly associated with scoliosis. Macewen's sign is a neurologic assessment for hydrocephalus. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?

The toddler stays neat while eating.The toddler finishes the meal within a specified period of time.The child lies down to rest after eating.The child eats finger foods by himself.

RATIONALE: The child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. Independence in eating should take precedence over neatness. The child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed to finish a meal by a specified time. The child with cerebral palsy may vomit after eating, due to a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

AutonomyInitiativeIndustryIdentity

RATIONALE: According to Erickson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she's separated from her peer group and her body image may be altered. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 3-year-old male comes to the ambulatory care clinic with his father for a routine visit. He has a runny nose and a cough. The father tells the nurse of a family history of asthma and eczema. What findings should the nurse assess for when auscultating the child's chest?

A prolonged inspiratory phase of the respiratory cycleA shortened expiratory phase of the respiratory cycleMarked inspiratory stridorRhonchi, especially on expiration, which is prolonged

RATIONALE: By history and symptomatology, the nurse would suspect that this child might have signs of bronchial asthma, which is manifested by bronchospasm and prolonged expiration. A child with this history and symptomatology would have a shortened inspiratory phase and prolonged expirations. Inspiratory stridor is more likely found in croup. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe mother of a 3-year-old boy calls the hospital to report that her child has ingested several acetaminophen (Tylenol) tablets. She has a poison kit with syrup of ipecac and activated charcoal at home. The family lives approximately 1 hour from the hospital. What should the nurse instruct the mother to do?

Administer 15 ml (r oz) of syrup of ipecac orally, followed by 4 to 8 oz (120 to 240 ml) of water to induce vomiting; then bring the child to the hospital.Administer 30 ml (1 oz) of syrup of ipecac orally, followed by 8 to 16 oz (240 to 480 ml) of fluid to induce vomiting; don't leave for the hospital until the child has vomited a large amount.Administer 10 g of activated charcoal, followed by 4 to 8 oz of milk to absorb the toxin; then bring the child to the hospital.Rush the child to the hospital immediately, where treatment will be started as soon as he arrives.

RATIONALE: The recommended dosage to induce vomiting and eliminate the poison from a 3-year-old is 15 ml of syrup of ipecac orally, followed by 4 to 8 oz of water (according to American Academy of Clinical Toxicology). Administering 30 ml of syrup of ipecac, followed by 8 to 16 oz of fluid, is excessive for a preschooler. Also, 90% of children vomit within 30 minutes of the appropriate dose of ipecac; waiting for vomiting to occur would delay stomach gavage and administration of the antidote. Activated charcoal shouldn't be given with milk products. Acetaminophen is rapidly absorbed from the GI tract, with peak levels at 1 to 2 hours after ingestion. Failure to evacuate the stomach contents increases the risk of organ damage and death. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA 2-year-old male is admitted for possible bacterial meningitis. Which of the following actions should the nurse take first?

Read the client's history and physical examination report.Assess the client's neurologic status.Interview the client's mother and father.Administer oxygen at 3 L/minute by nasal cannula.

RATIONALE: Acute meningitis can be a pediatric emergency. A diagnosis based on accurate assessments is a priority for correct treatment. A baseline neurologic assessment is needed for later comparisons. Reading the client's history and physical examination report and interviewing the client's parents don't take higher priority than assessing the client's neurologic status. No orders or data exist to warrant the administration of oxygen. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 10-year-old girl with sickle cell anemia has been admitted for vaso-occlusive crisis. Which of the following activities would be best for the client?

BowlingStringing beads on yarnSwimmingPainting

RATIONALE: During a vaso-occlusive crisis, the child needs to minimize oxygen consumption. Painting is the only quiet and age-appropriate activity. Bowling and swimming are too strenuous for a child in vaso-occlusive crisis. Stringing beads on yarn isn't an appropriate activity for a 10-year-old. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 10-year-old male with sickle cell anemia has been an active fifth grader with good grades. When reviewing the care plan, the nurse would expect to see which of the following medications prescribed to rebuild hemolyzed red blood cells (RBCs)?

Regular doses of folic acidProphylactic antibiotics to prevent cell damageDaily iron-fortified vitaminsHigh doses of vitamin C

RATIONALE: Folic acid helps rebuild RBCs without causing excessive levels of iron. Neither antibiotics nor vitamin C rebuild hemolyzed RBCs. Iron-fortified vitamins can cause the iron level to be too high. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 6-year-old child is immunosuppressed from human immunodeficiency virus (HIV) infection. The nurse should emphasize that the parents not allow their child to come in contact with:

a school-age child who has scoliosis.a 16-year-old who has just received a tetanus booster.a neonate who has just received an oral polio vaccine.a toddler who has eczema.

RATIONALE: The polio virus can be shed from the GI tract after administration of the oral vaccine. An immunosuppressed child should avoid contact with the virus, which is weakened but live. Scoliosis and eczema aren't contagious. The tetanus vaccine doesn't contain a live virus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA child with thalassemia major (Cooley anemia) is to receive a blood transfusion. Which of the following administration techniques represents safe nursing procedure?

Transfuse blood rapidly to complete the procedure as soon as possible.Discontinue the transfusion, and remove the I.V. needle if allergy symptoms develop.Slow the drip rate if allergy symptoms develop.Discontinue the transfusion but maintain the I.V. line if allergy symptoms develop.

RATIONALE: If allergy symptoms develop, the transfusion must be discontinued but the I.V. line should be maintained for administration of medications and fluids to counteract the allergic response. Blood shouldn't be transfused rapidly just to complete the transfusion as soon as possible. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisWhich of the following nursing diagnoses would be a priority for a child with iron-deficiency anemia?

Activity intolerance related to reduced oxygen-carrying capacity of bloodActivity intolerance related to iron-deficiency anemiaIneffective tissue perfusion (cardiopulmonary) related to hypervolemiaIneffective tissue perfusion (peripheral) related to skin pallor

RATIONALE: Reduced oxygen-carrying capacity of the blood in anemia decreases the energy available for normal activity. Iron-deficiency anemia is a medical diagnosis; it's not an appropriate nursing diagnosis. Iron-deficiency anemia doesn't result in hypervolemia (increase in blood volume). Skin pallor is a sign of ineffective tissue perfusion and, therefore, a defining characteristic, not an etiology. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisWhich of the following instructions would be most important when teaching home management of a child with hemophilia?

Toothbrushes should be held under warm water before use.Aspirin should be used for mild joint pain and inflammation.Bleeding extremities should be held in a dependent position to encourage stasis and clot formation.Wall-to-wall carpeting shouldn't be used anywhere in the home.

RATIONALE: Softening the toothbrush under warm water decreases the risk of bleeding gums. Aspirin is contraindicated because it interferes with platelet function. Bleeding extremities should be kept elevated. The home should have wall-to-wall carpeting to cushion falls. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA child with iron-deficiency anemia is being treated with iron supplements. The client's mother brings the child to the clinic 3 months after iron supplements have been prescribed. The child's hematocrit is about the same as it was 3 months ago. What information should the nurse first elicit from the mother?

Dietary historyDescription of the child's stoolsWhether the child has been exposed to sickle cell diseaseWhether the child is pale and more tired than usual

RATIONALE: The nurse must first determine if the child is receiving the iron supplements; stools that are green or black indicate that the child has been taking supplements. A dietary history doesn't offer objective evidence that the child has received the iron supplements. Sickle cell disease is a genetic trait, not a contagious disease. Because the physical effects of anemia are insidious, parents may not view their child as ill or in need of treatment. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAn 18-month-old female comes in for a well-baby checkup. Her mother reports that she drinks five 8-oz (236.6 ml) bottles of whole milk per day. Which of the following foods should the nurse tell the mother to include in the child's diet to improve iron intake?

Peanut butter, green vegetables, and raisinsCheese, yogurt, and fresh fishYellow vegetables, citrus fruits, and white breadBerries, turkey, and cheese

RATIONALE: Legumes, green vegetables, and dried fruits are high sources of iron. The other options have lower iron contents. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 10-year-old male with sickle cell anemia continues to wet the bed at night. He feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which of the following responses by the nurse is most appropriate?

"We can try a bladder training program.""Force fluids during the day and restrict fluids after 7 p.m.""Decrease fluid intake during the day and take no liquids before bedtime.""Perhaps your friends could sleep over at your house instead."

RATIONALE: About one-half of all children with sickle cell anemia have problems with enuresis because the kidney is damaged and can no longer concentrate urine. Bladder training programs may improve the situation. Restricting fluids in someone with sickle cell anemia can lead to a vaso-occlusive crisis. Suggesting that the friend sleep at the client's house doesn't properly address the issue and doesn't show understanding of the child's feelings. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe mother of an 18-month-old complains that the child seems tired and fussy even though she naps twice per day and sleeps through the night. The nurse notes that the child is pale and clinging to her mother during the health history and assessment. Which of the following findings should lead the nurse to suspect iron-deficiency anemia?

She drinks 40 to 48 oz (1183 to 1419.5 ml) of pasteurized cow's milk daily.She weighed 3883.9 g when she was born.She's often constipated, and her stool is very dark.She's in the 50th percentile for height and the 60th percentile for weight.

RATIONALE: A dietary history typically reveals abnormally high milk intake (over 32 oz [946.3 ml] of cow's milk daily). Preterm neonates are at greater risk for iron-deficiency anemia than babies born at full weight. Constipation and dark stool may be associated with iron supplements, which are used to treat iron-deficiency anemia. Between 30% and 56% of children with iron-deficiency anemia are below the 10th percentile for weight when diagnosed. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 4-year-old boy with acute lymphocytic leukemia has been receiving vincristine (Oncovin). Which of the following signs would be most important to the nurse in evaluating the adverse effects of vincristine therapy?

DiarrheaHematuriaMoon face and fluid retentionWeakness and constipation

RATIONALE: Vincristine is a plant alkaloid. Neurotoxicity, a possible adverse effect of vincristine therapy, may be manifested as weakness and constipation. Peristalsis is reduced, not increased, with vincristine; therefore, diarrhea is unlikely. Hematuria is a adverse effect of cyclophosphamide (Cytoxan), not vincristine. Moon face and fluid retention are adverse effects of prednisone (Sterapred). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 4-year-old girl is admitted to the hospital to rule out leukemia. Which of the following would be the best room assignment?

With a 4-year-old girl who has rheumatoid arthritisWith a 5-year-old boy who is having a tonsillectomyWith a 4-year-old girl who has leukemiaAlone in a private room

RATIONALE: Avoiding exposure to infection requires a private room. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA 2-year-old girl is being discharged from the hospital after treatment for croup. Her father asks, "What should we do if she gets croup again?" What's the best nursing response?

"You don't have to worry. She now has immunity to croup and won't get it again.""Come to the emergency room immediately when she starts coughing.""If she gets another cold, watch for croup. Keep a cool-mist humidifier running in her room, and give her lots of clear liquids.""You could put her crib in the bathroom and let her sleep with the hot shower running to make steam."

RATIONALE: A child can get croup more than once, particularly if she has an upper respiratory infection. The symptoms of croup may be relieved or lessened through adequate hydration and increased humidity. An attack of croup doesn't confer immunity. Going immediately to the emergency department may cause unnecessary parental anxiety and dependency on the health care provider; it doesn't teach the parents how to control croup. Putting the child's crib in the bathroom and running the shower water is unsafe; a child should never be left alone in the bathroom with hot water running. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA neonate with a tracheoesophageal fistula is to undergo a repair. Postoperatively, which of the following nursing measures should be implemented first?

Place the client in a prone position, with his head slightly elevated and turned to either side.Place the client in a side-lying position, with his neck hyperextended to maintain an airway.Give the first oral feeding with sterile water 24 hours after surgery.Change the client's position every 2 hours from the back to either side, keeping his head slightly elevated.

RATIONALE: The client's head should be elevated to facilitate drainage of secretions, and the client's position is changed frequently to maintain skin integrity and prevent pneumonia. The prone position compresses the abdomen and may cause gastric reflux. Hyperextension of the neck puts pressure on the suture line of the esophagus. Oral feedings aren't started until 2 to 10 days after surgery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung's disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority?

Changing the surgical dressingSuctioning the nasopharynx frequently to remove secretionsIrrigating the colostomy with 100 ml of normal saline solutionAuscultating lung sounds

RATIONALE: Immediately after surgery, the priority nursing intervention is assessing pulmonary function. The surgical dressing shouldn't require changing right away. Suctioning should be performed only if the client can't maintain a patent airway. Colostomy irrigation isn't warranted. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 2-week-old neonate returned 6 hours ago from surgery to correct pyloric stenosis. Which postoperative nursing interventions are most important?

Feeding small amounts frequently, assessing the amount of emesis, and encouraging parental involvement in careGiving the neonate nothing by mouth until the wound heals, and encouraging parental involvementMonitoring intake and output, and encouraging parental involvement in careMonitoring hydration status, and encouraging parental involvement

RATIONALE: Small, frequent feedings are resumed 4 to 6 hours after surgery. The amount given each feeding and the interval between the feedings should gradually increase. Occasional emesis is common after surgery, and nurses need to let parents know about this. Parental involvement is a must, both preoperatively and postoperatively, to promote bonding and decrease feelings of guilt. There's no reason to restrict oral feeding. Assessing and developing feeding tolerance are of primary importance. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 1-month-old neonate is admitted to the hospital after 2 days of diarrhea and vomiting. The neonate is lethargic and has a weak pulse. Which action should be taken first?

Obtain the health history.Obtain a fuller history of the present illness.Question the mother about formula preparation.Initiate I.V. rehydration.

RATIONALE: With moderate to severe diarrhea, the first goal is to restore vascular volume as rapidly as possible to prevent or treat shock. The other options are important but don't take top priority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 2-month-old neonate with diarrhea and vomiting has been receiving I.V. fluids for the past 24 hours. The specific gravity of the neonate's urine is 1.012. What should the nurse do next?

Check the neonate's blood pressure.Check the specific gravity again as soon as possible.Notify the physician.Continue the ordered I.V. flow rate.

RATIONALE: The neonate's urine specific gravity is within normal limits, indicating that he's being adequately hydrated. The other options aren't necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 4-year-old male is brought to the ambulatory care clinic for well-child care. His height (37" [94 cm]) and weight (29 lb [13.2 kg]) are below the 5th percentile for his age and sex. What should the nurse do first in evaluating his growth?

Compare his growth trends with those of his parents and siblings.Elicit more history to assess the presence of metabolic disease.

Gather additional data by assessing baseline vital signs.Initiate radiographic assessment to determine bone age.

RATIONALE: A child who falls above or below the standard in both height and weight may not be abnormal but may reflect a genetically large or small frame. Comparing a child's growth trends with those of parents and siblings is essential in evaluating adequate growth. Eliciting more history to assess the presence of metabolic disease and initiating radiographic assessment to determine bone age may be appropriate in evaluating short stature, but they wouldn't be the initial step. Gathering additional data by assessing baseline vital signs might assist in the assessment of an underlying metabolic cause of short stature, but taking vital signs isn't directly related to the initial evaluation of growth trends. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA mother brings her 15-month-old male child to the ambulatory care clinic for well-child care. He's crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first?

Ask the mother to leave the room because her anxiety is increasing the child's distress.Examine the ear with the child supine because this aids visualization of the tympanic membrane.Examine the affected ear last in order to minimize distress early in the examination.Examine the left ear first in order to assess what may be physically wrong with the child.

RATIONALE: The suggested sequence of a well-child exam changes when the child is in pain. In this case, it's preferable to examine the affected area last in order to minimize distress early in the examination and to focus on normal, healthy body parts. Parental presence is almost always conducive to a child's cooperation and sense of security. Examination of the ear in an upright position is preferable, especially in a crying child; it's less frightening for the child and decreases the bulging of the tympanic membrane from crying. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA healthy 6-year-old boy who has never been immunized is brought to the clinic by his mother to "get his shots for school." Which of the following immunizations should the client receive?

MMR (measles, mumps, rubella)DPT (diphtheria, tetanus, pertussis) and OPV (oral polio vaccine)Hib (Haemophilus influenza type b)DPT, OPV, and MMR

RATIONALE: A child over 15 months and under 7 years with no previous immunizations should receive DPT, OPV, and MMR at the first visit. The Hib vaccine isn't given to children over 5 years old. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA father brings his 2-year-old male child to the ambulatory care clinic for a routine well-child visit. He has a runny nose and a cough. The nurse examines his musculoskeletal system. Which physical finding would indicate further investigation?

A broad-based gaitAsymmetric or unilateral bowlegKnock-kneeLordosis of the lower spine

RATIONALE: Asymmetry of body parts is generally a clue to a problem. Unilateral bowleg that's present past age 2 may represent a pathologic condition. A broad-based gait and lordosis are normal findings in a toddler. Knock-knee is normally present in most children ages 2 to 7. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionWhich of the following assessments is the most significant finding in a history related to congenital hip dislocation?

The mother's activity during the third trimesterBreech presentation at birthThe client's serum calcium level at birthAn Apgar score of 4 at 1 minute and 6 at 5 minutes

RATIONALE: Breech presentation is a factor frequently associated with congenital dislocated hip. The other options have no bearing on hip dislocation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationImmediately after a 1-year-old client returns from a cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weak. The nurse should take which of the following actions?

Remove the pressure bandage from the insertion site.Perform passive exercises on the affected extremity.Notify the physician of the assessment.Record the data on the nursing notes and continue to evaluate.

RATIONALE: The pulse distal to the insertion site may be weak for a few hours but should gradually increase in strength. The pressure dressing shouldn't be removed because of the risk of hemorrhage. Passive exercises on the affected extremity wouldn't be performed after a cardiac catheterization. The physician doesn't need to be notified at this time but should be notified if the weak pulse continues for longer than 2 hours. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 12-month-old female client is at the clinic for a well-baby checkup. During the oral examination, the nurse discovers that the client's teeth are full of caries and that she still uses a bottle. What's the nurse's most appropriate intervention?

Ask the client's mother about her knowledge of dental caries and bottle weaning.Tell the client's mother that dental caries are caused by laying the neonate down to sleep with a bottle full of milk.Ask the client's mother about the client's bedtime routine.Tell the client's mother to take the neonate off the bottle and to see a dentist right away.

RATIONALE: This open-ended question allows the nurse to gather information without attaching blame. Asking the mother about her knowledge is likely to put her on the defensive. Telling the mother that dental caries are caused by laying the neonate down to sleep with a bottle full of milk is quick to assign blame. Telling the mother to take the neonate off the bottle and to see a dentist right away is inappropriate and peremptory. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA male client was born with a complete cleft palate and unilateral cleft lip. The client is now 2 months old and has just returned to the unit from the recovery room after cleft lip repair. The recovery room nurse reports that his vital signs have been stable and he now is awake and active. What should be the unit nurse's initial intervention?

Take the client's vital signs.Position the client on his abdomen.Restrain the client's elbows.Administer pain medication to decrease the client's activity.

RATIONALE: Because the neonate is awake and active, the suture area must be protected. Although vital signs are important, the recovery room nurse reported that they were stable; therefore, the restraints are more important at this time. The client shouldn't be positioned on his abdomen, as this can

cause trauma to the suture line. Pain medication may be required soon, but vital signs should be reassessed before it's administered. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA mother brings her 5-month-old female child to the pediatric clinic. The child has had recurrent middle-ear infections since she was 3 months old. Which of the following areas is most important to assess?

How well the client eatsThe client's weight gain since her last visitWhether the client received all of her prescribed antibiotic at the time of the last infectionThe client's temperature

RATIONALE: If the client isn't receiving her full course of antibiotic therapy, her ear infections will recur; permanent hearing loss or systemic infection may result. Parents may not understand this and may discontinue treatment when the neonate seems better. The other options are important aspects to assess, but none is as critical as ensuring full compliance with antibiotic therapy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA mother calls the hospital emergency department, sobbing that her 3-year-old male child has swallowed some acetaminophen (Tylenol). In assessing the situation, the nurse's first priority is to learn:

how the child was able to gain access to the acetaminophen.whether the child is complaining of right upper quadrant abdominal tenderness.whether the child looks jaundiced.the number and strength of the acetaminophen tablets ingested.

RATIONALE: Initial assessment requires finding out how much acetaminophen the child has ingested to determine whether the amount is toxic for his age and weight. Safety measures, including storage of medications, should be taught after the emergency is resolved. Right upper quadrant tenderness indicates liver toxicity, which would occur 1 or more days after ingesting a toxic amount of acetaminophen. Jaundice would be a late sign of liver toxicity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisWhich of the following positions is most appropriate for a neonate with congenital hip dislocation?

Semi-Fowler's with both legs flexedLegs adducted with head elevatedSwaddled in a baby carrierProne position with hips abducted

RATIONALE: Abduction places the femoral head into the acetabulum for correct alignment. Placing the client in semi-Fowler's position with both legs flexed or with his legs adducted and his head elevated won't help correct the problem. Swaddling the client in a baby carrier would worsen the dislocation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 12-year-old boy with cystic fibrosis (CF) is tested for duodenal enzyme activity. Measurements reveal that he's deficient in trypsin. To replace the absent pancreatic enzyme, pancrelipase (Pancrease) is prescribed. The nurse should teach the client and parents that pancrelipase should be taken under what conditions?

On an empty stomachBetween mealsWith meals and snacksAt bedtime

RATIONALE: Trypsin is absent in over 80% of clients with CF. Pancreatic enzyme replacement is given with all meals and snacks to help digest food. Pancrelipase is enteric-coated to delay release of the enzyme and to prevent its destruction in the acid environment of the stomach. Capsules may be swallowed whole or broken apart and sprinkled on cold or room-temperature food. The enzyme should be given with food to aid in digestion, so the other options are inappropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionA 1-year-old male is diagnosed with a congenital cardiac defect after cardiac catheterization. His parents have expressed concern about activities at home. Which is the best response by the nurse when teaching these parents?

"You'll have to establish strict discipline so that he learns what he can't do.""Allow him to play and be active as long as he doesn't get fatigued.""He'll only be able to play by himself.""Discipline and limit-setting need to be relaxed to reduce his stress and crying."

RATIONALE: Parents should promote normality within the limits of the child's condition. The child needs to have appropriate limits and discipline. Being too strict with the child or overindulging him makes it hard for him to learn acceptable behavior. Children of this age are beginning to explore their world and need to be exposed to activities with other children. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 7-month-old boy has a congenitally displaced hip despite having been in a Frejka splint for 10 weeks. He's placed in a spica cast in a position of external rotation. Which of the following instructions is most important to emphasize in teaching his parents how to care for him at home?

Avoid having plastic touch the edges of the cast.Powder his perineal area with a medicated powder after each diaper change.Check his circulation in both feet every hour.Rock and cuddle him often.

RATIONALE: Appropriate stimulation is needed to meet developmental needs. Holding, rocking, and cuddling help meet these needs by making the client feel cared for and secure. The edges of the cast should be petaled to protect his skin from rough edges; the perineal area should be lined with plastic to protect the cast from urine and feces. The use of powder should be discouraged, as it tends to cake under the cast. Checking circulation in both feet every hour is appropriate only for the first 24 hours the client is in the cast; daily checks are recommended thereafter. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 3-year-old boy is having the third and final surgery to repair severe hypospadias. He returns from surgery with an I.V. of D5W at 40 ml/hour, an indwelling urinary catheter to straight drainage, and orders for diet as tolerated and pain medication as needed. Which action would be best for the nurse to take in order to prevent separation of the incision?

