Medical-Surgical Nursing Critical Thinking in Client Care.docx

Medical-Surgical Nursing Critical Thinking in client care The nurse is caring for four clients on a medical surgical unit Which client should the nurse see initially A client admitted with hepatitis A who has had severe diarrhea for the last hours A client admitted with pneumonia who is has small amounts of yellow productive sputum A client admitted with fever of unknown origin FUO who has been without fever for the last hours A client admitted with a wound infection whose WBC is mm Answer Rationale The nurse must decide which client should be seen on the initial rounds of the day The nurse must remember that the first client to be seen should be the client who needs the attention of the nurse initially A client with hepatitis A does experience diarrhea but diarrhea for the last hours could cause the client to have a problem with dehydration and experience a state of fluid volume deficit Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning The nurse is preparing to administer influenza vaccines to a mass drive-through clinic Which statement by a client would indicate further questioning prior to giving the client the influenza vaccine I am allergic to horse hair I try to get my vaccine every year I am not allergic to anything except eggs My husband had a severe allergic reaction after he received his influenza vaccine Answer Rationale Influenza vaccines are recommended for person at high risk for serious sequelae of influenza The nurse should be aware that client with a sensitivity to eggs should not receive the vaccine Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment The nurse is caring for four clients on a medical surgical unit The secretary gives the nurse the morning labs Which of the following labs would require that the nurse call the physician and inform the healthcare provider about the client s abnormalities WBC mm Serum protein g dL I D incision and drainage showing no growth for the last hours Albumin g dL Answer Rationale When the nurse is caring for several clients all of the labs should be checked frequently throughout the shift to assess for any abnormalities The WBC in option is abnormal Normal WBC mm All of the other lab results are within acceptable range therefore the results should not be called in to the physician Cognitive Level Application Client Needs Physiologic Integrity Nursing Process Assessment The nurse is orienting a new graduate The nurse is reinforcing the importance of standard precautions Which of the following observations by the nurse would require further education regarding standard precautions The graduate nurse understands to wash hands when entering and exiting the client s room The graduate nurse wears gloves when serving breakfast trays to various clients The graduate nurse wears a gown gloves and goggles when suctioning a client The graduate nurse leaves all supplies in the room of a client who is in contact isolation Answer Rationale The nurse must have an understanding of standard precautions Prevention is the most important measure to prevent nosocomial infections Standard precautions were published in that provide guidelines for the handling of blood and other body fluids These guidelines are used with all clients regardless of whether they have a known infectious disease Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids It is not necessary for the nurse to wear gloves while delivering food trays to the client because there is not contact with the client Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Evaluation The admitting department alerts the nurse on a medical surgical unit that a client with active tuberculosis TB is being admitted to the unit Which type of isolation is appropriate based on the client s diagnosis Standard precautions Airborne precautions Droplet precautions Contact precautions Answer In addition to handwashing and standard precautions the nature and spread of some infectious diseases require that special techniques be used to protect uninfected clients and workers The client with pulmonary tuberculosis will be placed in airborne precautions The client should be placed in a private room with special ventilation that does not allow air to circulate to general hospital ventilation a mask or special filter respirators will be used for everyone entering the room Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment A client is receiving IV vancomycin for the treatment of Clostridium difficile The nurse understands that the client who develops flushing tachycardia and hypotension during the infusion of vancomycin indicates Ototoxicity effect Superinfection Red man syndrome Hives Answer Rationale Vancomycin inhibits cell wall synthesis and is used for serious infections It is only effective against gram-positive bacteria especially Staphylococcus aureus and Staphylococcus epidermidis The nurse should infuse this medication slowly over minutes or more to avoid red man syndrome The syndrome is characterized by erythematous rash flushing tachycardia and hypotension Clients can become dizzy and agitated Cognitive Level Application Client Needs Physiological Integrity Nursing Process Evaluation The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic The nurse understands that the trough should be ordered A few minutes before the next scheduled dose of medication hours after the oral administration of the medication minutes after the IV administration During the infusion of the antibiotic Answer Rationale Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication The therapeutic range the minimum and maximum blood levels at which the drug is effective is known for a given drug By measuring blood levels at the predicted peak hours after oral administration hour after intramuscular administration and minutes after IV administration and trough usually a few minutes before the next scheduled dose it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy increasing the likelihood of adverse effects Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment The nurse needs to change a dressing on the client s abdomen Which of the following techniques should be implemented Contact precautions Standard precautions Droplet precautions Airborne precautions Answer Rationale Standard precautions are used on all clients regardless of whether they have a know infectious disease Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids Since the client has an abdominal dressing the nurse will use standard precautions Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning The physician has ordered for the nurse to obtain a sputum specimen The nurse