Place him in semi-Fowler's position.Elevate the scrotal sac on a folded sheepskin.Use restraints as needed to keep him from touching the area.Clean the area every 2 hours with diluted hydrogen peroxide.

RATIONALE: Elevation of the affected area on a Bellevue bridge or similar structure helps avert separation of the suture line by preventing dependent edema. Placing him in semi-Fowler's position will increase the swelling. Staying with a 3-year-old client would be more appropriate than restraining him. Cleaning the area every 2 hours with diluted hydrogen peroxide would have no effect on incision separation. NURSING PROCESS STEP:

Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationAfter a computed tomography (CT) scan, a lumbar puncture for spinal fluid collection is performed on a 2-year-old with bacterial meningitis. The lumbar puncture shouldn't be performed if increased intracranial pressure (ICP) is reported in the CT scan in order to prevent:

herniation of the brain stem.the spread of organisms in the spinal fluid.traumatizing the child with additional testing.glucose removal from the already glucose-depleted spinal fluid

RATIONALE: Removal of spinal fluid in the presence of increased ICP can cause downward displacement of the brain and damage tissue. Lumbar puncture won't cause the spread of organisms in the spinal fluid or glucose removal from the already glucose-depleted spinal fluid. The procedure may be traumatic, but it's necessary for safe treatment and management of the child's condition. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 3-year-old girl is brought to the emergency department by her father, who found her playing with an empty bottle of acetaminophen. The child said she had swallowed "a lot of the pills to help her feel better." Her father thinks the bottle was about two-thirds full of acetaminophen tablets for children. The nurse explains that she must try to empty the child's stomach of the drug by inserting a nasogastric (NG) tube. Which of the following measuring techniques would best ensure the correct tube length?

Measure from the tip of the nose to the earlobe and, from there, to the end of the xiphoid process.Measure from the tip of the earlobe to the end of the xiphoid process, and multiply by 2.Measure from the tip of the nose to the umbilicus.Measure from the tip of the nose to the umbilicus, and multiply by 2.

RATIONALE: Correct measurements for the length of an NG tube would be from the tip of the nose to the earlobe and, then, from the earlobe to the end of the xiphoid. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ComprehensionA 6-year-old girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and she's now ready for discharge. Which of the following plans for her health care is most important for her future well-being?

Arrange for her to return to school as soon as possible to promote psychosocial development.Encourage her to engage in unrestricted physical activity to regain physical strength.Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.Maintain seizure precautions, as central nervous system involvement may persist for several months.

RATIONALE: Children who have had rheumatic fever are more susceptible to contract it again. Prophylactic antibiotics are typically maintained for at least 5 years. Psychosocial development can be promoted even before a return to school is appropriate. Physical activity should be limited until cardiac status is normal. Choreic movements aren't permanent and aren't seizures. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe physician orders an I.V. infusion of dextrose 5% in quarter-normal saline solution to be infused at 7 ml/kg/hr for a 10-month-old infant. The infant weighs 22 lb. How many ml/hr should the nurse infuse of the ordered solution?70RATIONALE: To perform this dosage calculation, the nurse should first convert the infant's weight to kilograms: 2.2 lb/kg = 22 lb/X kg X = 22 9 2.2 X = 10 kg Next, she should multiply the infant's weight by the ordered rate: 10 kg x 7 ml/kg/hr = 70 ml/hr NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the client and his family? Select all that apply:

Avoid foods high in folic acid.Drink plenty of fluids.Use cold packs to relieve joint pain.Report a sore throat to an adult immediately.Restrict activity to quiet board games.Wash hands before meals and after playing.

RATIONALE: Fluids should be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and other cold symptoms should be promptly reported because they may indicate the presence of an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia should learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition practices. Folic acid intake should be encouraged to help support new cell growth; new cells replace fragile, sickled cells. Warm packs should be applied to provide comfort and relieve pain; cold packs cause vasoconstriction. The child should maintain an active, normal life. When the child experiences a pain crisis, he limits his own activity according to his pain level. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is preparing to administer the first dose of tobramycin (Nebcin) to an adolescent with cystic fibrosis. The order is for 3 mg/kg I.V. daily in three divided doses. The client weighs 95 lb. How many milligrams should the nurse administer per dose?43.2RATIONALE: To perform this dosage calculation, the nurse should first convert the client's weight to kilograms using this formula: 1 kg/2.2 lb = X kg/95 lb 2.2X = 95 X = 43.2 kg Then, she should calculate the client's daily dose using this formula: 43.2 kg x 3 mg/kg = 129.6 mg Lastly, the nurse should calculate the divided dose: 129.6 mg 9 3 doses = 43.2 mg/dose NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA nurse caring for a client who is 4 weeks pregnant should expect to collect which assessment findings?

Presence of mensesUterine enlargementBreast sensitivityFetal heart tones

RATIONALE: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer:

ritodrine (Yutopar).bromocriptine (Parlodel).magnesium sulfate.

betamethasone (Celestone).RATIONALE: Ritodrine reduces frequency and intensity of uterine contractions by stimulating B2-adrenergic receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia - a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother). NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary?

Increased maternal blood pressure of 150/90 mm HgDecreased amount of vaginal bleedingFetal heart rate of 80 beats/minuteMaternal heart rate of 65 beats/minute

RATIONALE: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean section to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate delivery. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisAssessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which nursing intervention is most appropriate for this client?

Provide her with the information and teach her the skills she'll need to understand and cope during birth.Provide her with written information about the birthing process.Have a more experienced pregnant woman assist her.Do nothing in hopes that she'll begin coping as the pregnancy progresses.

RATIONALE: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:

assess the client's readiness to stop.suggest that the client reduce the daily number of cigarettes smoked by one-half.provide the client with the telephone number of a formal smoking cessation program.help the client develop a plan to stop.

RATIONALE: Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is recording an Apgar score for a neonate. The nurse should assess:

heart rate, respiratory effort, temperature, reflex irritability, and color.heart rate, respiratory effort, reflex irritability, and color.heart rate, respiratory effort, temperature, and color.heart rate, respiratory effort, temperature, sucking reflex, and color.

RATIONALE: When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is teaching the mother of a neonate about the importance of immunizations. The nurse should teach her that active immunity:

develops rapidly and is temporary.occurs by antibody transmission.results from exposure of an antigen through immunization or disease contact.may be transferred by mother to neonate.

RATIONALE: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission. It occurs rapidly but is temporary. Passive immunity may be transferred by the mother to the neonate. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: KnowledgeWhen evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?

"I'll report increased frequency of urination.""If I have blurred or double vision, I should call the clinic immediately.""If I feel tired after resting, I should report it immediately.""Nausea should be reported immediately."

RATIONALE: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate?

Encourage breast-feeding so that she can get her rest and get healthier.Encourage breast-feeding because it's healthier for the neonate.Encourage breast-feeding to facilitate bonding.Discourage breast-feeding because HIV can be transmitted through breast milk.

RATIONALE: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:

peripheral acrocyanosis.bradycardia.lethargy.jaundice.

RATIONALE: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?

Weak sucking responseEnlarged breast tissueSoft skinVernix caseosa

RATIONALE: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but she's concerned because she isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by:

referring her to counseling.telling her such feelings are normal in the beginning of pregnancy.exploring her feelings.recommending she talk her feelings over with her husband.

RATIONALE: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply - but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:

recognize these as normal early pregnancy signs and symptoms.question her further about these signs and symptoms.tell her that she'll need blood work and urinalysis.tell her that she may be excessively worried.

RATIONALE: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client with hypotonic labor dysfunction has been started on oxytocin (Pitocin). Despite adequate contractions, the fetus doesn't descend lower than 0 station. The physician recommends cesarean delivery. The client and her husband are confused because she had given birth previously to an average-size neonate. They ask several questions about cesarean birth. What would be the most accurate nursing diagnosis for this client?

Anger related to loss of planned birth experienceAnxiety related to lack of knowledge about the need for cesarean birthAcute pain related to long, unproductive laborFear related to the unknown

RATIONALE: The couple's questions indicate their lack of knowledge. Anxiety is expected because a cesarean delivery was unplanned. The other options aren't indicated by the stated assessment data. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:

take sleeping pills for a restful night's sleep.try to get more rest by going to bed earlier.take her prenatal vitamins.tell her not to worry because the fatigue will go away soon.

RATIONALE: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisThe nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:

"Now isn't a good time to begin dieting because you are eating for two.""Let's explore your feelings further.""Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems.""The prenatal vitamins should ensure the baby gets all the necessary nutrients."

RATIONALE: Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:

start using insulin.start taking an oral antidiabetic drug.monitor her urine for glucose.be taught about diet.

RATIONALE: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall dietary intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:

the delivery may need to be induced early.the delivery must be by cesarean.the mother will carry to term safely.it's too early to tell.

RATIONALE: Early induction or early cesarean delivery are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to stressing the importance of taking the vitamins, the nurse should advise the client to:

switch brands.take the vitamin on a full stomach.take the vitamin with orange juice for better absorption.take the vitamin first thing in the morning.

RATIONALE: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?

Keeping him away from draftsPutting a blanket between him and cold surfacesPutting a cap on his headDrying him thoroughly after a bath

RATIONALE: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss caused by evaporation. Keeping a neonate away from drafts prevents heat loss caused by convection. Keeping a neonate off a cold surface, such as a scale, prevents the heat loss caused by conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss caused by radiation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:

ensuring adequate nutrition.preventing infection.promoting neural tube sac drainage.conserving body heat.

RATIONALE: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisThe nurse is conducting a neonate assessment of a boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation?

Limited abduction of the affected legUnequal gluteal foldsLengthening of the limb on the affected sideCrepitus of the affected hip on movement

RATIONALE: Unequal gluteal folds are signs of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?

Placing the neonate flat during feedingsProviding fluids with a small spoonPlacing the nipple in the cleft palateBurping the neonate frequently

RATIONALE: Because a neonate with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A neonate with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client isn't in labor. Which nursing intervention should the nurse perform?

Allow the client to ambulate with assistance.Perform a vaginal examination to check for cervical dilation.Monitor the amount of vaginal blood loss.Notify the physician for a fetal heart rate of 130 beats/minute.

RATIONALE: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA nurse in a prenatal clinic is assessing a 28-year-old who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia?

Glycosuria, hypertension, seizures

Hematuria, blurry vision, reduced urine outputBurning on urination, hypotension, abdominal painHypertension, edema, proteinuria

RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits?

"The community health nurse will help fix my meals.""The community health nurse will give me my antihypertensive medication.""The community health nurse will check me and my baby and talk with my physician.""The community health nurse will give me prenatal care so that I won't have to see my physician."

RATIONALE: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia, this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home - this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis takes the highest priority?

Risk for deficient fluid volumeAnxietyAcute painImpaired gas exchange

RATIONALE: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but risk for deficient fluid volume through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Acute pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client delivered a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action?

Tachycardia and hypotensionGush of vaginal blood when she stands upBlood stain 2" (5.1 cm) in diameter on the abdominal dressingComplaints of abdominal pain

RATIONALE: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartal woman who has been sitting and may suddenly gush out when she stands up. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in the size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site once her anesthesia has worn off. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?

A 3-day-old neonate who has been fed I.V. since birthA 2-day-old neonate who has been breast-fedA 1-day-old neonate receiving formulaA breast-fed neonate being discharged within 24 hours of birth

RATIONALE: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA boy is born 8 weeks premature. At birth, he has no spontaneous respirations but is successfully resuscitated. Within several hours he develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. He's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the neonate's care plan to prevent retinopathy of prematurity?

Cover his eyes while receiving oxygen.Keep his body temperature low.Monitor partial pressure of oxygen (PaO2) levels.Humidify the oxygen.

RATIONALE: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm so that his respiratory distress isn't aggravated. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says:

"I won't use insulin if I'm sick.""I need to use insulin each day.""If I give myself an insulin injection, I don't need to watch what I eat.""I'll monitor my blood glucose levels twice a week."

RATIONALE: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid

periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?

Administer insulin subcutaneously.Administer a bolus of glucose I.V.Provide frequent early feedings with formula.Avoid oral feedings.

RATIONALE: The neonate of a mother with diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?

Soft, at the level of the umbilicusFirm, q" (1.9 cm) below the umbilicusFirm, at the level of the umbilicusBoggy, midway between the umbilicus and symphysis pubis

RATIONALE: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionWhich finding is considered normal in a neonate during the first few days after birth?

Weight loss of 25%Birth weight of 2,000 to 2,500 gWeight loss then return to birth weightWeight gain of 25%

RATIONALE: Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to the loss of excess extracellular fluids and meconium as well as limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 2,700 to 4,000 g. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse?

"Why don't you wait and see how things go? You may be tired of breast-feeding by then.""Let your daycare provider give the baby formula in a bottle and breast-feed when you're home.""Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work.""You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."

RATIONALE: Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the neonate at daycare. This will also keep the mother's milk production up. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationEarly detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?

Abdominal pain, vaginal bleeding, and a positive pregnancy testHyperemesis and weight lossAmenorrhea and a negative pregnancy testCopious discharge of clear mucus and prolonged epigastric pain

RATIONALE: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucus isn't indicative of an ectopic pregnancy, and referred shoulder pain, not epigastric pain, should be expected. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisThe client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho (D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho (D) Immune Globulin I.M. to the neonate within 72 hoursAdministration of Rho (D) Immune Globulin I.M. to the mother within 72 hoursInjection of Rho (D) Immune Globulin to the mother during her 6 week follow-up visitAdministration of Rho (D) Immune Globulin I.M. to the mother within 3 months

RATIONALE: When a mother is Rho (D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth due to the exchange of maternal and fetal blood during delivery. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rho (D) Immune Globulin within 72 hours, no antibodies will be formed. Rho (D) Immune Globulin may also be given to the mother during pregnancy, if the neonate is Rh-positive. The neonate isn't given Rho (D) Immune Globulin. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationOn the 9th postpartum day, a client breast-feeding her neonate experiences pain, redness, and swelling of her left breast. She's diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Wear a loose-fitting bra to avoid constricting the milk ducts.Stop breast-feeding permanently.Take antibiotics until the pain is relieved.Use a warm moist compress over the painful area.

RATIONALE: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when

symptoms subside. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement?

"I'll apply warm, moist compresses to my breasts.""I'll breast-feed every 1r to 3 hours.""I'll use an electric breast pump.""I'll wear a bra 24 hours per day."

RATIONALE: Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

One fingerbreadth above the umbilicusOne fingerbreadth below the umbilicusAt the level of the umbilicusBelow the symphysis pubis

RATIONALE: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: KnowledgeThe nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises?

To prevent urine retentionTo relieve lower back painTo tone the abdominal musclesTo strengthen the perineal muscles

RATIONALE: Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can't prevent urine retention, relieve lower back pain, or tone abdominal muscles. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ComprehensionThe nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

7 weeks11 weeks17 weeks21 weeks

RATIONALE: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?

Iron deficiency anemiaVaricositiesNausea and vomitingGestational diabetes

RATIONALE: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?

A glass of milkA cup of hot teaA liquid antacidA glass of orange juice

RATIONALE: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?

HypoglycemiaCracklesBradycardiaHyperkalemia

RATIONALE: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching?

"I'll need to lie perfectly still.""You won't need to come in and check on me while I'm wearing this monitor.""I can lie in any comfortable position, but I should stay off my back.""I know that the external monitor increases my risk of a uterine infection."

RATIONALE: A woman with an external monitor should lie in the position that's most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who is wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection. NURSING PROCESS

STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

Encouraging ambulationServing a nutritious dietPromoting adequate hydrationPerforming nipple stimulation

RATIONALE: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client treated for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Report a heart rate greater than 120 beats/minute to the physician.Take terbutaline every 4 hours, during waking hours only.Call the physician if the fetus moves 10 times in 1 hour.Increase activity daily if not fatigued.

RATIONALE: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client in labor. Which assessment finding indicates fetal distress?

Lack of meconium stainingEarly decelerations in fetal heart rate during contractionsAn increase in fetal heart rate with fetal scalp stimulationFetal blood pH less than 7.20

RATIONALE: A fetal blood pH less than 7.20 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.20 to 7.30 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are normal findings. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?

Deep breathingShallow chest breathingDeep, cleansing breathsChest panting

RATIONALE: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Administer ephedrine to raise her blood pressure.Administer oxygen using a mask.Place the woman flat on her back with her legs raised.Ensure adequate hydration before the anesthetic is administered.

RATIONALE: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in a supine position can contribute to hypotension because of uterine pressure on the great vessels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?

Gently pulling at the neonate 's head as it's deliveredHolding the neonate 's head back until the physician arrivesApplying gentle pressure to the neonate 's head as it's deliveredPlacing the mother in a Trendelenburg position until the physician arrives

RATIONALE: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. Never pull at the neonate 's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?

Checking for the umbilical cord around the neonate 's neckPlacing antibiotic ointment in the neonate 's eyesTurning the neonate's head to the side, to drain secretionsAssessing the neonate for respirations

RATIONALE: After the neonate 's head is delivered, the nurse should check for the cord around the neonate 's neck. If the cord is around the neck, it should be gently lifted over the neonate 's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.Take a Sitz bath.Perform perineal care after voiding or a bowel movement.Drink plenty of fluids.

RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a Sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection - not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is assessing a client on the second postpartum day. Under normal circumstances, the tone and location of the client's fundus is:

soft and one fingerbreadth below the umbilicus.firm and two fingerbreadths below the umbilicus.firm and to the right or left of midline.soft and at the level of the umbilicus.

RATIONALE: By the second postpartum day, the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be at the level of the umbilicus on the day of delivery and fall below the umbilicus by approximately one fingerbreadth (1 cm) per day, until it has contracted into the pelvis by the 9th or 10th day. The fundus should be firm, not soft. A soft or boggy fundus indicates that the uterus isn't contracting properly. The fundus should be palpated in the midline of the abdomen; if the client has a full bladder, however, the fundus may be deviated to the right or left. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole?

Rapid fetal heart tonesAbnormally high human chorionic gonadotropin (hCG) levelsSlow uterine growthLack of symptoms of pregnancy

RATIONALE: In a pregnant client with a hydatidiform mole, the trophoblast villi proliferate and then degenerate. Proliferating trophoblast cells produce abnormally high hCG levels. No fetal heart tones are heard because there's no viable fetus. Because there's rapid proliferation of the trophoblast cells, the uterus grows fast and is larger than expected for a given gestational date. Because of the greatly elevated hCG levels, a client with hydatidiform mole commonly has marked nausea and vomiting. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationThe nurse is caring for a client after evacuation of a hydatidiform molar pregnancy. The nurse should instruct the client to:

wait 1 month before trying to become pregnant again.make an appointment for follow-up human chorionic gonadotropin (hCG) level monitoring at the end of 1 year.discuss options for sterilization with the physician.use birth control for at least 1 year.

RATIONALE: After experiencing a hydatidiform molar pregnancy, the client should be counseled to use a reliable method of birth control for at least 1 year. Because of the risk of choriocarcinoma, her hCG levels need to be monitored monthly for 1 to 2 years. Sterilization isn't necessary after hydatidiform mole. If hCG levels remain low, she may try to become pregnant after a year. The risk of recurrence of a hydatidiform mole is low. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

Urine specific gravity 1.010Serum potassium 4 mEq/LSerum sodium 140 mEq/LKetones in urine

RATIONALE: Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. The other laboratory values listed are all within normal limits. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:

milk and ice pops.decaffeinated coffee and scrambled eggs.tea and gelatin dessert.apple juice and oatmeal.

RATIONALE: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: KnowledgeWhat's the best way to teach new parents about the care of their neonate?

Relate stories of other parents' experiences.Focus on the behavior of their own neonate.Show videotapes about neonate care.Distribute literature with photographs of neonate-care skills.

RATIONALE: Working directly with the neonate offers the best opportunity for the nurse to demonstrate neonate-care techniques and elicit return demonstration by the parents. Pointing out specific behaviors and characteristics of their neonate enhances parent-neonate attachment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:

red and moderate.continuous with red clots.brown and scant.thin and white.

RATIONALE: During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and

continue for several weeks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionHow does the nurse assess the rooting reflex of a neonate?

Placing an object in the neonate's palmStroking the sole of the neonate's footStroking the neonate's cheekTouching the neonate's lips

RATIONALE: The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. The Babinski reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski sign. The sucking reflex is seen when the neonate's lips are touched. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client's position.Prepare for emergency cesarean delivery.Check for placenta previa.Administer oxygen.

RATIONALE: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side lying may immediately correct the problem. An emergency cesarean delivery is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

Using a peri bottle to clean the perineum after each voiding or bowel movementCleaning the perineum from back to front after a bowel movementSpraying water from peri bottle into the vaginaChanging perineal pads every 8 hours

RATIONALE: Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they're soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (88.7 ml) or more of alcohol per day throughout her pregnancy. Which characteristic should the nurse expect to find?

Prominent nasal bridgeThick upper lipUpturned noseLarge for gestational age

RATIONALE: Neonates born with fetal alcohol syndrome have upturned noses, flattened nasal bridges, and a thin upper lip. They may also be small for gestational age. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationWhat's a common adverse effect of phototherapy?

KernicterusWatery stoolsPositive Coombs' testPolyuria

RATIONALE: Phototherapy involves exposing a neonate's bare skin to intense fluorescent light in the treatment of hyperbilirubinemia and jaundice. Watery stools result from excretion of bilirubin. Kernicterus is a complication of jaundice - not phototherapy. Coombs' test is performed to determine the cause of jaundice and is unrelated to phototherapy. Polyuria isn't a result of phototherapy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeA girl delivered at 38 weeks' gestation, who weighs 2324.7 g, is having difficulty maintaining body temperature. Her mother had pregnancy-induced hypertension (PIH). The neonate develops acrocyanosis of the extremities on the evening of her birth. The nurse should know that this isn't a dangerous sign for which of the following reasons?

This condition may be related to the neonate's temperature instability.Blue extremities may reflect a lower level of hemoglobin (Hb) present in neonates of mothers with PIH.Vasomotor instability causes venous blood to move readily through the circulatory system, resulting in acrocyanosis.Acrocyanosis is usual for neonates and may last up to 6 months.

RATIONALE: Cold stress commonly increases acrocyanosis in neonates. Neonates usually have a high level of Hb, which isn't affected by PIH. Venous stasis decreases blood flow from the extremities. Acrocyanosis in the neonate is transient. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA 26-year-old patient with type 1 diabetes mellitus who is in her second trimester of pregnancy has been hospitalized for diabetes management. She performs blood glucose testing at 6 a.m., 11 a.m., 4 p.m., and 9 p.m. At 8 a.m. the client receives NPH and regular insulins subcutaneously. A dextrose paste is kept at bedside, and the client has been instructed to report symptoms of hypoglycemia. At 4 p.m. the client obtains a blood glucose reading of 45 mg/dl. As instructed, she notifies the nurse. What's the nurse's first response?

Administer insulin.Notify the physician.Provide the client with a glass of skim milk.No nursing action is warranted at this time.

RATIONALE: A blood glucose level of 45 mg/dl indicates hypoglycemia. Skim milk will increase the blood glucose level. Administering additional insulin would further decrease the blood glucose level. Notifying the physician would be appropriate only after treating the hypoglycemia. Performing no nursing action may harm the client and her fetus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA woman in her 8th month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly chokes on a piece of chicken and appears to lose consciousness. What would be the best action by a nurse sitting at the next table?

Apply abdominal thrust.Apply chest thrust.Begin cardiopulmonary resuscitation (CPR).Reposition the client on her side.

RATIONALE: Because it prevents fetal injury, a chest thrust is the best way to force air through the throat and dislodge the obstruction. Abdominal thrust might cause fetal injury. CPR and repositioning the client on her side won't help dislodge the obstruction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client in labor has received an epidural of bupivacaine (Sensorcaine) and epinephrine. Which of the following conditions would take highest priority in a nursing assessment?

HypertensionHypotensionPolyuriaOliguria

RATIONALE: An epidural block acts similarly to spinal anesthesia. Both can produce hypotension by blocking the sympathetic division of the autonomic nervous system. Hypertension doesn't result from an epidural block. Polyuria isn't an effect of an epidural block. Oliguria could occur as a result of hypotension, but it wouldn't be the client's first response. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client with type 1 diabetes mellitus in the second trimester of pregnancy is consuming a 2,400-calorie American Diabetes Association diet divided into three meals and several snacks. Her breakfast meal plan consists of these exchanges: 3 breads, 1 meat, 1 fruit, 1 milk, and 2 fats. Which of the following menus would best comply with the meal plan?

One English muffin, r cup cooked grits, 1 egg, r banana, 1 cup skim milk, and 2 tsp margarineTwo bagels (r bagel per exchange), 1 cup cooked grits, 3 eggs, 1 banana, 1 cup whole milk, 3 tsp margarineFour breadsticks, 1 oz ham, 1 small apple, 2 slices bacon, and 1 cup low-fat yogurtThree breadsticks, 2 oz ham, 30 grapes (15 grapes per exchange), and 2 tsp fat

RATIONALE: This menu includes the following exchanges: 3 breads (two halves of the English muffin plus r cup cooked grits), 1 meat (1 egg), 1 fruit (r banana), 1 milk (1 cup skim milk), and 2 fats (2 tsp margarine). Option 2 exceeds the bread, meat, and fat exchanges. Option 3 exceeds the bread exchanges. Option 4 exceeds the meat and fruit exchanges. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA primigravida client with acquired immunodeficiency syndrome (AIDS) is in labor at term. In preparing her nursing care plan, the nurse should include which of the following nursing diagnoses?

Risk for fetal or maternal injury related to the crisis of childbearingRisk for infection related to suppressed immune statusRisk for deficient fluid volume related to dehydrationRisk for fetal injury related to uteroplacental insufficiency

RATIONALE: Infection at any time is a problem for the client with AIDS because the immune system is depressed. Invasive procedures, which always increase the risk of infection, are numerous during labor and delivery. Clients with AIDS usually die from opportunistic diseases, not childbirth itself. Deficient fluid volume isn't a major concern to the nurse at this time. The fetus may acquire AIDS in utero, but it isn't currently believed that AIDS directly affects the placenta or oxygen transfer to the fetus. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA client with type 1 diabetes mellitus is pregnant for the second time. Her previous pregnancy ended in spontaneous abortion at 18 weeks' gestation. She's now at 22 weeks' gestation. The nurse is responsible for teaching the client about exercise during her pregnancy. Which of the following statements indicates that the client has an appropriate understanding of her exercise needs?

"I know I need to walk with a friend or family member.""I know I need to vary the times of day when I exercise.""I know I need to exercise before meals.""I know I need to drink fluids while I walk."

RATIONALE: A client with type 1 diabetes mellitus may become hypoglycemic while exercising. Someone must accompany her for her safety. She should exercise at the same time each day. She needs to exercise after meals, when blood sugar is high. Fluids aren't necessary, but the client needs to bring a simple carbohydrate with her to treat hypoglycemia. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA 23-year-old primigravida delivers a healthy 3090.1-g boy by vaginal delivery. During an assessment the next day, the nurse is examining her lower extremities for signs and symptoms of thrombophlebitis. Which of the following signs should be assessed?

Chadwick's signHegar's signHomans' signGoodell's sign

RATIONALE: Assessment of Homans' sign is accomplished by asking the client to stretch her legs out with her knees slightly flexed. The nurse grasps and dorsiflexes the foot. Pain or discomfort at the back of the knee or calf during this manipulation suggests thrombophlebitis. Chadwick's sign, Hegar's sign, and Goodell's sign are observable or palpable changes in the cervix, vagina, or uterus that indicate pregnancy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionA 17-year-old gravida 2, para 1 at 38 weeks' gestation presents with a headache. She has had leg edema for the past 3 weeks. Her blood pressure is 150/100 mm Hg. The client is admitted for treatment of pregnancy-induced hypertension, and magnesium sulfate I.V. therapy is initiated. The client says she feels "doped and sleepy" and "doesn't like feeling this way." What's the nurse's best response?

"That just means the medicine is doing what it's supposed to be doing.""Don't worry; everybody feels like this after taking magnesium sulfate.""That doesn't seem right. I will call the physician and see what he says about it.""This is one side effect of magnesium sulfate therapy; the feeling will go away when the medication is discontinued."

RATIONALE: Magnesium sulfate acts as a central nervous system depressant, so lethargy is a common adverse effect. Options 1 and 2 provide incomplete information to the client. Option 3 might be appropriate if the nurse found evidence of toxicity (flushing, reflex depression, decreased urine output, or depressed respiration). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 38-year-old gravida 4, para 3 at 36 weeks' gestation is admitted with thrombophlebitis. An I.V. heparin drip has been started. The client is on strict bed rest, with the nurse checking vital signs every 4 hours and fetal heart tones every 8 hours. The client is concerned about the effect the drug might

have on her baby. She states, "If it makes my blood thinner, then won't it make my baby's blood change?" What's the nurse's most appropriate response?

"Your doctor can answer this for you. Wait until he comes tomorrow and ask him.""It's impossible for this drug to change your baby's blood.""Heparin doesn't cross the placenta, so it can't get into the baby's blood system.""The heparin molecule is too large to get to the baby, so it can't damage the baby."

RATIONALE: Because its molecular weight is too high, heparin doesn't cross the placenta and thus wouldn't affect fetal blood. The client's concern is urgent. She doesn't need to wait until tomorrow when the nurse can give her a simple explanation now. Option 2 is vague and doesn't explain why the heparin won't affect the neonate. Use of the word "damage" may frighten the client, especially because the response doesn't exclude the client from injury. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA pregnant client is receiving heparin. Which of the following should be a part of nursing assessment on every shift?

Change in fetal activity and positionIncrease in blood pressure and temperatureAny signs of preterm labor and bleeding from an orificeHomans' sign or periorbital edema

RATIONALE: Potential complications of heparin therapy are preterm labor and maternal hemorrhage. Assessment of fetal activity is important, but fetal position isn't significant at this time. The client should be assessed for Homans' sign if she's at risk for deep vein thrombosis; periorbital edema is assessed in pregnancy-induced hypertension. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 15-year-old primigravida gave birth 2 days ago. She tells the nurse that having her own little baby will be wonderful. Which nursing response would best evaluate the accuracy of the client's expectations?

"Tell me what your day will be like after you take your baby home.""Will anyone be available to help you at home with the baby?""Have you had any experience taking care of babies?""What are you planning to do with your baby when you return to school?"

RATIONALE: Teenage lifestyles and support systems can vary immensely. This open-ended question will best help the health team gather data about the teen mother's feelings and expectations. The other options aren't open-ended and don't clearly ask the client about her expectations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client notices that her neonate's eyes appear to be crossed. She anxiously points this out to the nurse. What's the nurse's best response?

"This is a temporary condition caused by immature neuromuscular control of the eye muscles.""Don't worry; it will go away.""You should call it to the attention of your pediatrician.""We may have to call in an eye specialist."

RATIONALE: This response provides specific information to promote the client's understanding of neonate characteristics. Option 2 gives false reassurance and is a nontherapeutic effort to reduce the mother's concern. Options 3 and 4 aren't needed; the condition is normal and will gradually resolve itself as the eye muscles strengthen over the next 3 to 4 months. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse assesses a neonate's respiratory rate at 46 breaths/minute after 6 hours of life. Respirations are shallow, with periods of apnea lasting up to 5 seconds. Which action should the nurse take next?

Attach an apnea monitor.Continue routine monitoring.Follow respiratory arrest protocol.Call the pediatrician immediately to report findings.

RATIONALE: Normal respiratory rate is 30 to 60 breaths/minute. The other options aren't necessary; the listed findings are normal respiratory patterns in neonates. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA pale, thin 15-year-old comes to the clinic for a pregnancy test, which is positive. The client states that she and her boyfriend have run away from home and that both are unemployed. Which of the following statements by the nurse would be most therapeutic in beginning the assessment and establishing a relationship based on trust?

"How does your mother feel about your situation?""Have you talked to your mother?""Sometimes young women find it hard to talk about this with their mothers.""You don't have to tell your mother. What are you going to do?"

RATIONALE: This response may encourage the client to explore her feelings with a nurse who seems to understand. Options 1 and 4 might elicit some information, but they make assumptions about the client's situation in a way that seems likely to limit further communication or trust. Avoid closed questions such as the one in option 2. Even if the response is "yes," the adolescent may have given the answer she thinks the nurse wants to hear rather than telling the truth. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 19-year-old primigravida is being treated for her second case of simple vaginitis during pregnancy. Which of the following instructions is most important for the nurse to focus on during client teaching?

"Increase the pH of the vagina by douching regularly.""Douche daily with a mild soap solution.""Maintain cleanliness and avoid contamination after elimination.""Report any signs and symptoms immediately."

RATIONALE: Simple vaginitis can result from poor hygiene, tight clothing, or emotional stress. Teaching the client proper hygienic measures could help prevent a recurrence. Douching isn't recommended during pregnancy. In any case, the client would want to decrease vaginal pH to support the DOderlein's bacilli, the main defense of the vagina. If douching were ordered, the pH would be lowered by using a weak acid solution (such as vinegar and water), not a soap solution. Immediately reporting signs and symptoms wouldn't help prevent recurrence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client in her 36th week of pregnancy is admitted to the hospital with vaginal bleeding. After undergoing an ultrasonic scan, she's diagnosed with placenta previa. Which assessment finding would best confirm this diagnosis?

A rigid abdomenA soft, nontender uterusPainful vaginal bleedingHypotension

RATIONALE: A soft, relaxed, nontender uterus accompanied by vaginal bleeding indicates placenta previa. A rigid abdomen indicates abruptio placentae, in which a normally implanted placenta in the upper uterine segment prematurely separates from its implantation site. In placenta previa, the placenta isn't normally implanted, and the client shouldn't feel pain when it begins to break away. Hypotension may indicate many conditions other than placenta previa. Also, bleeding with placenta previa may not be severe enough to cause hypotension. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA primigravida client is 16 weeks pregnant. Which client teaching instruction would be most important to prevent toxoplasmosis?

Cook meats thoroughly.Keep dogs outside.Wash and cook all vegetables.Have antibody titers drawn on a routine basis.

RATIONALE: Undercooked fresh meats that contain cysts with toxoplasmosis can cause infection. Cats, not dogs, carry toxoplasmosis. Toxoplasmosis isn't carried on vegetables. Antibody titers won't prevent toxoplasmosis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA primipara client is 6 weeks pregnant. At her first prenatal visit, she says to the nurse, "I just can't believe I'm really pregnant. I hope this baby is a good idea." What would be the most likely evaluation the nurse would make from the client's statement?

The client is afraid of pregnancy and birth.The client should have waited until she was committed to having a baby.The client is experiencing normal ambivalence about being pregnant.The client may have problems attaching to the baby after birth.

RATIONALE: Ambivalence is normal in the first trimester of pregnancy, even when a pregnancy is planned and desired. Fear and attachment problems aren't substantiated by the evidence supplied. Assuming that the client should have waited to have her baby is judgmental. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is 22 weeks pregnant with her first child. Her weight gain is normal, but she complains of constipation. What's the most effective recommendation the nurse can make?

"Take a mild laxative daily.""Increase intake of fluids and high-fiber foods.""Relax when trying to move the bowels.""Start a strenuous exercise program."

RATIONALE: Increased fluids and fiber will soften the stool, making it easier to pass without medication use. Taking a laxative makes the client rely on medication. Relaxing during bowel movements is important but doesn't address the problem as effectively as increasing fluids and fiber. Starting a strenuous exercise program is discouraged during pregnancy unless the client is already accustomed to it. Mild exercise is safe, however, and may increase peristalsis and enhance stool passage. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with type 1 diabetes mellitus is gravida 2, para 0, abortus 1. She's now at 37 weeks' gestation. Several tests to determine fetal lung maturity have been performed by amniocentesis. Which is the most reliable indicator of fetal lung maturity?

Lecithin-sphingomyelin (L/S) ratio of 2:1The presence of phosphatidylglycerolIncreasing bilirubin levelsDecreasing estriol levels

RATIONALE: The presence of phosphatidylglycerol is a reliable sign that the lungs are mature. The L/S ratio must be higher in the diabetic because high insulin levels inhibit surfactant production. Bilirubin levels don't measure fetal lung maturity and should decrease at term; increasing levels may signal a fetal blood incompatibility. Estriol levels don't measure fetal lung maturity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client in her 7th month of pregnancy has been complaining of back pain and wants to know what can be done to relieve it. Which of the following responses by the nurse is most effective?

"You need to lie down more during the day to get off your feet.""Avoid lifting heavy loads, and try using the pelvic tilt exercise.""Have others pick things up for you so you don't have to bend over so much.""Your back pain will go away after the baby is born."

RATIONALE: The pelvic tilt exercise, which can be done standing as well as lying down, can greatly relieve back discomfort. As the pregnancy progresses into the last trimester, women typically develop a "swayback" curvature of the spine to counterbalance the enlarging fetus. Tilting of the pelvis aligns the spine, decreasing pressure and back discomfort. Lying down more during the day may not be possible or convenient for some clients. Also, the supine position may not be comfortable for some clients and may cause vena cava syndrome (dizziness on rising and decreased circulation to the fetus). Avoiding bending over as much may not be realistic for the client's circumstances, nor does it address back pain as effectively as the pelvic tilt. The last response doesn't help to relieve the client's discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA nurse instructs a prenatal class about the importance of doing Kegel exercises frequently. Kegel exercises help to:

promote better breathing by strengthening the diaphragm muscle.maintain good perineal muscle tone by tightening the pubococcygeus muscle.minimize leg cramps by strengthening the calf muscles.prepare the mother for pushing by strengthening the abdominal muscles.

RATIONALE: Kegel exercises are performed by alternately tightening and releasing perineal muscles to strengthen the pubococcygeus muscle and increase its elasticity. The pubococcygeus muscle supports internal organs, such as the uterus and bladder. Kegel exercises don't affect breathing or muscles of the diaphragm, leg, or abdomen. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to assist her to turn every 2 hours. Which of the following conditions is this intervention intended to prevent?

Pressure ulcersMuscular stiffnessRespiratory complicationsVenous stasis

RATIONALE: General anesthesia and postoperative pain may lead to immobility, which predisposes to respiratory complications postoperatively. Changing positions, along with coughing and deep breathing, is done to prevent respiratory complications. It's unlikely that an otherwise healthy young woman would develop pressure ulcers during a brief postoperative period. Muscular stiffness would, of course, be decreased with frequent turning, but this isn't the most important rationale for turning. Turning may decrease venous stasis, but a more effective intervention to decrease venous stasis in the

early postoperative period would be leg exercises. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationAs part of a prenatal nutritional teaching program for a 17-year-old who is concerned about weight gain, which of the following statements by the nurse would be most accurate?

"If you stay away from fast foods, your weight gain will be minimal.""You're young. You'll be able to lose the weight after the baby is born with no problems.""During pregnancy, a woman's caloric needs increase by about 300 calories per day. If you like, I can help you with some meal planning.""Keep your caloric intake to around 1,000 calories per day. In this way you'll gain only the proper amount of weight."

RATIONALE: This statement supplies the client with facts and offers help and guidance for a healthier pregnancy. Options 1 and 2 are unrealistic and offer false reassurance. Option 4 is insufficient to nourish a teenage girl and the growing fetus. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 34-year-old client at 32 weeks' gestation tells the nurse that her baby will be sick because she saw a dead dog on the road yesterday. What's the best response by the nurse?

"Your baby will be fine. That's just superstition.""Don't worry. We'll make sure your baby is okay.""I can see that you are concerned. Let's talk about what's bothering you.""Perhaps so. Your baby should be seen by a physician as soon as it's born."

RATIONALE: Some cultures hold that if a pregnant woman looks upon a dead animal, the fetus is exposed to the realm of the dead and may later become ill as a baby. The nurse's response is sensitive to the mother's beliefs and eases the way for the mother to begin to talk about her concern. Option 1 discounts the mother's beliefs. Option 2 dismisses the mother's concerns and offers false reassurance. Option 4 carries empathy over into false validation and overreaction, yet it fails to set up any dialogue with the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhich of the following pregnancy complications are most common among adolescents?

Pregnancy-induced hypertension (PIH) and iron-deficiency anemiaHypothyroidism and obesityDiabetes and cardiac diseaseIron-deficiency anemia and Rh disease

RATIONALE: PIH is the most prevalent medical complication in adolescents. This may be related to parity rather than age, however. Most pregnant adolescents are nulliparous, and nulliparity has been determined as an important factor related to PIH. Many adolescents have iron-deficiency anemia even before beginning their pregnancy because of their previous rapid growth spurt. Hyperthyroidism, obesity, diabetes, and cardiac disease aren't specific to adolescent pregnancy. Rh disease has nothing to do with adolescence. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionThe human embryo grows at a rapid rate. At what gestational age does a single-chambered heart begin to beat and pump its own blood cells through main blood vessels?

Approximately 8 weeksApproximately 60 daysApproximately 5 weeksApproximately 24 days

RATIONALE: In the embryo's third week, the heart becomes the most advanced organ. Around the 24th day, a single-chambered heart forms just outside the embryo's body cavity and begins beating a regular rhythm, pushing its own primitive blood cells through the main blood vessels. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 22-year-old, gravida 1 client presents to the maternity clinic for her first prenatal visit. The approximate gestational age is 10 weeks. What's the simplest and most cost-effective means of determining her nutritional status?

Food frequency questionnaire and blood testsInterview focusing on food allergies and intolerancesAnthropometric measures and 24-hour recallDiet history interview

RATIONALE: A combination of anthropometric measurements and 24-hour recall provides information about the nutritional status and food choices that can be evaluated immediately and also serves as a starting point for nutrition counseling. A food frequency questionnaire might be useful for long-term monitoring after a problem is identified. Food allergies and intolerances are only a small part of the nutritional status profile. A complex diet history interview requires a highly trained nutritionist and is too costly for general practice. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 2-week postpartum client inquires about alcohol use during lactation. She tells the nurse she has heard that a small glass of wine or beer before nursing will increase her milk supply and be good for the baby. What's the nurse's best response?

"It's true that a little alcohol before breast-feeding will help your milk supply because it will help you relax.""Research has shown that it actually decreases the amount of milk the baby will get, perhaps because it affects the taste of your milk.""A little alcohol will help you to relax and the small amount that will pass through the milk may just help the baby relax.""You shouldn't even consider drinking alcohol while you are nursing a baby."

RATIONALE: According to several recent studies, breast-fed babies consume less milk on days when their mothers drink alcohol. In light of the recent studies and the incidence of alcohol-related problems in our society, encouraging alcohol use by breast-feeding mothers is unwise. This judgmental response negates the responsible behavior that the client demonstrated by asking a nurse for advice. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client in the first trimester complains of nausea every morning and asks about medicine to prevent it. What response by the nurse would be most helpful?

"Let me tell you about some methods to control nausea without medication.""You shouldn't take medication during pregnancy, especially during the early weeks.""I'll ask the physician if you can have something.""You'll probably have a lot less nausea in just a few weeks."

RATIONALE: This gives concrete help to the client without involving drug therapy. Options 2 and 4 may be true in general, but they don't give any help to the woman. They may be used as adjunct explanations along with the nurse's specific suggestions. Drug therapy is inappropriate without evidence that the nausea is detrimental to the client's health. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is in the second trimester of her first pregnancy. She confides that she has been smoking about one-half of a pack of cigarettes per day because she had been told that smoking results in smaller babies and she's fearful of delivery. What's the best response by the nurse?

"You should know better than to smoke at all. Your baby will be much better off if it's bigger.""I can understand your concern. A few cigarettes shouldn't hurt the baby.""Unfortunately, the smaller size of the baby of a smoking mother has more to do with its overall development than with the ease of delivery. Let's talk about it.""Unfortunately, that's just not true. Your baby's size is determined by factors unrelated to smoking."

RATIONALE: The truth is that smoking does affect the size of the baby - including the size of its brain. Option 1 is judgmental and doesn't enhance further communication about two important issues, smoking and the fear of delivery. Option 2 gives false reassurance; research has clearly shown cigarette smoking to be harmful to the developing fetus. Smoking can cause lower birth weight and intrauterine growth retardation, so option 4 is untrue. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhile evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following?

Feelings of disbelief and ambivalenceFeelings of clumsiness and "ugliness"Increasing introspection but a general sense of well-beingAnxiety about the labor and delivery experience

RATIONALE: Women generally feel best during the second trimester. Most enjoy a rather tranquil few months when they experience quickening and begin to "show" without the heaviness and awkwardness of the third trimester. Feelings of disbelief and ambivalence are more common in the first trimester; feelings of clumsiness and "ugliness" and anxiety about the labor and delivery experience are more common in the third trimester. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA primipara client in her 10th week of pregnancy calls the nurse to say that she's experiencing slight vaginal bleeding. What's the nurse's best response?

"Lie down on your left side and call again if the bleeding worsens.""Save any perineal pads, clots, and tissue and come to the clinic right away.""Avoid sexual intercourse for the next 2 weeks.""Continue your normal activities and increase your fluid intake."

RATIONALE: Vaginal bleeding, a sign of threatened abortion, warrants immediate attention. Saving perineal pads and any matter passed vaginally will make evaluation more reliable. The left lateral position is important during the last trimester, when the possibility of vena cava syndrome exists. Sexual activity isn't usually implicated in spontaneous abortion. Continuing normal activities and increasing fluid intake fail to address the client's need to see the physician immediately. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid?

Egg yolksFruitBreadMilk

RATIONALE: Egg yolks, nuts, seeds, and liver are all high in folic acid. The other options aren't good sources of folic acid. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 27-year-old primipara in her 5th month of pregnancy has been receiving regular prenatal care since week 8. She complains of feeling dizzy, breathless, and clammy on rising from bed in the morning. In responding to the client, the nurse would assess for which of the following conditions?

ShockHemorrhageSupine hypotensionFainting

RATIONALE: Supine hypotension is a common complication of pregnancy. Although some symptoms of shock resemble those seen in supine hypotension, the given data wouldn't predispose the client to shock. The assessment data don't indicate hemorrhage. The symptoms given in the case study don't describe fainting itself. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationIn assessing a client for pregnancy, the nurse would look for which positive sign?

QuickeningAmenorrheaFetal movement felt by the examinerEnlarged uterus

RATIONALE: Fetal movement detected by an examiner is an objective, positive sign of pregnancy. Quickening, a subjective sign of pregnancy experienced by the woman, isn't as reliable as an independent assessment. Amenorrhea and enlargement of the uterus can occur in a molar pregnancy or for various reasons unrelated to pregnancy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 35-year-old client is in the 8th month of her first pregnancy. Her physician orders a biophysical profile to be conducted the next day. What equipment would the nurse assemble to conduct this test?