understands that the sputum specimen should be collected Immediately after the first dose of antibiotic is administered minutes after the first dose of antibiotics is administered During the first dose of antibiotics Before the first dose of antibiotics is administered Answer Rationale When the physician orders a specimen to be collected the nurse should collect the specimen before the first dose of antibiotics is administered to ensure adequate organisms for culture Cognitive Level Comprehension Client Needs Safe Effective Care Environment Nursing Process Planning Which of the following manifestations indicates a systemic reaction associated with an inflammatory response Erythema Pain Tachypnea RR Edema Answer Rationale If the nurse observes a systemic reaction the client will exhibit manifestations including temperature increased pulse tachypnea and leukocytosis Erythema warmth pain edema and functional impairment indicate a local reaction Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment A client develops hyperthermia related to a diagnosis of Pneumonia Which of the following nursing interventions would be effective in the treatment of hyperthermia Select all that apply Increase the temperature of the room environment to prevent shivering Use ice packs and a tepid bath as needed Administer antipyretic medications per physician s orders Promote frequent rest periods to increase energy reserve Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance Answer Rationale Hyperthemia is an expected consequence of the infectious disease process Fever can produce mild short-term effects or when prolonged can cause life-threatening effects The nurse should administer antipyretic medications as indicated for elevated temperatures The nurse should use ice packs cool tepid baths or hypothermia blanket with caution The nurse should enforce frequent rest periods because rest increases energy reserve which is depleted by an increased metabolic heart and respiratory rate The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance Cognitive Level Assessment Client Needs Physiological Integrity Nursing Process Implementation The nurse is assessing a client s wound for signs and symptoms of inflammation Which of the following would alert the nurse that the client is exhibiting signs of inflammation Select all that apply Leg edema Leg cool to touch Severe pain from swelling Decreased peripheral pulses Severe erythema of leg Answer Rationale Regardless of the cause location or extent of the injury the acute inflammatory response follows the sequence of vascular response cellular and phagocytic response and healing Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged The cardinal signs of inflammation include erythema local heat caused by the increased blood flow to the injured area hyperemia swelling due to accumulated fluid at site pain from tissue swelling and chemical irritation of nerve endings and loss of function caused by the swelling and pain Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment Alternate item format Select all that apply Which of the following manifestations would the nurse expect to see with a client who has had previous knee surgery who suffered a surgical infection with signs of systemic manifestations Select all that apply Erythema WBC mm Pain at the surgical site Bands Respiratory rate of Pulse Answer Rationale The client is post surgical repair of the knee The nurse should be able to distinguish between local reactions and system reactions An elevated WBC and bands are indicative of an infection Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia Local manifestations include erythema warmth pain edema and functional impairment whereas systemic manifestations include elevated temperature above F pulse greater than min respiratory rate greater than and WBC greater than mm or bands Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment Chapter When collecting data at the immunization clinic which of the following disclosures by the client would cause the nurse to hold administration of the varicella vaccine a History of an allergic reaction to yeast bread b Itching and swelling on the face and hands after ingesting eggs c A low grade temperature within the past two days d A blood transfusion after undergoing surgery three months ago Answer d Rationale Contradictions for the varicella vaccine include pregnancy suppressed immunity and a recent history of a blood transfusion Recent hyperthermia and allergies to yeast or eggs do not indicate a potential difficulty with the administration of the varicella vaccine Nursing Process Step Assessment Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Prevention and or Early Detection of Health Problems Cognitive Level Analysis The nurse is planning an in-service to discuss primary levels of disease prevention Which of the following topics should be included in this presentation a A discussion concerning the use of available community rehabilitation facilities b Available locations for diabetes screening c The need for annual colonoscopy examinations d The elimination of smoking and alcohol use Answer d Rationale Primary prevention involves activities geared toward the prevention of illness and disease Screening activities such as glucose testing and colonoscopy examinations are a form of secondary prevention Rehabilitation activities are considered a tertiary level of prevention Nursing Process Step Planning Client Needs Category Health Promotion and Maintenance Client Needs Category Prevention and or Early Detection of Health Problems Cognitive Level Application A -year-old client voices concerns about gaining pounds over the past two years The client reports no change in dietary habits Which response by the nurse is most appropriate a Age-related changes in metabolism can result in weight gain despite consistent dietary intake b Are you exercising c You might be eating more than you think d You are getting older Answer a Rationale A reduction in metabolic rate often accompanies aging This will cause weight gain despite not eating more calories Asking the client about exercise fails to provide the needed information to the client It also assumes the client is sedentary Implying the client is overeating is judgmental and will do little to establish a therapeutic rapport The client is aware of aging Pointing this out does little to meet the client s obvious interest in more information Nursing Process Step Diagnosis Client Needs Category Physiological Integrity Client Needs Category Physiological Adaptation Cognitive Level Application The nurse is assisting an -year-old female client to plan a healthy diet to