Sphygmomanometer and thermometerUltrasound machine and fetal monitorUltrasound machine and sphygmomanometerFetal monitor and electronic blood pressure measuring device

RATIONALE: During a biophysical profile, the amount and quality of fetal movement and the amount of amniotic fluid are measured via ultrasonography followed by a nonstress test. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse assesses the client's lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day?

Dark red (lochia rubra), large amount, with many clotsPink (lochia serosa), moderate amount, no clotsWhite (lochia alba), scant amount, no clotsDark red (lochia rubra), moderate amount, with a few small clots

RATIONALE: Lochia rubra is usually seen during the first 1 to 3 days. It should be moderate in amount and may include some small clots. Four to eight perineal pads are used daily on average. Heavy bleeding could be from uterine atony or retained placental fragments and therefore requires further investigation. Lochia serosa follows lochia rubra and lasts to about the 10th postpartum day. Lochia alba is seen from approximately the 11th to the 21st postpartum day. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

A neonate born at 34 weeks' gestation has a surfactant deficit. Which of the following conditions would the nurse most likely find in completing a neonate assessment?

JaundiceSternal retractionsAbdominal distentionFrothy, blood-tinged sputum

RATIONALE: A surfactant deficit reduces lung compliance and increases the inspiratory pressure needed to expand the lungs. It doesn't affect the liver or abdomen. Frothy, blood-tinged sputum is more closely associated with pulmonary edema. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client has a boggy uterus during stage IV of her delivery. Four hours postpartum, the nurse is preparing to administer methylergonovine maleate (Methergine) 0.2 mg P.O. as prescribed every 6 hours. The client's vital signs are: temperature, 100.4% F (38% C); pulse, 60 beats/minute; respirations, 14 breaths/minute; blood pressure, 140/90 mm Hg. Which is the most appropriate intervention?

Immediately administer the drug.Administer the drug and call the physician.Administer the drug and recheck vital signs.Don't administer the drug.

RATIONALE: Methylergonovine maleate, a vasoconstrictor, can cause hypertension. It shouldn't be administered to a hypertensive client. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA multigravida in her 34th week of gestation presents in the emergency department complaining of vaginal bleeding. Which of the following should be the nurse's first action?

Establish I.V. access.Assess fetal heart rate (FHR) and maternal blood pressure.Prepare the client for a cesarean delivery.Assess maternal heart rate and respiratory rate.

RATIONALE: FHR and maternal blood pressure will provide important data on the conditions of mother and fetus. An I.V. should be started after the maternal-fetal dyad is assessed. Preparing the client for a cesarean delivery before determining the cause of the vaginal bleeding would be premature. Maternal heart rate and respiratory rate aren't the best indicators of maternal health status and provide no information about fetal health. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client at term arrives at the labor room experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electronic fetal monitor is applied. Which of the following would alert the nurse to an increased potential for fetal distress?

Weight gain of 30 lb (13.6 kg)Maternal age of 32 yearsBlood pressure of 146/90 mm HgTreatment for syphilis at 15 weeks' gestation

RATIONALE: Blood pressure of 146/90 mm Hg indicates pregnancy-induced hypertension (PIH). Over time, PIH reduces blood flow to the placenta; it can cause intrauterine growth retardation and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb is within the expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationDuring labor, meconium in the amniotic fluid is a normal finding in which of the following situations?

Preterm laborCephalopelvic disproportionProlonged latent phaseBreech presentation

RATIONALE: Meconium in a breech presentation may be caused by compression of the fetus's intestinal tract on descent. Meconium in the other situations could signify fetal distress caused by a brief period of fetal hypoxia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionWhich of the following assessments indicates fetal distress?

Fetal scalp pH of 7.14Fetal heart rate (FHR) of 144 beats/minuteAcceleration of FHR with contractionsLong-term variability

RATIONALE: A scalp pH of less than 7.25 indicates acidosis and fetal hypoxia. The other options are normal responses of a healthy fetus to labor. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ComprehensionA primipara at 32 weeks' gestation presents complaining of vaginal bleeding. She has soaked one peripad. She has no pain or cramps. In performing an assessment, the nurse would suspect which of the following?

Placenta previaAbruptio placentaeVasa previaIncompetent cervix

RATIONALE: Painless vaginal bleeding is the classic sign of placenta previa. Abruptio placentae is painful. Vasa previa occurs with ruptured membranes. An incompetent cervix causes pressure sensations. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client at 42 weeks' gestation is 3 cm dilated and 30% effaced with membranes intact and the fetus at +2 station. The client is started on oxytocin (Pitocin) to induce labor. After 2 hours, the nurse notes on the electronic fetal monitor that the fetal heart rate (FHR) has been ranging from 160 to 190 beats/minute for the past 10 minutes. The client states that her baby has been very active. Contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. What part of this assessment data would indicate fetal distress?

Uterine contractions lasting 40 to 60 secondsStrong uterine contractionsUterine contractions occurring every 3 to 4 minutesFHR ranging from 160 to 190 beats/minute

RATIONALE: Fetal tachycardia and excessive fetal activity are the first signs of fetal hypoxia (distress). The duration of uterine contractions is within normal limits. Uterine intensity can be mild, moderate, or strong. The frequency of contractions is within normal limits for the active phase of

labor. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisWhich of the following effects of pregnancy would be most likely to occur in an adolescent client?

Delayed independence from parentsDevelopment of the maturity to sustain complex interpersonal relationshipsIncreased motivation to develop financial stabilityIncreased awareness and use of contraceptives

RATIONALE: A pregnant adolescent enters a cycle of defeat that strains relationships, disrupts education, and impairs earning power. Pregnancy and child rearing usually force the adolescent into prolonged dependence on the parents for support and assistance. Pregnancy and child rearing can delay adolescent development and interfere with the formation of stable relationships. Financial independence proves difficult to achieve for adolescent parents, many of whom never complete their education. One teenage pregnancy is commonly followed by another, especially if the first one occurred in younger adolescence. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is admitted to the labor and delivery unit in active labor. She has had no prenatal care but appears to be between 32 and 35 weeks' gestation. History reveals that she's gravida 5, para 1, abortus 3. She tells the nurse she thinks her friend gave her a cigarette containing crack cocaine. What should the nurse do next?

Move the precipitant delivery cart to the labor room, and notify the neonatologist on call.Teach the mother controlled breathing techniques.Call a family member to come to the hospital.Call the friend who gave the client the cigarette and find out exactly what the drug was.

RATIONALE: Cocaine causes increased uterine contractility, preterm labor, and illness in babies born to addicted mothers. This client is in active labor, has a questionable history, and an undetermined length of gestation. The nurse should anticipate a quick delivery and a small, sick neonate. This client isn't in a teachable frame of mind or situation. Calling a family member isn't a priority when a high-risk birth is imminent. The client's friend may be impossible to locate and may not know exactly what was in the cigarette. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationA client at 32 weeks' gestation who is leaking amniotic fluid is placed on an electronic fetal monitor. The nurse interprets the monitor strip to indicate uterine irritability, with contractions occurring every 4 to 6 minutes. The physician orders subcutaneous terbutaline (Brethine). Which of the following teaching statements is appropriate for this client?

"This medicine will make you breathe better.""You'll probably feel no different than if you had taken a Tylenol.""You may feel a fluttering or tight sensation in your chest.""This will make your mouth feel dry and make you thirsty."

RATIONALE: A tight or fluttering sensation in the chest is a common side effect of terbutaline. To counter this effect, the drug is commonly administered with hydroxyzine hydrochloride (Vistaril). Terbutaline does relieve bronchospasms, but this isn't why the client is receiving it. Terbutaline can produce clearly perceived adverse effects. Mouth dryness may occur with the inhaled form of terbutaline but is unlikely with the subcutaneous form. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client vaginally delivers a 4,365.8-g neonate, with a midline episiotomy. Shortly after delivery, the client complains of not feeling well. In assessing for possible uterine hemorrhage, the nurse should note:

severe cramping, chills, and shaking.extreme fatigue and lethargy.cool, clammy, pale skin and anxiety.hunger, thirst, and hot flashes.

RATIONALE: Cool, clammy, pale skin and anxiety are signs of impending hypovolemic shock that requires immediate assessment of lochia, fundus tone, and vital signs. Severe cramping, chills, shaking, extreme fatigue, and lethargy are normal for the recovery phase. Hunger and thirst are common in mothers who have a normal vaginal delivery without heavy sedation. Hot flashes commonly occur several hours postpartum and are brought about by hormonal changes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA 31-year-old primigravida has had an uncomplicated pregnancy. At 41 weeks' gestation, she's admitted to the labor suite for oxytocin induction of labor. The pre-labor evaluation reveals the client's cervix to be 3 cm dilated, 50% effaced, soft, and in anterior position. Fetal station is 0. These assessment data yield a score of 9 in the Bishop scoring system. Based on these findings, what would the nurse expect to take place?

The induction most probably will be successful because the cervix is favorable.The induction most probably won't be successful because the cervix isn't favorable.The induction should be delayed until the cervix is 75% effaced.The induction should be delayed until 42 weeks' gestation.

RATIONALE: A soft cervix in the anterior position, 50% effaced, and dilated at least 2 cm, with the fetal head at +1 station or lower (Bishop score of 9), is favorable for successful induction of labor. Assessment data don't indicate that induction won't succeed or that it should be delayed. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 26-year-old primigravida is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the physician prescribes an epidural regional block. What position should the nurse help the client to assume when the epidural is administered?

LithotomySupineProneLateral

RATIONALE: The client is placed on her left side, with shoulders parallel and legs slightly flexed. The epidural space, the potential space between the dura mater and the ligamentum flavum, is readily accessed with the client on her side. None of the other positions allows proper access to the epidural space. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client is in labor with her first child. Which of the following would indicate that the client has moved into the second stage of labor?

The client has an uncontrollable urge to bear down.The client has a decrease in bloody show.The client becomes increasingly talkative.The client takes three deep cleansing breaths.

RATIONALE: One sign that indicates onset of labor's second stage is the involuntary urge to bear down. This is caused by the Ferguson reflex, which is activated when the presenting part of the fetus approaches or touches the perineal floor. The bloody show increases, not decreases, in stage II labor.

The client wouldn't become more talkative. She would either be more apprehensive and irritable or be pushing and then resting between contractions. Cleansing breaths may be taken any time to increase oxygenation and promote relaxation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionAfter assessing the nutritional status of a 21-year-old client at 10 weeks' gestation, the nurse chooses the diagnosis Deficient knowledge (lack of exposure) related to nutritional needs during pregnancy. What should the nurse include in the care plan?

Identify learning goals for the client.Tell the client to establish appropriate learning goals.Outline the decisions that the client will need to make.Identify factors that may affect the client's learning.

RATIONALE: This involves establishing a baseline that will be more likely to result in relevant and appropriate learning. The other options fail to include the client in the planning. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy?

"I expect to gain a few pounds each month at first. Then I'll really get big and put on 20 pounds or so.""I guess I will get big and gain 20 to 30 pounds and look pregnant.""Because I have to eat for two, I should eat whatever I want whenever I feel hungry.""I will need to eat more so that I will gain about 25 pounds, but I want to make sure I don't fill up with junk food."

RATIONALE: This statement shows an understanding of nutritional needs during pregnancy. Option 1 accurately portrays weight gain but doesn't express an understanding of nutritional needs. Option 2 doesn't show an understanding of either nutritional needs or how and when the weight gain will occur. Option 3 is a common rationalization that can result in excessive weight gain. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client in active labor is having difficulty remaining focused. Her husband, sister, and mother are in the room with her. The fetal monitor shows slowing of the fetal heart rate (FHR) that begins after the peak of each contraction. Which of the following nursing interventions is best for the client?

Have the client get up and walk for a while.Have the client lie on her left side, and ask the family to take turns being with the client one at a time.Leave the client and the family alone.Turn on the television to give the client something to focus on.

RATIONALE: FHR can slow for various reasons, including decreased maternal blood flow to the uterus. Turning onto the left side promotes effective blood flow by relieving pressure from the great vessels that run down the back to the legs and feed the uterus. Limiting the client to one visitor at a time will cause fewer distractions and improve her chances of focusing properly on breathing techniques. The client can't walk at this stage of labor. Intervention is appropriate at this time. Turning on the television would increase the stimuli and make focusing even more difficult for the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 15-year-old pregnant client who comes alone to the maternity clinic states that she and her boyfriend have quit their jobs and run away from home. Which of the following goals is likely to have the greatest long-term effect on the future well-being of this client?

Promotion of self-esteemPromotion of physical well-beingPromotion of family adaptationFacilitation of prenatal education

RATIONALE: Teenage pregnancy is commonly related to problems of indecision, poor self-image, and egocentrism. If the client can develop self-esteem, the other goals may follow, and such problems as child abuse, drug abuse, and unemployment may be overcome or avoided. Options 2, 3, and 4 are important goals but not as far-reaching as the development of self-esteem. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 17-year-old primigravida with severe pregnancy-induced hypertension has been receiving magnesium sulfate I.V. for 3 hours. The nurse assesses deep tendon reflexes (DTR), vital signs, and fetal heart tones every 15 minutes and urine output hourly. The latest assessment yields the following data: DTR, +1; blood pressure, 150/100 mm Hg; pulse, 92 beats/minute; respiratory rate, 10 breaths/minute; urine output, 20 ml/hour. The client appears flushed and complains of feeling warm. Which nursing action would be most appropriate?

Take no action; continue monitoring per standards of care.Discontinue the magnesium sulfate infusion.Increase the infusion rate by 5 gtt/minute.Decrease the infusion rate by 5 gtt/minute.

RATIONALE: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls below specified levels or if reflexes are diminished or absent. Many protocols require discontinuing magnesium sulfate if respirations fall below 12 breaths/minute. Normal DTR is +2; this client's have fallen to +1. Urine output is below the accepted minimum of 25 to 30 ml/hour. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction won't resolve the client's suppressed DTR and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate. Impending toxicity indicates that the infusion should be discontinued rather than just slowed down. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client with diabetes delivers a 2,721.6-g neonate at 36 weeks' gestation. The neonate is placed in the neonatal intensive care unit. The mother is grieving over the early delivery. What action by the nurse would be most helpful to the client?

Seek involvement of external support systems to provide emotional comfort and material resources for the client.Generalize how the client must be feeling based on her written history and pregnancy course.Encourage the client to immerse herself in her intense feeling of grief.Call the client's minister to obtain spiritual support for her and her family.

RATIONALE: Based on their knowledge of the client's unique needs and coping mechanisms, close family and friends can offer support and resources to deal most effectively with the client's concerns. Seeking involvement of external support systems to provide emotional comfort and material resources for the client doesn't allow the client to express her feelings. Although expressing grief is important, it doesn't address the critical need for support systems. Calling the client's minister to obtain spiritual support for her and her family is one of many support systems covered by seeking involvement of external support systems to provide emotional comfort and material resources for the client. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA neonate weighed 3,350 g at birth. On discharge (postpartum day 3), his weight had decreased to 3,100 g. His mother is upset and asks whether the neonate was fed in the nursery. Which of these responses would be most helpful?

"Most neonates lose 10% to 30% of their birth weight.""I understand your concern. His weight loss is excessive.""Show me how you have been feeding the baby.""I can see that you're worried. His weight loss is an expected one. He'll probably start to gain weight now."

RATIONALE: Physiological weight loss of 5% to 10% occurs after birth due to fluid shift; 10% to 30% is too high. This neonate's weight loss is within expected percentages. Asking the mother to show you how she feeds the baby implies to the mother that she has been doing something wrong. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA new mother is discharged 16 hours after delivery. Which of the following symptoms would require the new mother to contact her health care provider?

Vaginal tenderness and dryness during sexual activityUterus that's no longer palpable abdominally after 2 weeksBright red lochia with an increased flow rateFatigue and weight loss

RATIONALE: New mothers should be aware of complications that can occur after discharge. A change in the color of lochia with increased flow may indicate retained placental fragments. Vaginal tenderness and dryness during sexual activity, a uterus that's no longer palpable abdominally after 2 weeks, and fatigue and weight loss are normal symptoms after delivery; in addition, sexual activity is usually not resumed until several weeks after delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 21-year-old primigravida had an emergency cesarean delivery because of anticipated fetal distress. Three days after her delivery, the client seems preoccupied and troubled, and the nurse notes her crying in her room after visitors leave. She tells the nurse that her incision is ugly and that she "feels like a failure." In responding to the client, the nurse should consider which of the following?

The client is experiencing abnormal feelings and needs psychiatric care.The client is grieving the loss of her anticipated childbirth experience.The client is in the dependent taking-in phase described by Rubin.The client is tired and upset from having too many visitors.

RATIONALE: Some women who give birth by cesarean delivery, especially when unexpected, have negative feelings afterward and blame themselves for their inability to deliver "normally." Grieving such a loss of vaginal delivery is normal. The client's feelings aren't abnormal. The taking-in phase occurs in the first day or two. There isn't enough evidence to indicate that the client was having too many visitors. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA gravida 3 delivered her first child vaginally and her second child by cesarean delivery due to a complete placenta previa. After consulting with her physician about the third delivery, the client agrees to attempt a vaginal birth after cesarean (VBAC). She presents at the local hospital in early labor, 3 to 4 cm dilated, 80% effaced, at +1 station. The nurse reviewing the client's prenatal record notes that the client had received the appropriate incision to attempt a VBAC. Which type of incision should be listed on her prenatal record?

Upper uterine segment classical incisionLower uterine segment vertical incisionCombination upper and lower uterine T incisionLower uterine segment transverse incision

RATIONALE: The lower uterine segment transverse incision has less side to side tension; therefore, dehiscence is rare. This is the only type of uterine incision that allows for a VBAC. The other options include vertical cuts, and the incisions are more likely to rupture with contractions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationDuring her first prenatal visit to the obstetrician's office, a client complains of increased vaginal drainage. Which of the following responses by the nurse is most appropriate?

"This is normal during pregnancy. Just be sure to wash daily with soap and water.""This may indicate an infection, and the drainage will have to be cultured.""This is normal during pregnancy, and you can douche daily.""This is an unusual occurrence, and you must be seen by the physician immediately."

RATIONALE: Increased vaginal drainage is normal during pregnancy. The client should be instructed on proper perineum care and told not to douche during pregnancy. Responses 2 and 4 incorrectly suggest that the increased drainage is abnormal. Response 3 inappropriately instructs the client to douche daily. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 19-year-old primigravida is admitted to the labor and delivery unit in labor. She's 2 cm dilated and 50% effaced, and the fetal head is at 0 station. She's having moderately strong 40-second contractions every 5 minutes. She seems rather anxious and becomes very tense during each contraction. When the client asks for pain relief, what should the nurse do next?

Determine the source of her anxiety and institute interventions to help her relax.Immediately check the physician's order and give her the analgesic ordered.Inform her that the neonate's head isn't down far enough just yet but that, as soon as it is, medication will be given.Tell her that her contractions are only moderately strong and that she should wait until later to take medication.

RATIONALE: Decreasing anxiety can break the fear-tension-pain cycle. Analgesics given too early can prolong labor. Informing the client that the neonate's head isn't down far enough and telling her that her contractions are only moderately strong aren't helpful or encouraging; she obviously needs immediate attention of some kind. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 24-year-old gravida 2 asks the nurse about the safety and effectiveness of a pudendal block. Which of these statements about a pudendal block would be most helpful to the client?

"A 6" needle is used to inject anesthetic into your vagina.""A pudendal block commonly causes the mother's pulse to increase temporarily.""A pudendal block can't be given until the baby's head is far down in the birth canal.""There's usually little effect on the baby or on the course of labor."

RATIONALE: A pudendal block contains a moderate dose of anesthetic, which has minimal effects on the fetus or on labor unless inadvertently injected intravenously. The response in option 1 isn't worded sensitively; the client doesn't need to know the needle's exact length. A pudendal block doesn't usually cause changes in maternal vital signs. A transvaginal pudendal block is performed before the fetal head is far down in the birth canal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionA first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor?

Discomfort located chiefly in the abdomenConstant intensity of contractionsContractions occurring every 10 to 15 minutes and lasting 20 to 30 secondsCervix that's 100% effaced and 2 cm dilated

RATIONALE: In true labor, the cervix becomes effaced and dilated. In false labor, contractions are located chiefly in the abdomen, the intensity of contractions remains the same, and the interval between contractions remains long. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client in labor is informed that she's going to receive epidural analgesia. She asks the nurse about disadvantages to this procedure. What's the nurse's best response?

"Fetal distress is a frequent problem.""The incidence of operative delivery may be increased.""The amount of blood loss is excessive.""Only partial motor paralysis develops."

RATIONALE: An epidural block takes 10 to 20 minutes to relieve pain and can result in maternal hypotension, decreased variability of the fetal heart rate, and increased incidence of operative delivery if the woman can't bear down effectively. Fetal distress is rare unless the mother experiences hypotension. Blood loss isn't excessive. Partial motor paralysis isn't a disadvantage as long as the mother is alert, responsive, and relaxed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA 24-year-old client on the labor unit is being coached in the Lamaze method by her husband. On assessment, the nurse finds the client to be 5 cm dilated, 90% effaced, at +1 station with contractions coming every 2 to 3 minutes and lasting 35 to 40 seconds. The client has asked for pain relief. What's the nurse's best action?

Check maternal blood pressure and pulse and fetal heart rate in response to contractions.Realize that it's too early to give pain medication, and encourage the husband to continue with the Lamaze coaching.Arrange for a sonogram to determine fetal position.Perform a vaginal examination to determine dilation, effacement, and station.

RATIONALE: Before administering medication to a client in labor, the nurse must assess the client and fetus. Pain medication can be given when the client is in active labor. A sonogram is inappropriate for a client in labor. The vaginal examination had just been performed and therefore isn't necessary at this time. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA primigravida in labor for 13 hours clenches her fists, tightens her muscles, and screams during every contraction. Her reaction to labor seems exaggerated compared to the contraction pattern recording from the electronic fetal monitor (EFM). What's the nurse's best response?

Explain to the client that the EFM shows mild contractions, so she should just relax and let the contractions work.Take over as her coach because her husband isn't helping her properly.Ignore her reactions, realizing that this is her first time in labor and her reactions will soon match the intensity of contractions shown on the EFM.Palpate her abdomen to determine the intensity of labor contractions as they're taking place.

RATIONALE: Internal and external fetal monitors are helpful in assessing the duration and frequency of contractions, but the external monitor doesn't accurately portray the intensity of the contraction. The labor room nurse must evaluate this by palpation. Taking over as her coach, ignoring her reactions, and telling her to relax fail to recognize the need for palpation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is to have a cesarean delivery because of continuous vaginal bleeding and an abnormal fetal heart rate tracing. Which of the following would be the best preoperative medication for this client?

Meperidine (Demerol)Oxytocin (Pitocin)Promethazine (Phenergan)Glycopyrrolate (Robinul)

RATIONALE: Glycopyrrolate is a parasympatholytic that will decrease the risk of aspiration. Meperidine and promethazine can cause central nervous system and respiratory depression in neonates. Oxytocin precipitates labor. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client is in the second trimester of her first pregnancy. Which of the following findings should the nurse bring to the attention of the obstetrician or nurse midwife?

Diagonal conjugate of 12.5 cmFundal height of 22 cm on August 20 (last menstrual period March 20)Rubella titer of 1:10.No ballottement

RATIONALE: Ballottement should be felt from the fourth to fifth month; no ballottement would suggest oligohydramnios and thus should be referred for further evaluation of fetal status. The other options 1, 2, and 3 are normal findings. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains of a need to push. While performing a vaginal examination, the nurse accidentally ruptures the membranes, and as she withdraws her hand, the fetal cord comes out. What should the nurse do next?

Put the client in a knee-chest position.Call the physician.Push down on the uterine fundus.Set up for fetal blood sampling to detect fetal acidosis.

RATIONALE: The knee-chest position gets the weight of the neonate off the cord to prevent disruption of blood flow. Calling the physician and setting up for fetal blood sampling are important, but they have a lower priority than getting the neonate off the cord. Pushing down on the uterine fundus increases danger by compromising cord blood flow. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisA client with hypotonic labor dysfunction is receiving oxytocin augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at station +1. The nurse notes a soft bulge just above the symphysis. Which of the following actions is best?

Re-evaluate the fetal presentation.Change the client's position.Offer a narcotic analgesic.Help the client urinate.

RATIONALE: Assessment data indicate a full bladder that may impede fetal descent. The other options are inappropriate because they don't address the assessment findings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: AnalysisA baby girl is delivered at 38 weeks' gestation. She weighs 2,324.7 g and is having difficulty maintaining body temperature. Which nursing activity would best prevent cold stress in a term neonate?

Immediately after birth, dry the neonate thoroughly, place her in a radiant heater, and monitor her temperature for the next 2 hours.Administer oxygen for the first 30 minutes of life.

Decrease integumentary stimulation after birth.Maintain the environmental temperature at 86% F (30% C).

RATIONALE: Immediately after birth, drying the neonate thoroughly, placing her in a radiant heater, and monitoring her temperature helps prevent the loss of body heat from evaporation, conduction, and convection. Administering oxygen for the first 30 minutes of life and decreasing integumentary stimulation have no effect in preventing cold stress. Maintaining the environmental temperature at 86% F could still cause loss of body heat via conduction and convection. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: ApplicationIn which of the following instances is it safe to continue an oxytocin (Pitocin) induction?

When contractions are painful to the motherWhen contractions last 100 seconds or moreWhen contractions occur every 90 secondsWhen the fetal heart rate (FHR) is 100 beats/minute

RATIONALE: Maternal pain isn't in itself an unsafe condition. Painful uterine contractions can be controlled with analgesia. When contractions last 100 seconds or longer or they occur every 90 seconds, fetal hypoxia can result. Slowed FHR is a sign of fetal hypoxia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionA gravida 2, para 1 with pregnancy-induced hypertension is receiving magnesium sulfate I.V., 2 g/hour via infusion pump. In assessing the client, the nurse notes a decrease in respirations from 16 to 12 breaths/minute and slightly pink-tinged urine (output is 25 ml/hour). The client still complains of feeling sleepy. The nurse's action should include:

checking the most recent serum level of magnesium sulfate and notifying the physician of the results.turning the client on her left side and taking vital signs again.flushing the client's indwelling urinary catheter with sterile normal saline solution to see if it's draining properly.instructing the client to turn, cough, and deep breathe every 30 minutes.

RATIONALE: Urine that's scant (less than 30 ml/hour) and tinged with blood indicates potential renal damage and must be reported to the physician. Turning the client on her left side and taking vital signs increases blood perfusion to the uterus. Flushing the client's indwelling urinary catheter is unnecessarily invasive and doesn't address the blood-tinged urine. Instructing the client to turn, cough, and deep breathe every 30 minutes has nothing to do with the client's symptoms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client at term arrives in the labor room experiencing contractions every 4 minutes. While she's in active labor, the electronic fetal monitor registers a pattern indicating a variable deceleration. Which nursing intervention should be initiated first?

Monitor blood pressure every 5 minutes.Change maternal position.Increase I.V. fluid rate.Prepare for an immediate cesarean section.

RATIONALE: A variable deceleration usually indicates fetal cord compression. Changing the mother's position usually relieves the pressure on the cord, thereby increasing blood flow to the fetus. Alterations in maternal blood pressure aren't correlated with variable decelerations. Increasing the I.V. fluids could increase placental perfusion but wouldn't be the best first action. An occasional or isolated variable deceleration isn't an indication for an emergency cesarean delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisThe community health center physician has confirmed that a 16-year-old client is at 16 weeks' gestation. The client confides to the nurse that she's afraid to tell her parents she's pregnant. Which of the following best explains the client's feelings?

The client lacks a stable relationship with her family.The client fears rejection by her family because of her unplanned pregnancy.The client's parents may force an abortion.The client can't rely on her family for emotional support.

RATIONALE: The adolescent's perception of parental response causes fear of rejection. Parents' initial reactions to the news of their daughter's pregnancy usually include shock, anger, shame, guilt, and sorrow. However, in general, adaptation occurs as the pregnancy progresses, and the adolescent's mother usually becomes her key support system. No data in this case study indicate abnormally unstable or nonsupportive family relationships. The evidence given is insufficient to conclude that the client can't rely on her family for support. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse should anticipate which psychological reactions during the second trimester of pregnancy?

Self-centeredness and concentration on the behavior and appearance of childrenExtroversion and emotional labilityAmbivalence and uncertaintyDismay over body image and readiness for the end of pregnancy

RATIONALE: Women during the second trimester are somewhat narcissistic; at the same time, they're commonly fascinated by children. Extroversion is a personality trait not specific to pregnancy; emotional lability may be present in every trimester. Ambivalence and uncertainty are characteristic of the first trimester. Dismay over body image and readiness for pregnancy to be over are characteristic of the third trimester. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationAs the neonate nursery nurse, you are responsible for the initial feeding of a neonate. You give a feeding of plain sterile water. The mother asks why this was given. What response would be best?

"Plain sterile water will cause less irritation to the respiratory tract if the baby accidentally breathes some in and is preferred until the baby's ability to feed is assessed.""The physician always orders this.""Glucose water would give the baby too many calories.""Formula and breast milk should be withheld for 12 hours after birth."

RATIONALE: Plain sterile water is best for the initial feeding because it's less irritating to the respiratory tract if any is accidentally aspirated. Glucose water and formula, if aspirated, can cause an inflammatory response and pneumonia. Option 2 is a peremptory response that doesn't give any explanation to the client. The caloric content of glucose water isn't a threat to the neonate, so option 3 is inappropriate. The issue isn't how long to withhold feeding, but to assess in the safest way the neonate's ability to feed, so option 4 is inappropriate as well. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 3288.5-g baby boy is born by spontaneous vaginal delivery. During the initial assessment at 1 hour postpartum, the nurse notices lanugo, acrocyanosis, mongolian spots, and hemangiomas. Which of these is an abnormal finding in a neonate?

Lanugo

AcrocyanosisMongolian spotsHemangiomas

RATIONALE: Hemangiomas are vascular tumors considered deviations from the norm. The other options are normal neonatal findings. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationIf toxic levels of magnesium sulfate are reached, which of the following is the antidote of choice?

Terbutaline (Brethine)Calcium gluconate (Kalcinate)Hydralazine (Apresoline)Dopamine (Intropin)

RATIONALE: Calcium gluconate is the antidote for magnesium sulfate toxicity. Terbutaline is a tocolytic used in the treatment of preterm labor. Hydralazine is an antihypertensive used in the treatment of pregnancy-induced hypertension. Dopamine is an adrenergic agonist frequently used to treat hypotension. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionA client who is 41 weeks pregnant is about to undergo a biophysical profile (BPP) to evaluate her fetus's well-being. The nurse knows that which components are included in a BPP? Select all that apply:

Fetal toneFetal breathing movementsFemur lengthAmniotic fluid volumeBiparietal diameterCrown-rump length

RATIONALE: The BPP is an ultrasound assessment of the fetus's well-being that includes the following components: nonstress test, fetal tone, fetal breathing, fetal motion, and quantity of amniotic fluid. Crown-rump length is used to assess gestational age and is done during the first trimester. Measurements of the biparietal diameter and femur length are also used to assess gestational age and are done in the second and third trimesters. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is palpating the uterus of a client who is 20 weeks pregnant to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus.RATIONALE: At 20 weeks, fundal height should be at approximately the umbilicus. Fundal height should be measured from the symphysis pubis to the top of the uterus. Serial measurements assess fetal growth over the course of the pregnancy. Between weeks 18 and 34, the centimeters measured correlate approximately with the week of gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionAssessment of a client progressing through labor reveals the following findings. Order the findings in the most likely sequence in which they would have occurred. 1. Uncontrollable urge to push 2. Cervical dilation of 7 cm 3. 100% cervical effacement 4. Strong Braxton-Hicks contractions 5. Mild contractions lasting 20 to 40 seconds45231RATIONALE: Strong Braxton-Hicks contractions typically occur before the onset of true labor and are considered a preliminary sign of labor. During the latent phase of the first stage of labor, contractions are mild, lasting approximately 20 to 40 seconds. As the client progresses through labor, contractions increase in intensity and duration. In addition, cervical dilation occurs. Cervical dilation of 7 cm indicates that the client has entered the active phase of the first stage of labor. Together with cervical dilation, cervical effacement occurs. Effacement of 100% characterizes the transition phase of the first stage of labor. Progression into the second stage of labor is noted by the client's uncontrollable urge to push. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA nurse is administering vitamin K (AquaMEPHYTON) to a neonate following delivery. The medication comes in a concentration of 2 mg/ml and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters should the nurse administer?0.25RATIONALE: Use the following formula to calculate drug dosages: Dose on hand/Quantity on hand = Dose desired/X Plug in the values and the equation is as follows: 2 mg/ml = 0.5mg/X; X = 0.25 ml NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:

psychotherapy.total abstinence.Alcoholics Anonymous (AA).aversion therapy.

RATIONALE: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

barbiturates.amphetamines.methadone.benzodiazepines.

RATIONALE: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

delusions.hallucinations.loose associations.neologisms.

RATIONALE: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that

have meaning only to the client. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:

give him privacy in the bathroom.allow him to shave.open the window and allow him to get some fresh air.observe him.

RATIONALE: The nurse has a responsibility to observe continuously the acutely suicidal client - not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects, such as belts, razors, suspenders, glass, and knives. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan?

Restrict visits with the family until the client begins to eat.Provide privacy during meals.Set up a strict eating plan for the client.Encourage the client to exercise, which will reduce her anxiety.

RATIONALE: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals - not given privacy. Exercise must be limited and supervised. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?

"Are you sure you want to kill yourself?""I know if my husband left me, I'd want to kill myself. Is that what you think?""How do you think you would kill yourself?""Why don't you just look at the positives in your life?"

RATIONALE: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option 1 requires a yes-or-no response and is self-limiting. In option 2, the nurse is telling the client what to think and feel. Option 4 dismisses the client's feelings. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include:

dilated pupils and slurred speech.rapid speech and agitation.dilated pupils and agitation.euphoria and constricted pupils.

RATIONALE: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:

turning on the lights and opening the windows so that the client doesn't feel crowded.leaving the client alone.staying with the client and speaking in short sentences.turning on stereo music.

RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:

a depressed client.a manic client.a suicidal client.an anxious client.

RATIONALE: Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, anxious, or suicidal clients don't physically or mentally test the limits of the caregiver. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:

highly important or famous.being persecuted.connected to events unrelated to oneself.responsible for the evil in the world.

RATIONALE: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include:

hyperalertness and sleep disturbances.memory loss of traumatic event and somatic distress.feelings of hostility and violent behavior.sudden behavioral changes and anorexia.

RATIONALE: Signs and symptoms of posttraumatic stress disorder include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't usual signs or symptoms of posttraumatic stress disorder. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:

offering high-calorie meals and strongly encouraging the client to finish all food.

insisting that the client remain active throughout the day so that he'll sleep at night.allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.listening attentively with a neutral attitude and avoiding power struggles.

RATIONALE: The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms?

The opportunity to verbalize memories of trauma to a sympathetic listenerFamily supportPrescribed medications taken as orderedAlcoholics Anonymous (AA) meetings

RATIONALE: Although it's difficult, clients with posttraumatic stress disorder can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?

WithdrawalLogical thinkingRepressionDenial

RATIONALE: Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?

Inability to make choices and decisions without adviceShowing interest only in solitary activitiesAvoiding developing relationshipsRecurrent self-destructive behavior with history of depression

RATIONALE: Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, this isn't a typical response. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe major goal of therapy in crisis intervention is to:

withdraw from the stress.resolve the immediate problem.decrease anxiety.provide documentation of events.

RATIONALE: During a period of crisis, the major goal is to resolve the immediate problem with hopes of getting the individual to the level of functioning that existed before the crisis. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. Anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:

impending coma.manipulating behavior.suppression.perceptual disorders.

RATIONALE: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

Aggressive behaviorParanoid thoughtsEmotional affectIndependence needs

RATIONALE: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client?

Assigning him to group activitiesReducing his stimulationAssisting him with self-careHelping him express his feelings

RATIONALE: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients aren't able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

avoid shopping for large amounts of food.control eating impulses.identify anxiety-causing situations.eat only three meals per day.

RATIONALE: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?

Has perceptions based on realityAssumes responsibility for actionsGenerates new levels of awarenessHas maximum ability to solve problems and learn new skills

RATIONALE: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development - not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:

sedation.diarrhea.vertigo.urticaria.

RATIONALE: Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as frequently or as commonly as diarrhea. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?

Inadequate dietDivorceJob promotionAdopting a child

RATIONALE: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices - divorce, job promotion, and adopting a child - are considered life events. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium?

Sexual dysfunctionConstipationPolyuriaSeizures

RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:

tension and irritability.slow pulse.hypotension.constipation.

RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: AnalysisDuring a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as:

barbiturates.antianxiety drugs.depressants.amphetamines.

RATIONALE: Antianxiety drugs provide symptomatic relief. Barbiturates and amphetamines can precipitate panic attacks. Depressants aren't appropriate for treating panic attacks. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:

staying with the client until the attack subsides.telling the client everything is under control.telling the client to lie down and rest.talking continually to the client by explaining what's happening.

RATIONALE: The nurse should remain with the client until the attack subsides. If the client is left alone, he may become more anxious. Giving false reassurance is inappropriate in this situation. The client should be allowed to move around and pace to help expend energy. The client may be so

overwhelmed that he can't follow lengthy explanations or instructions, so the nurse should use short phrases and slowly give one direction at a time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:

take the client's vital signs.explore the content of the hallucinations.tell him his fear is unrealistic.engage the client in reality-oriented activities.

RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what's going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:

tell him that she'll leave for now but will return soon.ask him if it's okay if she sits quietly with him.ask him why he wants to be left alone.tell him that she won't let anything happen to him.

RATIONALE: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:

psychotic symptoms.parkinsonism.akathisia.dystonia.

RATIONALE: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:

benztropine (Cogentin).diphenhydramine (Benadryl).propranolol (Inderal).haloperidol (Haldol).

RATIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisThe nurse is providing care for a female client with a history of schizophrenia who is experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What's the nurse's best action?

Administer the haloperidol orally if the client agrees to take it.Call the physician to clarify whether the haloperidol should be given orally or I.M.Call the physician to clarify the order because the dosage is too high.Withhold haloperidol because it may worsen hallucinations.

RATIONALE: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of hallucinations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is providing care to a client with catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:

ask the client which activity he would prefer to do first.negotiate a time when the client will perform activities.tell the client specifically and concisely what needs to be done.prepare the client ahead of time for the activity.

RATIONALE: The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhich information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?

Monthly blood tests will be necessary.Report a sore throat or fever to the physician immediately.Blood pressure must be monitored for hypertension.Stop the medication when symptoms subside.

RATIONALE: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ml, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

CalciumSodiumChloride

PotassiumRATIONALE: Lithium is chemically similar to sodium. When sodium levels are reduced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?

"I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you.""I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.""You're wrong. Nobody is trying to kill you.""A foreign government is trying to kill you? Please tell me more about it."

RATIONALE: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism?

Restlessness, difficulty sitting still, pacingInvoluntary rolling of the eyesTremors, shuffling gait, masklike faceExtremity and neck spasms, facial grimacing, jerky movements

RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and pill rolling. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionA 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?

Observing for extrapyramidal symptomsBeginning a therapeutic relationshipCanceling any no-suicide contractsContinuing suicide precautions

RATIONALE: As antidepressants begin to take effect and the client feels better, she may have the energy to initiate and complete another suicide attempt. As the client's energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics and aren't adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. It's through this relationship that the client develops feelings of self-worth and trust and problem-solving takes place. In a no-suicide contract, the client states verbally or in writing that she won't attempt suicide and will seek out staff if she has suicidal thoughts. When the time period for a contract has expired, a new contract should be obtained from the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 26-year-old male reports losing his sight in both eyes. He's diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client?

Not focusing on his blindnessProviding self-care for himTelling him that his blindness isn't realTeaching eye exercises to strengthen his eyes

RATIONALE: Focusing on the client's blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren't under the client's control and are real to him. Eye exercises won't resolve the client's blindness because no organic pathology is causing the symptoms. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

Provide an unstructured environment for the client.Rotate the nurses who are assigned to the client.Ignore the client's behaviors.Bend unit rules to meet the client's needs.

RATIONALE: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:

not occur at all because the time period for their occurrence has passed.begin anytime within the next 1 to 2 days.begin within 2 to 7 days.begin after 7 days.

RATIONALE: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days - even up to 7 days - after the last

drink. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous (AA) meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:

You must first stop drinking.Your physician must refer you to this program.Admit you're powerless over alcohol and that you need help.You must bring along a friend who will support you.

RATIONALE: The first of the Twelve Steps of AA is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although AA promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionThe nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

TachycardiaWarm, flushed extremitiesParotid gland tendernessCoarse hair growth

RATIONALE: Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: KnowledgeThe nurse is assessing an adult's developmental stage. The nurse should consider:

height and weight.blood pressure.previous problem-solving strategies.pulse rate.

RATIONALE: The nurse can use problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning such as problem-solving. The other choices are related to physiological attributes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeWhich of the following factors would have the most influence on the outcome of a crisis situation?

AgePrevious coping skillsSelf-esteemPerception of the problem

RATIONALE: Coping is a process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic, focusing on relieving the discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, previous coping skills is the best answer. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for an elderly client in a long-term care facility. The client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?

Setting aside time to listen to the clientRemoving items that the client could use in a suicide attemptCommunicating a nonjudgmental attitudeReferring the client to a mental health professional

RATIONALE: The nurse's first responsibility is to protect the client from injuring himself. Listening and being nonjudgmental are important elements of the nurse's communication with the client. After the client's safety has been established, he would benefit from a referral to a mental health professional. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?

Wearing tight-fitting clothingIncreased blood pressureOily skinExcessive and ritualized exercise

RATIONALE: A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle, and blood pressure and body temperature drop from excessive weight loss. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeA high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?

The student discusses conflicts over drug use.The student accepts a referral to a substance abuse counselor.The student agrees to inform his parents of the problem.The student reports increased comfort with making choices.

RATIONALE: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child:

internalize his feelings about death and dying.accept responsibility for his situation.

express feelings that he can't articulate.have a good time while he's in the hospital.

RATIONALE: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It's important for the child to find a way to express internalized feelings. The child must also know that he isn't to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?

Abstinence is the basis for successful treatment.Attendance at Alcoholics Anonymous (AA) meetings every day will cure alcoholism.For treatment to be successful, family members must participate.An occasional social drink is acceptable behavior for the alcoholic.

RATIONALE: The foundation of any treatment for alcoholism is abstinence. Attendance at AA is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client exhibits the following defining characteristics: denial of problems that are evident to others, expressions of shame or guilt, perceptions of self as being unable to deal with events, and projection of blame or responsibility for problems onto others. How would a nurse diagnose this client?

AnxietyChronic low self-esteemIneffective denialIneffective individual coping

RATIONALE: The defining characteristics are those of chronic low self-esteem. The definition of this diagnosis is negative self-evaluation, along with negative feelings about self or capabilities, which may be directly or indirectly expressed. Anxiety, ineffective denial, and ineffective individual coping all have different sets of defining characteristics. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhat herbal medication for depression, widely used in Europe, is now being prescribed in the United States?

Ginkgo bilobaEchinaceaSt. John's wortEphedra

RATIONALE: St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant, similar to ephedrine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Fill out the client's menu and make sure she eats at least half of what's on her tray.Let the client eat her meals in private then engage her in social activities for at least 2 hours after each meal.Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal.Let the client eat food brought in by the family if she chooses, but keep a strict calorie count.

RATIONALE: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should be allowed to eat food only provided by the dietary department. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 15-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

"I like the way I look. I just need to keep my weight down because I'm a cheerleader.""I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends.""I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls.""I do diet around my periods, otherwise I just get so bloated."

RATIONALE: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a desirable weight is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be overweight when she looks in the mirror. Preferring fast food to healthy food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in a client with anorexia nervosa. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhich psychological or personality factors are most likely to predispose an individual to medication abuse?

Low self-esteem and unresolved rageDesire to inflict pain upon oneselfObsessive-compulsive disorderCodependency

RATIONALE: Low self-esteem and repressed anger and rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. The final two options are psychological disorders not usually associated with medication abuse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA client chronically complains of being unappreciated and misunderstood by others. She's argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which of the following personality disorders?

Dependent personalityPassive-aggressive personalityAvoidant personality disorderObsessive-compulsive disorder

RATIONALE: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions. In addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. NURSING PROCESS STEP:

Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client diagnosed with depression tells the nurse, "I won't allow myself to cry because it upsets the whole family when I cry." This is an example of:

manipulation.insight.rationalization.repression.

RATIONALE: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. Insight is comprehension of one's own behavior, often followed by an attempt to change it. Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness. Based on the information provided, the client doesn't seem to be manipulating those around her. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client diagnosed with major depression has started taking amitriptyline (Elavil), a tricyclic antidepressant. What's a common adverse effect of this drug?

Weight lossDry mouthIncreased blood pressureMuscle spasms

RATIONALE: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain - not loss - is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: KnowledgeA client has received treatment for depression for 3 weeks. Which behavior suggests that the client is recovering from depression?

The client talks about the difficulties of returning to college after discharge.The client spends most of the day sitting alone in the corner of the room.The client wears a hospital gown instead of street clothes.The client shows no emotion when visitors leave.

RATIONALE: By talking about returning to college, the client is demonstrating an interest in making plans for the future, which is a sign of recovery from depression. Decreased socialization, lack of interest in personal appearance, and lack of emotion are all symptoms of depression. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?

Ask other clients and staff members to ignore the client's behavior.Set limits with consequences for belittling or demanding behavior.Offer the client an antianxiety drug when belittling or demanding behavior occurs.Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.

RATIONALE: To protect others from a client who exhibits belittling and demanding behaviors, the nurse may need to set limits with consequences for noncompliance. Asking others to ignore the client is likely to increase those behaviors. Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change problematic behaviors. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with hypochondriasis. Which behavior would the nurse most likely encounter?

Ready acceptance of the physician's explanation that all medical and laboratory tests are normalExpression of fear of dying after being diagnosed with advanced breast cancerExpression of fear of colorectal cancer following 3 days of constipationLack of concern about having a serious disease

RATIONALE: The client with hypochondriasis is preoccupied with having a serious disease. She may convince herself that a relatively minor symptom, such as constipation, is a sign of a serious disorder. The client's fear of serious illness persists, even after a physician reassures her that all medical and laboratory tests are normal. The fear of dying after receiving a diagnosis of advanced breast cancer wouldn't be considered hypochondriasis. A client with hypochondriasis shows an exaggerated level of anxiety, rather than a lack of concern about having a serious disease or illness. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client who has been diagnosed with hypochondriasis. The client attributes his cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially?

Let the client know the nurse understands his fears of serious illness.Encourage the client to discuss his fear of having a serious illness.Report the complaint of chest pain to the physician.Determine if the illness is fulfilling a psychological need for the client.

RATIONALE: Because of the risk of missing an actual medical problem, any new symptoms reported by a client with hypochondriasis should be reported to the physician. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is talking with a client who recently attempted suicide. The client asks her not to tell anyone one about their conversation. How should the nurse respond?

I'll need to share information with the rest of your health care team if it's important to your care.I promise I won't tell anyone about the information you share with me today.I promise I won't tell anyone about the information you share with me today unless you give me permission to do so.Please don't tell me anything that you wouldn't want others on your health care team to know.

RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse - not the client - should judge what specific information must be shared with others on the health care team. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy. Which assessment indicates that the medication is effective?

The client's heart rate is 48 beats/minute.The client states that his mouth is dry.The client appears calm and relaxed.The client falls asleep.

RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions; therefore, the client's mouth would feel dry. Atropine also blocks the vagal stimulation of the heart, causing a rise in heart rate (much higher than 48 beats/minute). Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. Which intervention should the nurse include?

Monitoring the client's vital signs every hour for 4 hoursPlacing the client in Trendelenburg's positionEncouraging early ambulationReorienting the client to time and place

RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. The nurse should continually reorient the client to time and place as he wakes up from the procedure. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until he's fully awake and oriented. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationThe nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate?

Expressing feelings of anxietyDisplaying anger, shouting, and banging the table.Withdrawing from the nurse in silenceRationalizing the termination, saying that everything comes to an end

RATIONALE: Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. While anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren't appropriate behavior. Withdrawal isn't a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client with a borderline personality disorder has been playing one staff member against another. In formulating a care plan for this client, the nursing staff should include which intervention?

Assigning the same staff members to work with the clientAvoiding setting limitsRotating staff members who work with the clientAvoiding interaction with the client until splitting behaviors stop

RATIONALE: Rotating staff members who care for a client with borderline personality disorder reduces the incidence of splitting behaviors. Helping the client to learn to relate to several staff members may reduce fears of abandonment. The staff should set limits on unacceptable behaviors; the client doesn't have the self-control to set his own limits. Avoiding the client won't reduce splitting behaviors. The client needs to interact with staff members to develop relationships and reduce fears of abandonment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?

Risk for self- or other-directed violenceImbalanced nutritionIneffective copingImpaired verbal communication

RATIONALE: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?

To reduce psychotic symptomsTo reduce extrapyramidal symptomsTo control nausea and vomitingTo relieve anxiety

RATIONALE: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe nurse is leading group therapy with psychiatric clients. During the working phase, what should the nurse do?

Explain the purposes and goals of the group.Offer advice to help resolve conflicts.Encourage group cohesiveness.Encourage a discussion of feelings of loss regarding termination of the group.

RATIONALE: During the working phase, or the middle phase of a group, the nurse continues to encourage cohesiveness among its members. During the orientation phase, or the initial phase, the nurse leading the group should explain the purpose and goals of the group. During the termination phase, or the final phase, the leader encourages a discussion of feelings associated with termination. When leading a group, the nurse should act as a facilitator; offering advice isn't appropriate. The group members should work together to resolve conflicts. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?

Naloxone (Narcan)Haloperidol (Haldol)Magnesium sulfateChlordiazepoxide (Librium)

RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ComprehensionThe client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?

Why didn't you get someone else to drive you?Tell me how you feel about the accident.You should know better than to drink and drive.I recommend that you attend an Alcoholics Anonymous meeting.

RATIONALE: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client suffers from depression after the accidental death of her daughter. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the client tells the nurse that she no longer wants to die. The nurse should:

suggest that the client no longer requires close observation.place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process.inspect the client's personal belongings for potentially dangerous objects.avoid any further discussion of suicide, unless the client brings up the topic.

RATIONALE: The client must be protected from harming herself. This includes checking all personal items that the client brought to the hospital, such as a suitcase or pocketbook. The client must be closely observed until she has been evaluated and receives treatment. A client who is suicidal should be placed in a room near the nurses' station in full view of a nurse or other observer. The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the suicide attempt and knowing that she'll be protected from harm. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?

Stay with the client during the panic attack.Shout for help and obtain assistance.Teach the client relaxation exercises.Help the client explore the reason for the anxiety.

RATIONALE: Because the presence of a calm nurse provides a feeling of security, the nurse should remain with a client during an anxiety attack and assure the client of his safety. Shouting for help and bringing others running to the scene can increase the client's anxiety. The nurse should keep the client's environment calm by reducing noise and limiting the number of people present. Teaching the client relaxation exercises and other methods to reduce stress and exploring the reasons underlying anxiety are important interventions but shouldn't be performed during an anxiety attack. During an attack a client isn't capable of learning new behaviors or achieving insight. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits?

Administering sleeping pillsEncouraging the use of relaxation exercisesSuggesting he talk with other clients until he feels ready to sleepTelling him to play ping-pong in the day room

RATIONALE: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiological response opposite to that produced by stress. Giving a sleeping pill would provide short-term relief for sleeplessness but wouldn't teach healthy sleep habits. Suggesting the client stay up and talk won't help him develop healthy sleep habits or control stress and anxiety. Playing ping-pong or engaging in other exercises just prior to sleep produces a physiological response similar to stress. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA teenager was driving a car that slipped off an icy road, killing two of his friends. He repeatedly tells the nurse that he should be dead instead of his friends. The client's behavior is an example of:

survivor's guilt.denial.anticipatory grief.repression.

RATIONALE: Individuals who survive a traumatic experience in which others have died commonly report powerful feelings of guilt that they survived and others didn't. This guilt is referred to as survivor's guilt. In denial, a person refuses to accept that a situation or feeling exists. Anticipatory grief occurs when an individual experiences grief before a loss occurs. In repression, an individual involuntarily blocks an unpleasant experience, memory, or feeling from consciousness. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with schizophrenia. Which of the following outcomes is least desirable?

The client spends more time by himself.The client doesn't engage in delusional thinking.The client doesn't harm himself or others.The client demonstrates the ability to meet his own self-care needs.

RATIONALE: The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

Approach the client and touch him to get his attention.Encourage the client to go to his room where he'll experience fewer distractions.Acknowledge that the client is hearing voices, but make it clear that the nurse doesn't hear these voices.

Ask the client to describe what the voices are saying.RATIONALE: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms?

Benztropine (Cogentin)Dantrolene (Dantrium)Clonazepam (Klonopin)Diazepam (Valium)

RATIONALE: Benztropine mesylate is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine drug, is administered to reduce anxiety. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?

Carbonated beveragesAftershave lotionToothpasteCheese

RATIONALE: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationWhich statement about somatoform pain disorder is accurate?

The pain is intentionally fabricated by the client in order to receive attention.The pain is real to the client, even though there may not be an organic etiology for the pain.The pain is less than would be expected from what the client identifies as the underlying disorder.The pain is what would be expected from what the client identifies as the underlying disorder.

RATIONALE: In a somatoform pain disorder, the client has pain even though a thorough diagnostic work up reveals no organic cause. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic relationship based on trust. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is often in excess of what would normally be expected. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?

History of gainful employmentFrequent expression of guilt regarding antisocial behaviorDemonstrated ability to maintain close, stable relationshipsA low tolerance for frustration

RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is caring for a client with antisocial personality disorder. Which of the following statements is most appropriate for the nurse to make when explaining unit rules and expectations to the client?

"I and other members of the health care team would like you to attend group therapy each day.""You'll find your condition will improve much faster if you attend group therapy each day.""You'll be expected to attend group therapy each day.""Please try to attend group therapy each day."

RATIONALE: Rules and explanations must be brief, clear, and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. The other options leave open the interpretation that attendance is suggested but not mandatory. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four-point restraints. Which nursing measure should be taken next?

Release one restraint every 15 minutes.Have a staff member stay with the client at all times.Leave the client alone to reduce his sensory stimulation and allow him to regain control.Restrict fluids until the restraint period is over.

RATIONALE: A client such as this one needs sensory stimulation and should never be left alone (although the nurse should maintain the client's privacy). Restraints should be removed for 5 minutes at least every 2 hours. A client in restraints should have someone with him at all times. Fluids are offered, and the client is given food at mealtimes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationWhich nursing assessment has priority while a client's extremities are restrained?

Measuring urine outputChecking circulation in extremitiesAssessing pupillary responsesNoting respiratory pattern

RATIONALE: The nurse must check extremities for signs of circulatory impairment. Measuring urine output isn't crucial; the client may void into a urinal as necessary. Assessing pupillary responses isn't relevant to the situation. Although the nurse should check vital signs every 15 minutes for 1 hour, assessment for circulation takes priority over respiratory pattern. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What's the most important assessment the nurse should make of the client?

Ability to care for himselfDegree of danger to self and othersLevel of psychosisIntended compliance with aftercare

RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. The other options are important assessments, but the client's danger to himself or others takes priority. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse should determine that restraints are no longer needed when the client:

falls asleep.ceases verbalizing threats.is calm verbally and nonverbally.expresses being okay.

RATIONALE: The nurse should look for consistency in subjective and objective data. Falling asleep, cessation of verbal threats, and saying that he's okay may indicate that restraints are no longer needed, but the nurse needs more data than any one of these options provides. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: ApplicationA client on an inpatient psychiatric unit at a community mental health center is pacing up and down the hallway. The client has a history of aggression. Which response by the nurse would be best when approaching the client?

"If you can't relax, you could go to your room.""Would you like your antianxiety medication now?""You're pacing. What's going on?""Let's go play a game of pool."

RATIONALE: This response acknowledges the client's behavior and explores his feelings. Options A and B assume that the client is anxious, which may be a projection on the nurse's part, considering the client's history of aggression. Option D ignores what might be going on with the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 37-year-old male with a history of schizophrenia is having auditory hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What's the nurse's best action?

Administer the haloperidol orally if the client agrees to take it.Call the physician to clarify whether the haloperidol should be given orally or I.M.Call the physician to clarify the order because the dosage is too high.Withhold haloperidol because it may cause hallucinations.

RATIONALE: The dosage is too high (normal dosage ranges from 5 to 100 mg daily). Administering additional haloperidol could cause an overdose. Haloperidol helps with symptoms of hallucinations; it doesn't cause them. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationAn inpatient psychiatric client suddenly becomes loud and visibly anxious. What's the best action for the nurse to take?

Summon help and escort the client to his room.Face the client squarely and say, "You must be quiet."Say, "Calm down; you're safe here."Say, "Let's go talk in your room."

RATIONALE: This response acknowledges that the client is important to the nurse and preserves the client's dignity with minimal restriction. The client doesn't need to be escorted to his room at this point; he hasn't yet been given a chance to go on his own. The nurse should use the least restrictive form of treatment at all times. Facing off with the client and demanding quiet is challenging. Telling the client to calm down is a placating response, which will likely increase the client's anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA voluntary client on an inpatient psychiatric unit has a history of auditory hallucinations and self-aggression. The nurse is talking with the client when the client suddenly jumps up and says, to no one in particular, "Get away from me." What's the nurse's best response?

Escort the client to his room.Say, "I won't let them harm you."Sit quietly until the client becomes calm.Ask, "Who are you talking to?"

RATIONALE: This question aims to clarify the client's remark. Option A ignores what the client said and violates the client's right to the least restrictive environment. Option B assumes that the client is hallucinating. Option C fails to address what the client said. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 35-year-old voluntary client suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which of the following would be most important for the nurse to consider when planning an intervention?

Because the client is a voluntary admission, restraints can't be used.The family must be called for permission to restrain the client.Restraint should be used as a last resort.Restraint can't be initiated until the physician is called.

RATIONALE: Restraint should always be used as a last resort, with the least restrictive measures used first. The criteria for restraint involve danger to self or others and don't exclude voluntary clients in emergencies. Unless a family member is a guardian, calling the family violates the client's confidentiality. In an emergency, the nurse may restrain a client before calling the physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

Before forcing a client to take a medication, the nurse should give priority to:the client's danger to self or others.what the "voices" are saying to the client.whether the client's admission was voluntary.the client's insight into the illness.

RATIONALE: Client rights prohibit the forcing of medication unless the client poses a danger to self or others. If the client is judged incompetent, the guardian or court must approve the forced medication. The other options overrule the client's basic rights. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA client was admitted to the hospital 2 days ago for disrupting a town meeting, shouting religious delusions, and fighting with police. The client now refuses to take prescribed haloperidol (Haldol), saying, "I don't want it." Which response by the nurse would be best?

"It will help you feel better.""You must take it or get an injection.""What are you afraid of?""You sound concerned."

RATIONALE: The nurse's open-ended response encourages exploration. Option A is placating the client. Option B is threatening or, at least, too restrictive because the client hasn't exhibited dangerous behavior. Option C assumes that the client is afraid. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client has been prescribed 75 mg of amitriptyline (Elavil) at bedtime and 15 mg of phenelzine (Nardil) three times per day. Which nursing action takes priority?

Teaching the client about the adverse effectsCalling the physician and questioning the orderInstituting dietary restrictionsTaking baseline vital signs

RATIONALE: Administering amitriptyline (a tricyclic antidepressant) and phenelzine (a monoamine oxidase [MAO] inhibitor) together could cause hypertension, tachycardia, or a potentially fatal reaction; the nurse should call the physician to check the order. The other options are important nursing actions, but they don't take priority over calling the physician. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client on an inpatient psychiatric unit has been taking a tricyclic antidepressant without satisfactory results, so the physician changes to a monoamine oxidase (MAO) inhibitor. In evaluating the physician's order, the nurse must first be sure:

adequate time has elapsed between discontinuing the first medication and beginning the second.the MAO inhibitor is begun at the same dosage as the tricyclic antidepressant.the client isn't suicidal.the client isn't allergic to cheese.

RATIONALE: Administering these two medications within a short time frame increases the risk of hypertension and hyperpyrexia. Dosages of MAO inhibitors can vary widely. The client's suicidal state and his allergy to cheese are irrelevant to the choice of drug or timing of administration. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client reports no improvement in mood since beginning a regimen of 15 mg of tranylcypromine (Parnate) twice per day 1 week ago. Which of the following is the best nursing action?

Say to the client, "The medication may need up to 4 weeks to take effect."Say to the client, "You should feel the effects any day now."Consult with the physician about a dosage adjustment.Consult with the physician about a change of medication.

RATIONALE: MAO inhibitors, such as tranylcypromine, may take up to 4 weeks before improving the client's mood. Telling the client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Consulting the physician is premature. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client who has been hospitalized with depression is about to be discharged with a prescription of phenelzine (Nardil). In planning for discharge, the nurse should have a teaching plan that emphasizes:

getting adequate rest.avoiding smoking.avoiding red wine.taking the drug with food or milk.

RATIONALE: A client taking phenelzine (a monoamine oxidase inhibitor) must avoid foods that contain tyramine (such as red wine) to prevent a hypertensive or hyperpyretic crisis. Getting adequate rest and avoiding smoking are healthy behaviors to reinforce, but they don't relate directly to phenelzine. Taking the drug with food and milk may be recommended if the medication causes GI distress, but it's secondary to teaching about the food restrictions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationThe physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching?

Risk for injuryDisturbed thought processesDeficient fluid volumeDisturbed sleep pattern

RATIONALE: Because an MAO inhibitor can cause hypotension, the client must be given precautions related to driving. Disturbed thought processes and disturbed sleep pattern are possible but not likely, and they have lower priority than client safety. Excessive fluid volume is more likely than a deficit. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA nurse is teaching clients in an outpatient clinic about monoamine oxidase (MAO) inhibitors. The nurse would best evaluate the clients' understanding of how their medications work by noting:

food selections.fluid intake.potential for self-harm.level of anxiety.

RATIONALE: A client taking an MAO inhibitor must avoid tyramine-rich foods to prevent a hypertensive or hyperpyretic crisis. Fluid intake, potential for self-harm, and level of anxiety are important assessment areas, but they don't relate directly to the clients' understanding of

medications. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take?

Note the complaints as usual adverse effects.Withhold the next dose of medication.Administer an analgesic, as needed and as prescribed.Help the client relax.

RATIONALE: A stiff neck and headache may be prodromal symptoms of hypertensive crisis. Rather than dismiss the symptoms, the nurse should continue to assess them and consult the physician. Administering an analgesic and helping the client relax would be appropriate measures for a tension headache. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: AnalysisA client avoids leaving home to shop for groceries or complete other errands. At times the client feels "crazy" because of her fear. The client seeks out her neighbor, a nurse, for help. The nurse's assessment is phobic reaction. Which of the following statements about a phobia is true?

The condition is a persistent, intrusive image that seems senseless to the person.It's important not to force the person to face the phobic object or situation.The phobic condition can be cured by hypnosis.It's necessary to agree with the client's assessment that the phobia is silly.

RATIONALE: Forcing can provoke panic in the client; gradual desensitization is more successful. Option A defines an obsession. Hypnosis is used to help identify sources of anxiety responsible for amnesia and fugue and in establishing contact with a client who has multiple-personality disorder. Option D fails to acknowledge that the phobia serves a purpose for the person and thus inhibits insight. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 76-year-old widowed mother of six is admitted to a long-term care facility with a diagnosis of organic mental disorder. Which of the following approaches would be most helpful for the nurse in meeting the client's needs?

Make sure the client completes tasks that she begins.Maintain a gentle approach that doesn't set limits.Give the client alternative choices in making decisions.Simplify the environment as much as possible.

RATIONALE: This helps maintain the client's orientation and prevents further confusion from overstimulation. Making sure the client completes her tasks and giving her alternatives may confuse the client with organic mental disorder, who typically can't make decisions and is easily distracted. Maintaining a gentle approach that doesn't set limits is also incorrect; it's necessary for all staff members to consistently set limits to lower anxiety and increase orientation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationWhich of the following snacks would be best for a client with anorexia nervosa who requires a high-protein, high-calorie diet?

Chicken soup and crackersDoughnut and orange juiceEgg salad and peanutsCashews and strawberries

RATIONALE: Egg salad and peanuts are high in protein and calories. Chicken soup, crackers, and strawberries are low-protein, low-calorie foods. A doughnut and orange juice are low in protein. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationWhat's the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior?

Ineffective copingImbalanced nutrition: Less than body requirementsImbalanced nutrition: More than body requirementsInterrupted family processes

RATIONALE: The client's coping skills are ineffective when anxiety increases. The other diagnoses don't correspond to the observed behavior. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 28-year-old accountant is admitted to the neurologic unit after a sudden onset of blindness the day before an important project is due for her boss. After preliminary evaluation and testing yields no positive findings, the physician's initial reaction is that the client may be demonstrating which defense mechanism?

RepressionTransferenceReaction formationConversion

RATIONALE: A person can convert unbearable feelings into a physical symptom with no organic cause. This defense mechanism usually manifests itself near the time of a traumatic or conflict-producing event. The symptom commonly provides attention or a means of escaping the conflict. Repression is a defense mechanism in which a person unconsciously keeps unwanted feelings from entering awareness. Transference involves the projection of feelings, thoughts, and wishes (positive or negative) onto someone, usually a therapist, who represents a figure from the person's past. Reaction formation is a means of alleviating unresolved conflicts between feelings or impulses by reinforcing one feeling and repressing another, thereby disguising the true feelings from the self. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client with bipolar disorder, manic phase, who usually dresses conservatively, appears at breakfast with brightly colored cheeks, wearing a miniskirt, sheer blouse, and designer boots. Which of the following actions should the nurse take to deal with the client's attire?

Redirect the client to her room and help her put on her more customary clothing.Allow her the freedom to wear what she prefers for now.Remind the client of the dress code and the consequences of violation.Tell the client what to wear and advise her that she has lost the privilege of choosing her wardrobe.

RATIONALE: The nurse must protect the client from actions that will cause embarrassment when her condition improves. Allowing her the freedom to wear what she prefers doesn't remove the client from the embarrassing situation. Reminding the client of the dress code and telling her what to wear offer chastisement rather than guidance and support. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationWhat's the most effective intervention for handling a client with an antisocial personality?

Reason with the client.Set limits with the client.Ignore the client.

Agree with the client.RATIONALE: Limits must be maintained by all staff members and reinforced with restrictions when rules are broken. Reasoning with the client, ignoring him, and agreeing with him don't modify the unwanted behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client on the nursing unit, charged with child abuse, doesn't speak to the staff when approached. Which response by the nurse would be best?

"If you need me, I'll be in the nurses' station.""You need to come to grips with what has happened.""Not speaking to the staff won't help your situation.""Admission to a psychiatric unit can be very difficult."

RATIONALE: This helps the client realize he's having difficulty without asking direct questions or focusing on specific behavior. Option A constitutes avoidance. Option B negates the client's feelings. Option C focuses on a specific behavior and doesn't convey sensitivity or caring. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationAfter refusing to eat for 4 days, a 17-year-old college freshman is referred to the inpatient eating disorders unit of a general hospital. Her affect is flat, her eyes downcast, and her long blonde hair dull and limp. Her clothes hang loosely on her body, and she appears sullen and frightened. Her weight on admission is 89 lb (40.4 kg); her normal weight is 114 lb (52 kg). Which of the following assessments would best enable the nurse to develop a specific nursing diagnosis?

Family history, including genogramsPsychiatric history, including all hospital admissionsCardiac and respiratory historyWeight loss history and general condition of skin, hair, and nails

RATIONALE: This will help the nurse formulate a nursing diagnosis that addresses the self-control and compliance needed to regain nutritional requirements. Other important areas to assess include nausea, vomiting, edema, and excretory functions. Family, psychiatric, and cardiac and respiratory histories may yield useful data, but they aren't as critical at this early stage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa?

"I've gained 3 pounds in the last month.""I eat loads of spinach and yellow vegetables each day.""I'm a perfectionist, and I work hard to get A's.""I binge frequently in the morning and feel fat."

RATIONALE: Typically, the anorexic client works hard to achieve perfection and loses the ability to accept help. Option A refers to weight gain, which may indicate bulimia. Option B is atypical of anorexic clients, who have an intense fear of becoming obese and compulsively resist any attempts at eating. Binge eating (option D) is characteristic of bulimia (although bulimics tend to binge more frequently in the evening, and "feeling fat" is characteristic of anorexia). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhich of the following nursing interventions would be included in the care of a client with anorexia nervosa as therapy progresses?

Let the client eat alone to avoid embarrassment.Weigh the client once a week in the same clothing.Monitor the client for self-destructive tendencies.Praise the client for "looking better," and remind the client that she isn't "too fat."

RATIONALE: Self-starvation is life-threatening; the client should be monitored for self-destructive tendencies. The nurse must stay with the client during meals to ensure that food is being eaten. The client should be weighed three times daily in light clothing to ensure accuracy. Praising the client for looking better could signal a power struggle with the client and the nurse's unconscious means of exerting control. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with a personality disorder exhibits manipulative behavior. Care planning for this client should include:

freedom to do as the client chooses when behavior improves.limitations per unit rules without restrictions for broken rules.reasonable expectations with varying limits.verbal reinforcement when the client functions within established limits.

RATIONALE: This encourages the client to follow unit rules. The other options are inconsistent with changing manipulative behavior. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 40-year-old woman is brought to the hospital by her husband, who states that she has refused to eat or get out of bed for 2 days. The woman says that she's tired all the time and doesn't feel up to going to work. Her admitting diagnosis is major depression. Which question would be most appropriate for the admitting nurse to ask?

"What has been troubling you?""Why do you dislike yourself?""How do you feel about your life?""What can we do to help?"

RATIONALE: The nurse must base nursing interventions on a client's perceived problems and feelings. Option A asks the client to draw a conclusion, which she may have difficulty doing at this time. Option B places the client in a defensive position. Option D is beyond the scope of the client's present abilities; she would probably rather have the nurse tell her how she can help herself. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 24-year-old secretary is transferred to your psychiatric unit. Her husband says that she has been overeating and that she vomits soon after she eats. Her weight stays about the same, at 96 lb (44 kg). In planning care for the client, the nurse should anticipate which medical diagnosis?

Anorexia nervosaBulimiaKlein-Levin syndromeDysthymia

RATIONALE: The client exhibits the binging and purging typical of bulimia. Anorexia nervosa involves severe weight loss. Klein-Levin syndrome includes symptoms of a disturbed eating behavior, but the condition isn't characterized by the client's excessive concern with body shape and weight. Dysthymia is a type of depression. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationFor a client with bulimia, which assessment is least important in the care plan?

Observe the client after eating for 1 hour.Note the client's intake.

Note changes in appetite.Note changes in respiratory rate.

RATIONALE: Respiratory rate usually isn't affected by bulimia. Observing the client after eating for 1 hour is important because it's the time that she's likely to vomit. Noting the client's intake and changes in her appetite are important factors to monitor in bulimia or any other eating disorder. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: ApplicationA client with personality disorder gets along poorly with the immediate family. The client's manipulative behavior most likely shows a failure to develop:

intimate relationships.trust.industry.feelings of guilt.

RATIONALE: Manipulative behavior arises from a lack of trust. The client can't develop trust in others when he doesn't trust his own feelings. The other options can't be accomplished until trust is established. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 32-year-old client is admitted to the unit. She states, "I'm a well-known, wealthy designer," and begins to order the nurses to prepare her bath while she orders her tray and telephones her colleagues. Her husband states that she's too busy to eat and sleep and is losing weight. Her admitting diagnosis is bipolar disorder, manic phase. For which of the following events should the nurse plan?

Erratic and unpredictable behavior if challengedBoredom and the need for minute-to-minute activitiesRapid mood changes from elation to depressionOne-to-one treatment to occupy the client's time

RATIONALE: Bipolar clients are often unpredictable and exhibit angry outbursts. The unit itself, with its regularly scheduled activities, may provide too much stimulation for the manic client. The course of illness wouldn't be expected to move rapidly through the manic-depressive-manic cycle, although the client should be observed for signs of depression. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 32-year-old lawyer is admitted to the neurologic unit with a sudden onset of blindness the night before an important case is scheduled to go to trial. Tests reveal no physical findings. Which of the following is the best assessment of the client's anxiety?

It's diffuse and free floating.It's consciously experienced.It's localized and relieved by the blindness.It's projected onto the environment.

RATIONALE: Anxiety is relieved by keeping an internal need or conflict out of conscious awareness. The sudden onset of blindness without physiologic basis impairs normal activity and may promote the development of a chronic sick role. The anxiety-provoking impulse (the trial) is converted unconsciously into a functional symptom. The other options don't accurately describe the client's anxiety. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 50-year-old client has been admitted for psychological testing after having been charged with physical abuse of a 7-year-old child. The client refuses to come to the day room, saying, "I don't want people to stare at me." Which response by the nurse is best?

"That's okay for now if that's what you want.""It will be easier for you if you face people as soon as possible.""The staff are the only people who know why you were admitted.""You're very hard on yourself."

RATIONALE: The client is in the hospital for treatment, not for judgment. Option A avoids dealing with the client's feelings. Option B gives false reassurance. Option C isn't necessarily true. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 26-year-old office manager is hospitalized after developing acute leg pain. Diagnostic tests reveal no organic cause. What's the best long-term goal to include in this client's care plan?

Develop insight into the client's psyche.Accelerate the client's developmental tasks.Restore the client's previous adaptive behaviors.Eliminate responsibility for the client's behavior.

RATIONALE: The treatment team should identify ways to reduce the anxiety that caused the client's symptoms, develop more positive ways of managing the stress, and prevent secondary gains from the hospitalization. Conversion symptoms aren't under voluntary control; they commonly represent a symbolic solution to an underlying conflict. The other options aren't closely related to the clinical picture of conversion disorder. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 16-year-old student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is 5'4" (1.6 m) tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagnosis would be most appropriate for the client?

Disturbed thought processesImpaired adjustmentImbalanced nutrition: Less than body requirementsIneffective sexuality patterns

RATIONALE: Addressing the client's urgent physical needs is most important. The other diagnoses are possible with anorexia nervosa, but no data in the case study directly support them. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: AnalysisA client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best?

"It's policy here for all clients to bathe daily.""It's time for your shower. I'll help you with it.""Don't worry about your shower until tomorrow.""Do you want people to make fun of you?"

RATIONALE: This response offers support and sets limits. Option A doesn't offer support. Option C allows the client to continue to break rules. Option D offers neither support nor respect. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with major depression states, "Everything is my fault, and I'd be better off dead." What's the priority nursing intervention?

Assess the seriousness of the client's comment.Notify the psychiatrist of the client's verbalization.

Assign staff members to a suicide watch.Engage the client in a no-suicide contract.

RATIONALE: This situation demands an accurate assessment of the client's suicide potential. The other options require more thorough assessment data before implementation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisAn abused child is scheduled to be on the unit for 3 to 4 weeks. Which of the following assignments would be best for the child?

Assign a different primary nurse to the child each day.Assign the primary nurse who is transferring next week to another unit.Assign the same primary nurse to the child each day of the hospital stay.Assign a new primary nurse every 3 days.

RATIONALE: This will provide continuity of care and allow trust to develop. The other options aren't in the best interest of the client and won't further a trusting relationship. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA 38-year-old client is hospitalized with obsessive-compulsive disorder. On admission, she becomes nervous and asks to go to the bathroom to brush her teeth. Her husband says that she brushes her teeth at least 25 times per day. The nurse notes that the client's gums are inflamed and bleeding. What's the best nursing intervention?

Have her stop brushing her teeth until the gums heal.Allow her to continue her routine of daily brushing.Monitor her dental care and set limits on the amount of daily brushing.Brush her teeth for her.

RATIONALE: This allows the behavior that reduces anxiety for the client, but it sets limits as a first step in modifying the behavior. Having her stop brushing her teeth until her gums heal may leave the client unable to manage anxiety. Allowing her to continue her routine of daily brushing does nothing to change the behavior. Brushing her teeth for her treats the client like a toddler. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: ApplicationA client with a diagnosis of organic mental disorder becomes verbally and physically abusive when the nurse enters the client's room to assist with daily care. Which of the following interventions should the nurse engage in first?

Check orders for physical and chemical restraints.Set firm limits verbally.Give clear directions while gently securing the client's arms from hitting the nurse.Leave the room and let the angry, hostile behavior work itself out.

RATIONALE: Clear limits protect the client, staff, and others. A verbally and physically abusive client sometimes responds to verbal controls. Checking orders for physical and chemical restraints may be carried out, but not as a first priority. The goal is to use the least restrictive intervention needed to reduce anxiety and control behavior. Restraints would be used only as a last resort. Giving clear directions while gently securing the client's arms from hitting the nurse will likely escalate the hostile behavior. Additional staff help may be needed here. Leaving the room and letting the angry, hostile behavior work itself out could pose a safety problem. The client could fall or otherwise hurt herself in an attempt to strike out at the nurse or at an imagined threat. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: AnalysisA 2r-year-old client is hospitalized with a fractured left arm, a concussion, and multiple bruises. The client appears quite withdrawn. The bruises appear to have occurred at different times, with some new and some nearly healed. Emergency department staff report suspected child abuse to the authorities. During an assessment, the nurse would expect which behavior in the child?

Quiet and passive about painCrying and sensitive to painHappy to see new peopleHaving good eye contact with the parents

RATIONALE: The abused child usually shows little emotion. The other options describe conspicuous behavior that an abused child would typically avoid, for fear of provoking further abuse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA bulimic client admitted to the psychiatric unit suddenly shouts, "I want to leave right now. I'm not crazy and don't belong here." Which response should the nurse make?

"You can't go home until we cure your eating problems.""You seem upset; I'll stay with you.""Don't worry. You'll feel better tomorrow.""Let's talk about something more pleasant."

RATIONALE: This response acknowledges the client's feelings and offers support. Option A fails to acknowledge the client's feelings, and the client probably can't be kept against her will. Option C gives the client false reassurance and denies her feelings. Option D also denies the client's feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 22-year-old client has been diagnosed with antisocial personality disorder. She has been having problems since age 15, when she ran away from home. She has had two broken marriages, has been unable to keep a job for more than 2 months, and has had difficulties with the law because she has abused drugs and passed bad checks. Although the client has made all the telephone calls she is allowed for the day, she asks the nurse, "Can't I just make one more phone call?" Which response by the nurse would be best?

"Okay, but don't talk too long.""Okay, if you promise to obey the rules the rest of the day.""No, you can't. The rules apply equally to everyone, and you are asking to break them.""No, you can't. Go watch television."

RATIONALE: This response enforces the limits and explains why the client can't use the phone. Options A and B don't encourage the client to follow the rules. Option D doesn't explain why the client's request is being denied. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with anorexia nervosa who is on bed rest stares at her dinner tray. She has made little effort to eat. Which statement by the nurse would be most therapeutic?

"You should be ashamed of yourself. There are starving people who would love that food.""Hurry up with your tray. I have several more clients to see.""Don't worry. You can eat more tomorrow.""I'll stay with you while you eat and help you fill out tomorrow's menu."

RATIONALE: This response shows that the nurse values the client, and it promotes eating by having the client select food preferences. Option A doesn't promote eating; in her weakened condition, the client probably doesn't care about world hunger. Option B implies that the nurse is too busy to spend time with the client. Option C placates the client and permits her to continue poor eating habits. NURSING PROCESS STEP:

Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client is hospitalized after experiencing sudden-onset paralysis. Diagnostic tests reveal no positive physical findings. What's a likely cause?

Demonstrated organic pathologyIntense feelings of worthlessnessA primary and conscious need for attentionAn involuntary attempt to solve a conflict

RATIONALE: In conversion disorder, the client unconsciously converts anxiety-provoking impulses into functional symptoms. Although primary gains occur (the anxiety-provoking impulse is avoided), the internal need or conflict is usually kept out of conscious awareness. No physical pathology was discovered. Anxiety, rather than feelings of worthlessness, is the primary motivator. A hallmark of conversion disorder is that its attention-seeking activities aren't conscious. The typical client can't see the connection, obvious to others, between the anxiety-laden situation and the sudden illness that provides a means of escape. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ComprehensionA 19-year-old male just arrived on the psychiatric unit from the emergency department. His medical diagnosis is personality disorder, and he exhibits manipulative behavior. As the nurse reviews the unit rules with him, the client asks, "Can I go to the snack shop just one time, and then I'll answer whatever you want?" What's the nurse's best response?

"Okay, but hurry up. I need to finish your assessment.""Okay, but only for 5 minutes.""No, you can't go.""No, you can't go. The rules here are for everyone."

RATIONALE: This response sets limits with an appropriate explanation. Options A and B give in to the manipulative behavior. Option C doesn't explain the purpose of the refusal. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA client with major depression begins to improve and participates in treatment programs on the unit. The nurse should recognize that the client is ready for discharge when the client:

asks the staff for advice about how to handle the future.speaks to the employer about a return date to work.identifies personal weaknesses and plans to work on them.discusses plans to return home and continue outpatient treatment.

RATIONALE: The client's plan to return home and continue treatment as an outpatient indicates responsibility for her own level of wellness. Asking the staff for advice implies that the client is still unable or unwilling to accept responsibility for herself. Although talking to her boss is a positive step, it won't help the client comprehensively. Identifying and working on weak areas represent short-term steps taken before discharge. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisWhich of the following concepts about anorexia nervosa should the nurse consider in understanding a client's cry for help?

Focus on anorexia as an effort to gain status and resolve conflictRejection of food as a way to obtain love and care from parentsUse of eating behavior to resolve conscious sexual needsAvoidance of eating as a response to voices that threaten the client

RATIONALE: An anorexic client rigidly controls potentially disabling anxiety by controlling eating to the point of self-destructiveness. Conflicts most commonly encountered are issues of identity, separation, and autonomy; parents are commonly central figures in these struggles. The function of anorexia nervosa as a means of dealing with anxiety is itself rooted in conflict. The client can't seek resolution of the conflict without therapeutic intervention. Far from embracing sexuality, the typical anorexic client stops menstruating, avoids adolescent sexual issues, and hides her body under baggy clothing. An anorexic client usually doesn't experience hallucinations. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA noticeably withdrawn 14-year-old female client is being treated on the unit for anorexia nervosa. Which nursing assessments should be made daily?

Edema of the legsPulse and blood pressure elevationFrequent binging and purgingLevel of depression and anxiety

RATIONALE: Depression and anxiety commonly accompany anorexia nervosa. Edema of the legs and pulse and blood pressure elevation aren't associated with eating disorders. Frequent binging and purging is typical of bulimia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 76-year-old client is admitted to a long-term care facility with a diagnosis of organic mental disorder. The client has been wearing the same dirty, torn undergarments for several days. The nurse contacts family members to bring in clean clothing. Which of the following interventions would best prevent further regression in the client's personal hygiene habits?

Encourage the client to perform as much self-care as possible.Make the client assume responsibility for physical care.Assign a staff member to take over the client's physical care.Accept the client's desire to go without bathing and to wear dirty clothing.

RATIONALE: Clients with organically based problems tend to fluctuate in their capabilities. Encouraging self-care will help increase the client's orientation, provide a safe environment, and promote a trusting relationship with the nurse. Option B is unreasonable, given the client's possible confusion; self-esteem and independence must be developed as much as possible, but with assistance in activities of daily living. Option C restricts the client's independence. Option D promotes poor hygiene. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 37-year-old man with a history of schizophrenia is having hallucinations. He shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse is best?

"No, I don't. Quit talking foolishly.""Yes, I see them, and they sure are big ones.""No, I don't see them, but I believe that you do see them.""Let's go to the recreation room."

RATIONALE: The nurse should present reality while acknowledging that the hallucination is real to the client. Option A presents reality but demeans the client in doing so. Option B encourages the client's hallucinations. Option D changes the subject and ignores the issue. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationTeaching for a client taking antipsychotic medication should include which of the following instructions?

Take the medication with antacid to prevent upset stomach.Get fresh air and plenty of sunshine.

If a dose is missed, take two the next time.Avoid abrupt withdrawal of the medication.

RATIONALE: Abrupt withdrawal could result in nausea or seizures. Antacids decrease the effectiveness of antipsychotics when taken within 1 hour of the drug. Because of the adverse effect of photosensitivity, clients taking antipsychotic drugs should avoid sun exposure. Doubling up the medication could cause an overdose. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationA client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone." What's the nurse's best approach?

Say "Okay" and walk away.Summon help in case the client becomes aggressive.Say nothing and pace with the client.Say "You sound upset. I'd like to help."

RATIONALE: This demonstrates the nurse's concern and encourages the client to discuss feelings. Given the likelihood of an increase in anxiety level, the client shouldn't be left alone. Summoning help may escalate the client's anxiety. Saying nothing and pacing with the client acknowledge the client's emotional state. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisA 23-year-old married homemaker has been on the psychiatric unit for 2 days. She has a history of bipolar disorder and came to the hospital in the manic phase. She stopped taking her medication (lithium carbonate [Eskalith]) 2 weeks ago. Which of the following findings is the nurse least likely to see?

Flight of ideasDelusions of grandeurIncreased appetiteRestlessness

RATIONALE: The manic client is usually unwilling or unable to slow down enough to eat. Flight of ideas, delusions of grandeur, and restlessness are associated with the manic phase. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationWhich of the following instructions is most important for a client taking lithium carbonate [Eskalith]?

Limit fluids to 1r qt (1,500 ml) daily.Maintain a high fluid intake.Take advantage of the warm weather by getting outside exercise when possible.When feeling a cold coming on, take over-the-counter (OTC) medications.

RATIONALE: Clients taking lithium need to maintain a high fluid intake. Fluids shouldn't be limited. Photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium. The client shouldn't take OTC drugs without the physician's approval. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: ApplicationWhat's the best room assignment for a client with bipolar disorder, manic phase?

Alone, at the end of the hallAlone, nearest the nurses' stationWith another bipolar client at the end of the hallWith a depressed 40-year-old near the nurses' station

RATIONALE: Such an assignment provides a quiet environment without the additional stimuli of a roommate and the noise of the nurses' station. The other options provide too much stimulation and would likely increase the client's manic behavior. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which of the following is the nurse's best response?

Tell the client that the physician will prescribe an antidepressant and she will feel better.Encourage the client to get on with her life and stop feeling sorry for herself.Advise the client that it isn't unusual for grieving and loss to continue for quite some time.Suggest that the client return in 3 months if the feelings persist.

RATIONALE: This provides the client with validation and support for her feelings. The other options neither validate the client's bereavement nor allow her to resolve them. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 50-year-old bookkeeper arrives for a follow-up visit after a severe wrist fracture 3 months ago. The tearful client expresses helplessness, frustration, and anxiety, stating that the injury was the worst experience of her life. The client's level of function is severely compromised. She has been unable to return to work and is currently receiving disability payments. What's the nurse's best response?

"I can see how upsetting this is for you. It must be very difficult to be unable to function independently.""I know how you must feel. I broke my arm a long time ago, but I am fine now. You'll be as good as new soon.""You are overly anxious. These injuries take time to heal, and you just have to be patient.""I know it's difficult, but you'll just have to get hold of yourself and get on with your life."

RATIONALE: This provides validation for the client's feelings. The other options don't offer the client either support or the opportunity to discuss her feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationWhile making rounds in a senior citizens' housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85-year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. What's the nurse's best response?

"It shouldn't be hard to find another cat. You'll feel better once you have another pet.""It was only a cat. Why are you allowing yourself to be so upset? It would be different if it were a person.""I'm so sorry that your pet had to be put to sleep. I know how important your cat was to you.""It's probably best for the cat because it was so old and ill."

RATIONALE: This offers support and empathy and enhances the grieving process. The other options don't address the client's need for support and grieving. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 42-year-old homemaker presents in the emergency department with uncontrollable tension and anxiety, difficulty in eating and sleeping, and feelings of extreme insecurity. Her husband of 17 years has recently asked for a divorce. The client is crying hysterically and rocking in a chair. Which response by the nurse would be best?

"You must stop crying so that we can discuss your feelings about the divorce."

"Once you find a job, you'll feel much better and more secure.""I can see how upset you are. Let's sit in the office so that we can talk about how you're feeling.""Once you have a lawyer looking out for your interests, you'll feel better."

RATIONALE: This response validates the client's distress and provides an opportunity to talk about her feelings. Because clients in crisis have difficulty making decisions, the nurse must be directive as well as supportive. Option A doesn't provide the client with adequate support. Options B and D don't acknowledge the client's distress. Moreover, clients in crisis can't think beyond the immediate moment, so discussing long-range plans isn't helpful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 35-year-old married truck driver presents at a mental health clinic. Since losing his job 2 weeks ago, he has slept only a few hours a night and has lost 10 lb (4.5 kg). Pale and haggard, he has trouble answering questions and is easily distracted. What's the best action for the nurse to take?

Ask him if he has tried to find another job.Determine his current and previous level of function and conduct a mental status examination.Ask him if he has ever sought mental health counseling before and whether he's taking any medications.Ask about his family's reaction to his job loss.

RATIONALE: This action assesses the client's current level of function, emotional state, and stability. The other options don't offer the client support or assist in evaluating his current status. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 50-year-old single male is brought to the crisis unit by the police after having escaped unharmed from his apartment, which was destroyed by a fire caused by his smoking in bed. The nurse observes the client sitting silently, almost motionless. Several other clients in the waiting room have commented about the heavy odor of smoke around the man. Which of the following is the nurse's best approach to the client?

"Would you like to change your clothes? The odor of smoke must be very disturbing.""You have been through a very difficult experience. Let's move into the office so that we can talk.""I hope you have learned your lesson today and have given up cigarettes.""You must consider yourself one very lucky man."

RATIONALE: The client is immobilized by his near-death experience, the loss of his home, and his responsibility for these situations based on his smoking. Because he can't make decisions at this point, the nurse's direction is appropriate and therapeutic. It also provides a tactful way to alleviate the odor of smoke in the waiting room. The other options don't provide support or direction for the client during this crisis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationA 19-year-old nursing student preparing for final exams arrives at the student health center, accompanied by two friends. She hasn't slept all night, is sobbing hysterically, is hyperventilating, and states that she "can't go on." Which of the following is the best response for the nurse to make?

"Relax, we've all felt this way. You'll get through it.""Perhaps you need more time to study. Have you discussed this with your advisor?""You're pretty upset right now. Studying for finals can be very stressful. Let's work on a plan that might be helpful.""You need to calm down. Nurses have to learn to take a lot of stress."

RATIONALE: This provides support, reassurance, and a concrete plan for dealing with the issues. Option A provides false reassurance. Option B is unrealistic; a client in high anxiety can't think coherently enough to respond to such a suggestion. Option D negates the client's feelings and may cause further anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? Select all that apply:

Right to select health care team membersRight to refuse treatmentRight to a written treatment planRight to obtain disabilityRight to confidentialityRight to personal mail

RATIONALE: An inpatient client usually receives a copy of the Bill of Rights for psychiatric patients, where they would find options 2, 3, 5, and 6 in writing. However, a client in an inpatient setting can't select health team members. A client may apply for disability as a result of a chronic, incapacitating illness; however, disability isn't a patient right, and members of a psychiatric institution don't decide who should receive it. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationIn the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?" Select all that apply:

"You may leave the hospital at any time unless you are suicidal.""Let's talk more after the health team has assessed you.""Once you've signed the papers, you have no say.""Because you could hurt yourself, you must be safe before being discharged.""You need a lawyer to help you make that decision.""There must be a court hearing before you leave the hospital."

RATIONALE: A person who is admitted to a psychiatric hospital on a voluntary basis may sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Option 3 is incorrect because it denies the client's rights; option 5 is incorrect because the client doesn't need a lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't mandated before discharge. A hearing is held only if the client remains unsafe and requires further treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: ApplicationThe nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? Select all that apply:

The client addresses how the addiction has contributed to family distress.The client reluctantly shares the family history of addiction.The client verbalizes difficulty identifying personal strengths.The client discusses the financial problems related to the addiction.The client expresses uncertainty about meeting with the nurse.The client acknowledges the addiction's effects on the children.

RATIONALE: Options 1, 3, and 6 are examples of the nurse-client working phase of an interaction. In the working phase, the client explores, evaluates, and determines solutions to identified problems. Options 2, 4 and 5 address what happens during the introductory phase of the nurse-client

interaction. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: AnalysisIf parents or legal guardians aren't available to give consent for treatment of a life-threatening situation in a minor child, which of the following statements is most accurate?

Consent may be obtained from a neighbor or close friend of the family.Consent may not be needed in a life-threatening situation.Consent must be in the form of a signed document; therefore, parents or guardians must be contacted.Consent may be given by the family physician.

RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisYou're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client?

In isolation off a side hallwayA private room near the nurses' stationA room with another child who also has meningitisA room with two toddlers who have croup

RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisWhich of the following points should a team leader consider when delegating work to team members in order to conserve time?

Assign unfinished work to other team members.Explain to each team member what needs to be done.Relinquish responsibility for the outcome of the work.Assign each team member the responsibility to obtain dietary trays.

RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless:

the client is mentally ill.the client refuses to give informed consent.the client is in an emergency situation.the client asks the nurse to give substituted consent.

RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ComprehensionThe nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as:

a quality improvement issue.an ethical dilemma.an informed consent problem.a risk-management incident.

RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take?

Speak to the manager and document in writing all concerns related to the assignment.Refuse the assignment.Ignore the assignment and leave the unit.Trade assignments with another nurse.

RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take?

Ignore it because it isn't directly the nurse's problem.Document the problem in writing for the manager.Talk to other staff members to ascertain their practices.Instruct the clients to remind this colleague to wear gloves.

RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't

meeting standards. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisAn adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed?

FraudDefamation of characterAssault and batteryBreach of confidentiality

RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:

call the facility's attorney.inform the client's family.complete an incident report.do nothing because the client's condition is stable.

RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

encourage the client to ask questions about personal sexuality.provide time for privacy.provide support for the spouse or significant other.suggest referral to a sex counselor or other appropriate professional.

RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation?

The nurse may assign the two nonprofessionals to work independently with a client assignment.The nurse is responsible to supervise assistive personnel.Nonprofessionals aren't responsible for their own actions.Nonprofessionals don't require training before they work with clients.

RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisEach state has guidelines that regulate the different levels of nursing - licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as:

consent to treatment.client's bill of rights.nurse practice acts.licensure requirements.

RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to:

detain him until he signs the paperwork.detain him until his physician arrives.call security for assistance.let him leave.

RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't:

properly educated this client about safety measures.restrained the client.documented that she left the client.arranged for continual care of the client.

RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to turn on the call bell or elicit help on the way to the client's room. Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationWhen prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:

allowing the family to see a newly admitted client.ambulating the client in the hallway.administering pain medication.

placing wrist restraints on the client.RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationWhen developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:

at discharge.during the first meeting.at the midpoint of the relationship.when the client demonstrates the ability to function independently.

RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationTo be effective, a clinical nurse-manager in a managed care environment must:

expect all staff to accept change.go along with a proposed change.be a catalyst for change.document staff nurses' reactions to change.

RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change - she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeIn community-based nursing, primary responsibility for decisions related to health care belongs to the:

nurse.client.health care team.physician.

RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable?

No one because it was an accidentThe hospitalThe nurseThe nurse and the hospital

RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:

change his own dressing.walk in the hallway.walk from his room to the end of the hall and back before discharge.eat a special diet.

RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client?

Tell him that it's a legal question beyond the scope of nursing practice.Give him a copy of the client's bill of rights.Provide information on active euthanasia.Discuss documenting his wishes in an advance directive.

RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeWhile admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to:

document findings thoroughly.question the client about the bruising.inform appropriate local authorities.tell the client's physician.

RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease?

The client's familyPastoral care

Support groupHospice care

RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?

Approach the client's family about organ donation.Make the decision to withdraw life support.Sedate the client.Talk to the staff about their feelings.

RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?

Social workerRegistered dietitianOccupational therapistEnterostomal nurse therapist

RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include?

Check on the client once per shift.Provide mouth and skin care only if the family requests it.Turn the client only if he's uncomfortable.Provide emotional support and pain relief.

RATIONALE: When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant:

interprets clinical data.collects clinical data.is trained in the nursing process.can function independently.

RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills - they don't learn the nursing process. Unlicensed assistants don't function independently - they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following considerations has the highest priority?

Complexity of care requiredAge of the clientsSkills of the assigned personnelThe number of clients

RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment?

Referring the client to a social worker for discharge planningProviding individualized client educationHaving the client attend a formal education sessionAttempting to contact a member of the client's family to provide assistance

RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway?

A nursing care plan that helps the nurse to decide which intervention to perform firstA multidisciplinary care plan that helps the nurse to use a variety of critical interventionsA standardized care plan that lists basic interventions for the nurse to use with every clientA clinical management tool that organizes the major interventions for a multidisciplinary health care team

RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which one of the following nursing actions will best serve the hospital in a disaster situation?

The nurse should know the hospital's disaster plan and what's expected of her during a disaster.During a disaster, the nurse should volunteer to help where she thinks assistance is most needed.The nurse should offer advice about how to keep the operation running smoothly.If told to do so, the nurse should perform tasks that are beyond her scope of practice.

RATIONALE: Before a disaster occurs, the nurse should know how the hospital's disaster plan works and what she'll be required to do in a disaster. During a disaster, the charge nurse will assign staff to areas where the needs are; therefore, a nurse may find herself performing tasks outside of her usual practice. This practice is permitted if the nurse has the knowledge, skill, and comfort level to perform assigned tasks. However, the nurse should never perform activities outside of the nurse's scope of practice as outlined in the state's nurse practice act. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse-manager of a hospital unit holds monthly staff meetings. During these meetings, she maintains control over the meeting and agenda, resists consensus decision making, and uses discipline and coercion to elicit desired behavior from staff. This manager uses what type of leadership style?

AutocraticDemocraticParticipativeLaissez-faire

RATIONALE: Autocratic leaders obtain power with a group by maintaining control over the group. Democratic leaders share power by allowing consensus decision making and distribution of power. Participative leadership is another term for democratic leadership. Laissez-faire leaders maintain no control over the group; decision making is unstructured and commonly performed by an unofficial leader of the group. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe registered nurse of a hospital unit is acting as charge nurse. The charge nurse's responsibility is to delegate client care appropriately to the licensed practical nurse (LPN) and the nurse's aide. Delegation of activities should be primarily based on which factors?

Whether the LPN or nurse's aide provided care for the client beforeThe staff member whose turn it is to perform certain, less pleasant tasksThe job description and experience level of the LPN and the aideThe staff member who volunteers to perform the various tasks

RATIONALE: The primary considerations related to appropriate and effective care delegation are the job descriptions of the assistive staff members and their levels of expertise. Both factors must be considered together, neither in isolation. The other options identify factors that may help determine client care assignments, but only after considering job description and experience levels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA task force is formed to analyze institutional problems, such as inadequate staffing and a rise in the number of negative evaluations from clients. During the meeting, members express their concerns, disagree over the most significant factors contributing to these problems, and compete for influence over the group. Which of the following four stages of group development does their behavior represent?

FormingStormingNormingPerforming

RATIONALE: Storming refers to the stage when resistance to group influence occurs and the objectives of the group aren't yet clearly established. Forming is the first stage, when the members of the group first meet. During the norming stage, which occurs after storming, consensus begins to evolve, cohesion and norms develop, and conflict and resistance are resolved. Performing is the stage when the group focuses on the task at hand and constructive group efforts improve task performance. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA client in the final stages of terminal cancer tells his nurse, "I wish I could just be allowed to die. I'm tired of fighting this illness. I've lived a good life. I continue my chemotherapy and radiation treatments only because my family wants me to." What's the nurse's best response?

"Would you like to talk to a psychologist about your thoughts and feelings?""Would you like to talk to your minister about the significance of death?""Would you like to meet with your family and your physician about this matter?""I know you are tired of fighting this illness, but death will come in due time."

RATIONALE: The nurse has a moral and professional responsibility to advocate for clients who experience decreased independence, loss of freedom of action, and interference with their ability to make autonomous choices. Coordinating a meeting between the physician and family members may allow the client an opportunity to express his wishes and promote awareness of his feelings, as well as influence future care decisions. All other options are inappropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse works in a managed-care environment. The nurse is expected to be oriented to which of the following criteria?

Performing tasks in the shortest time possibleAdhering to client preferencesProblem solving and time managementQuality of care and cost-containment

RATIONALE: Managed care principles mandate the most efficient use of limited resources; therefore, quality of care and cost-containment are the main issues. Nurses must look for the most cost-effective method of achieving a desired outcome without compromising quality. Problem solving and time management are skills used to implement the care plan, but aren't unique to the managed care environment. Performing tasks quickly doesn't always achieve quality care. Adhering to client preferences isn't a guiding principle. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do?

Take measures to prevent the client from leaving.Ask the client to sign an AMA form.Call a security guard to help detain the client.Notify the physician.

RATIONALE: If a client requests discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form. This form releases the hospital from legal responsibility. If the physician isn't available, the nurse should obtain the client's signature on the AMA form. A client who refuses to sign the form shouldn't be detained; forced detention violates the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with renal failure who requires peritoneal dialysis. The nurse doesn't feel comfortable performing the procedure. What would be the most appropriate action for the nurse to take?

Omit the procedure and tell the next nurse in report that she'll need to perform the dialysis.Ask the nursing supervisor for assistance in using the equipment.Ask the client how to use the equipment.Perform the procedure to the best of her ability, utilizing her knowledge of basic health principles.

RATIONALE: When a nurse is unsure about a procedure or piece of equipment, she should tell the nursing supervisor that she isn't comfortable and ask for assistance with the task. If appropriate training or assistance isn't available, the nurse should ask for a different assignment. The procedure shouldn't be omitted for the shift because this could lead to serious complications for the client. The nurse should never perform a procedure that she doesn't feel prepared to perform. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA registered nurse suspects that another nurse has been drinking. She smells alcohol on the nurse's breath and notes slurred speech. What's the best course of action for the registered nurse to take?

Cover for the nurse because the profession depends on loyalty from colleagues.Call the police and ask them to arrest the nurse because she's endangering the lives of clients.Tell the nurse she has one more chance, but if she drinks on duty again she'll be reported.Immediately notify the nursing supervisor.

RATIONALE: A nurse who suspects another nurse of impaired practice has a duty to report the colleague to the nursing supervisor, not the police. A nurse who fails to report an impaired nurse may face disciplinary action. The nurse shouldn't cover for an impaired nurse or give her one more chance. These actions place clients at risk, place the nurse at risk for disciplinary action, and prevent the impaired nurse from receiving help. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisWhen documenting care in a client's medical record, the nurse should:

record the nurse's interpretation of data.correct a mistake using a correcting fluid.record the time and date for all entries.leave blank spaces to record information at a later time, if necessary.

RATIONALE: All entries in the medical record should include the time and date they were written. The nurse should document observations and measurements, but avoid giving an interpretation of the data. Correcting fluid is never used to correct an error. When a mistake in documentation is made, the nurse should draw a single line through the entry, write the word error next to it, and sign her name; otherwise, it may appear as if a nurse is trying to alter or hide information. Never leave blank spaces in the medical record. The nurse should draw a line through any blank spaces and sign her name at the end to prevent others from adding information to the entry. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse is completing a change-of-shift report. Which statement wouldn't be appropriate for a nurse to include in the report?

The client was admitted with a diagnosis of myocardial infarction.The client lives at home with his wife and two children.The client had chest pain relieved with one sublingual nitroglycerin tablet.The client is scheduled for a cardiac catheterization in the morning and will be nothing by mouth after midnight.

RATIONALE: Biographical data provided in the client's Kardex or care plan shouldn't be repeated in a change-of-shift report. The shift report should include essential information, such as the client's name, sex, age, changes in the client's condition, treatments, and the client's response to treatment. Other significant information, such as scheduled tests and preparations, may be included. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeA 19-year-old male client is diagnosed with prostate cancer. Which nursing action constitutes an invasion of the client's privacy?

Covering the client with a blanket before transporting him through the hospital corridorsPulling a curtain around the bed before performing a prostate examinationRefusing to discuss the details of the young man's condition with coworkers in an elevator filled with staffTelling the family that the client has cancer without the client's knowledge

RATIONALE: Providing information to an adult client's family without the client's knowledge or permission is an invasion of the client's privacy. The other options - properly covering a client before moving him through hospital corridors, shielding a client during personal care, refusing to discuss client information with people who don't have a need to know - all demonstrate appropriate respect for the client's privacy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to?

ClergySocial workerCertified nurse midwifeGenetic counselor

RATIONALE: A genetic counselor can educate the couple about an inherited disorder, screening tests that can be done, and treatments and can provide emotional support. Clergy are available to provide spiritual support. A social worker can provide emotional support and help with referrals for financial problems. A nurse midwife cares for women during pregnancy and birth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ComprehensionThe family of a child dying from leukemia asks the nurse about organ donation. Who must give consent for the child's organs to be donated?

Member of the clergyPhysicianParentsCourt-appointed surrogate, as designated under the Uniform Anatomical Gift Act

RATIONALE: A parent or legal guardian may give permission for organ donation. A member of the clergy can't give permission for organ donation; however, a family member may seek the clergy's guidance in making this decision. The physician may only ask the family to consider organ donation. The Uniform Anatomical Gift Act provides clients and family members with the right to choose organ donation, but doesn't allow for designation of a

surrogate to make decisions related to organ donation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ComprehensionParents whose first child has celiac disease ask the nurse if all of their children will have the disease. To whom should the nurse refer them?

Registered dietitianGenetic counselorCertified nurse midwifeSocial worker

RATIONALE: Celiac disease is believed to be a dominantly inherited, inborn error of metabolism. A genetic counselor could explain about inherited disorders, how they're inherited and, when appropriate, provide screening tests. A registered dietitian could provide in-depth education about a gluten-free diet and help the family adapt the diet to their special needs. A social worker could provide the family with emotional support and help with referrals for financial problems. A nurse midwife cares for women during pregnancy and childbirth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ComprehensionThe nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate?

Registered dietitianPhysical therapistOccupational therapistNurse's aide

RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy, but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nurse's aide can help a child eat; however, the nurse's aide isn't trained in modifying utensils. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationAn 18-year-old pregnant woman tells the nurse that she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that she:

may not take care of herself.may not be fit to take care of a child.needs to take up a second job.should be referred to community resources available for pregnant women.

RATIONALE: The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly, but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily rectify this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?

On the day of dischargeWhen the client expresses readiness to learnWhen the client's vomiting has stoppedOn admission to the hospital

RATIONALE: Discharge planning should begin when a client is first admitted to the hospital. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge won't be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Factors such as when the client stops vomiting or expresses readiness to learn shouldn't influence when the nurse begins discharge planning. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe parents of a 5-year-old call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What should the nurse advise them to do?

Take the child to the emergency department of the local hospital.Schedule an immediate appointment with their health care provider.Call the child protective services to file a complaint.Talk to their attorney to file charges against the accused.

RATIONALE: Because more information needs to be obtained from the child and family, an immediate appointment is most appropriate. It's unclear what type of abuse the parents are concerned about. Taking the child to the emergency department would be appropriate if the child had been sexually abused within the past few hours or if the child needed immediate treatment for trauma. Calling child protective services is appropriate but isn't the first action to take; neither is talking to an attorney. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager?

The nurse keeps communication channels open among herself, the family, physicians, and other health care providers.The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions.The nurse works with the family members to find ways to decrease their dependence on health care providers.The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently.

RATIONALE: When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse's part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisWhen meeting with parents who will learn that their 3-year-old is seriously ill, which action demonstrates the nurse's role as collaborator of care?

Provide the parents with information about financial assistance programs.Inform the family of the diagnosis and recently discovered findings.Coordinate the multidisciplinary services and provide information about them.Refer and consult with other specialties to help in treating the diagnosis.

RATIONALE: The nurse can coordinate care when multiple services are involved, explaining the function of each service (social services, case management, counseling services, and so forth). For instance, providing parents with information about financial assistance programs is the responsibility of social services. Informing the family of the diagnosis and recently discovered findings is a physician's responsibility, as are referring

and consulting with other specialties. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ComprehensionIn planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:

institutional resources.standards of practice.client-care quality.nursing recruitment.

RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeThe employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if the client has given consent to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?

"I'm not permitted to discuss her progress.""I'll give you the name and telephone number of her physician.""I'll have her call you.""I can't confirm whether your employee is a client here."

RATIONALE: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationBased on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step the nurse would take in developing an educational program is:

assessing for a decrease in referrals following a pediatric safety class.assessing the strengths and needs of the community while identifying barriers to learning.choosing a health promotion or health belief model as a framework.developing and implementing a specific plan to decrease childhood injuries.

RATIONALE: Following the identification of a learning need, the first step is to assess the strengths and needs of the community while identifying barriers to learning. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisA registered nurse who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short staffed and needs additional help to care for the clients. The nurse has never worked in the CCU. Which of the following responses is the most appropriate nursing action?

Call the hospital lawyer.Report to the CCU and identify tasks that she feels she can safely perform.Speak to the nursing supervisor.Refuse to go to the CCU.

RATIONALE: When the nurse is placed in this situation, the most appropriate action is to set priorities and identify potential areas of harm to the client. Reassignment to another nursing area is an acceptable legal practice used by hospitals to meet their staffing needs. A nurse can't legally refuse to be reassigned unless there's a specific clause in her union contract. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationA nurse-manager is explaining the unit's performance improvement (PI) program to a newly hired nurse. Which of the following should she include as one of the primary purposes of the PI program?

Evaluation of client outcomesEvaluation of staff member performanceImprovement in the efficiency of carePreparation for accreditation

RATIONALE: PI programs ensure that the best care is delivered to clients. This can be measured by evaluating client outcomes. Staff performance evaluations focus on staff, not client outcomes. Improvement in the efficiency of care may be an aspect of quality care but it isn't the goal. Although PI is one component required for accreditation, the goal is to ensure that the best care is delivered, not to ensure accreditation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationTwo family members are arguing in a child's room. They start to hit each other and the child is crying. What's the most appropriate nursing action?

Call security to come and intervene.Remove the child from the room.Ask one of the family members to leave the room.Try to reason with both family members.

RATIONALE: The first action would be to protect the child by removing him from the room. Calling security is necessary but only after ensuring the safety of the child. Asking one of the family members to leave the room or reasoning with them would be ineffective at this point and may even escalate the situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nursing supervisor is called to the emergency department to assist with a 10-month-old infant with injuries consistent with child abuse. The nursing supervisor confers with the emergency department physician. To whom must she report the incident?

A social workerThe medical director of the emergency departmentA Children's Protective Services (CPS) representativeA public health nurse

RATIONALE: Suspected child abuse must be reported to a CPS representative. Reporting a potential abuse doesn't indicate guilt, only suspicion or risk. The CPS and the judicial system will follow the correct legal process to establish the need for prosecution and counseling. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe nurse-manager has noticed a sharp increase in the mediation errors with I.V. antibiotics over the last month. She discusses the situation with each nurse involved. What other action should she take?

Document it on their evaluation.Ask them to attend inservice training for administration of I.V. medications.Report them to the supervisor.Report the incidents to the hospital attorney.

RATIONALE: Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures. Documenting or reporting the situation wouldn't directly assist the nurses in eliminating errors. Reporting the incidents to the hospital attorney isn't necessary. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationWhen reporting to the surgeon that a chest tube is malfunctioning, the nurse is ordered to reposition the tube and obtain a chest radiograph. The nurse should:

inform the surgeon this isn't within her scope of practice.report the surgeon to the Ethics Committee.report the surgeon to the nursing supervisor.follow the order as requested by the surgeon.

RATIONALE: Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice. If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practice according to the hospital's policy. The nurse must not comply with any order that goes beyond the scope of nursing practice. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeAn Iranian mother and father admit their 14-month-old son to the pediatric unit for treatment of leukemia. When the female pediatric oncologist, who isn't Muslim, introduces herself, they became uncooperative and refused treatment. The nurse should be aware that this change of behavior is probably related to:

the gender of the physician.fear of being accused of child abuse and neglect by an authority figure.religious barriers that prevent the family from accepting care from someone who isn't of their religion.aggressiveness of Middle Easterners.

RATIONALE: The Iranian tradition of male authority is still strong. Accepting a woman making life-and-death decisions for their son may be very difficult for these parents. Discussing with the parents other options, such as the idea of turning the case over to a male Muslim oncologist, would be appropriate. The gender issue is a stronger cultural factor than the religious difference. There's no basis to relate the parents' behavior to fear of being charged with abuse or neglect. Attributing the behavior to Middle Eastern aggressiveness reflects a stereotype, not a culture value. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: KnowledgeWhich of the following clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the day shift?

The client who had a total laryngectomy the previous dayThe client with diabetes who had a fasting blood glucose of 150 mg/dlAn elderly client who has Alzheimer's disease and periods of confusionA client with a pneumothorax who had a chest tube inserted earlier in the day

RATIONALE: Based on the information provided, the client who is on day 1 after a total laryngectomy would be the priority client for the nurse to evaluate. This client is at risk for impaired respiratory status and should be monitored closely. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisThe nurse receives report on the assigned clients at the beginning of the evening shift. Which of the following clients should the nurse plan to assess first?

A client who is scheduled for a cardiac catheterization in the morning and is visiting with his familyA client receiving an I.V. infusion via a central line at 60 ml/hour with 400 ml remaining in the I.V. fluid bottleA young male client with chest tubes placed for treatment of a pneumothorax who is resting comfortablyAn elderly client with pneumonia who has periods of confusion

RATIONALE: Because of the elderly client's diagnosis of pneumonia and periods of confusion, there's a potential for client injury and decreased levels of oxygenation. The nurse should assess this client first. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: AnalysisTwo nurses are in the cafeteria having lunch in a quiet, secluded area. There's a person sitting at a table near to them. During lunch, the nurses discuss a client who was physically abused. Later, that same person is visiting the client and asks the client questions about the physical abuse. The client discovers that the visitor overheard the nurses talking about the abuse situation and is emotionally harmed. The ramifications associated with the nurses' discussion about the client are most appropriately associated with which of the following?

None, because they were in a quiet, secluded area.They can be charged with slander.They can be charged with libel.None because the person who overheard is a friend of the client.

RATIONALE: Defamation occurs when information is communicated to a third party that causes damage to someone else's reputation either in writing (libel) or verbally (slander). The most common examples are giving out inaccurate or inappropriate information from the medical record; discussing clients, families, or visitors in public areas; or speaking negatively about coworkers. This situation can cause emotional harm to the client, and the nurses could be charged with slander. This situation also violates the client's right to confidentiality. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: ApplicationThe registered nurse asks the licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the registered nurse that although she received inservice training for this procedure, she never performed it on a client. What's the most appropriate action for the registered nurse to take?

Request that the LPN review the procedure in the hospital manual.Request that the LPN review the materials from the inservice before performing the procedure.Perform the procedure with the LPN.Request that another LPN observe the procedure when it's performed.

RATIONALE: The registered nurse must remember that even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that another LPN observe the procedure doesn't ensure that the procedure will be done correctly. Because this is a new procedure for this LPN, the registered nurse should accompany the LPN, provide guidance, and answer questions after the procedure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application

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