support recent weight loss Which of the following should be included in the dietary plan Select all that apply a mg folic acid are recommend in the daily diet b Eat at least six servings of grains c To avoid constipation keep daily iron intake below mg d Fat intake should be limited to less than of the daily caloric intake Answer b d Rationale Grain intake should include at least six servings daily To maintain a healthy weight and reduce incidence of cardiovascular disease fat intake should not exceed of the daily intake Folic acid intake should be at mg daily Iron is a vital ingredient in the daily diet mg daily is reflective of the desired amount Constipation should be managed by an adequate fluid and fiber intake Nursing Process Step Planning Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Prevention and or Detection of Early Health Problems Cognitive Level Application During a routine physical examination for a -year-old Caucasian male the client declines to have his prostate gland examined He states he does not have a family history and does not feel he is at risk What initial response by the nurse is most appropriate a You may refuse any screening test you wish b I will need to tell the physician about your refusal c Your risk factors increase with aging d You are right Caucasian men have less incidence of prostate cancer Answer c Rationale The need for prostate screening begins at age Individuals with risk factors should begin screening at age The client s age places him at an increased risk so he should begin the screening process While the client may refuse any testing this does not allow the client to engage in secondary levels of prevention The client s refusal should be recorded in the medical record but not used as a means to coerce the client Nursing Process Step Implementation Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Growth and Development through the Lifespan Cognitive Level Analysis The nurse is preparing to teach a class for a group of new parents The nurse is attempting to determine what topic would be of the greatest interest to the audience What selection would be most appropriate a Safety b Chronic illness prevention c Problem-solving skills d Interventions to manage depression Answer a Rationale The parents of small children are interested in information geared toward keeping them safe Household safety is a priority for children of all ages The families attending the session likely will have limited interest in preventing illness as they typically represent a healthy segment of the population Depression is a greater concern for older adults Nursing Process Step Assessment Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Growth and Development through the Lifespan Cognitive Level Analysis An African-American male is discussing his dietary intake with the nurse The nurse encourages the client to keep sodium intake below mg per day The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive How should the nurse respond a African-Americans typically have higher sodium levels than their Caucasian counterparts b This is the amount of sodium intake recommended for everyone c This is what will be best for you d Do you eat a great deal of salt Answer a Rationale After generations of conditioning African-Americans frequently have higher sodium levels The recommended sodium intake for African-Americans is slightly lower than are the levels for their Caucasian peers Simply telling the client the recommendation is best does not provide an adequate level of information The amount of salt ingested by the client should be recorded but this is not the best response Nursing Process Step Implementation Client Needs Category Physiological Integrity Client Needs Subcategory Physiological Adaptation Cognitive Level Analysis A -year-old woman presents to the ambulatory clinic for a gynecological examination The health history reveals no significant personal or family medical history What information concerning health-promotion behaviors should be presented to the client a It is time to begin having mammograms every other year b If the client is in a monogamous relationship Pap smears will not be needed c Bone density examinations are indicated every year d Recommended calcium intake is at least mg per day Answer d Rationale The recommended calcium intake is at least mg per day This will be beneficial in the prevention of osteoporosis Women should begin having annual mammograms by age Pap smears are continued for women in monogamous relationships For women with no significant risk for the development of osteoporosis bone density examinations should be done every other year Nursing Process Step Implementation Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Prevention and or Early Detection of Health Problems Cognitive Level Analysis A -year-old client seeks care at an ambulatory clinic The client reports having experienced extreme drowsiness after recently taking dosages of an over-the-counter cold medication When collecting data the nurse notes the client reports taking only the prescribed amount of the preparation What inferences can be made by the nurse concerning the events a The client likely has taken more of the preparation than stated b The client likely has experienced a reaction between the cold medication and other routine medications c The client s age has influenced his response to the medication d The client is allergic to the cold medication Answer c Rationale Older clients often experience altered responses to medications These changes are in response to age-related developments in the kidneys and liver There is no evidence the client has taken too much medication There is no information provided to indicate the client is taking other medications Allergic reactions typically manifest with integumentary- or respiratory-related symptoms Nursing Process Step Evaluation Client Needs Category Physiological Integrity Client Needs Subcategory Pharmacological and Parental Therapies Cognitive Level Analysis Chapter A nursing student is reading about the concept of parish nursing Which of the following statements indicates understanding of the key concepts of parish nursing You must practice a certain faith to be involved in parish nursing Parish nurses are independent practitioners providing care to members of a selected church Parish nursing is reserved for nurse practitioners Parish nurses may be employed by a hospital Answer Rationale Parish nursing seeks to provide health care to traditionally underserved populations Involvement in parish nursing is not limited to select faiths The parish nurse may work directly for the church involved or be contracted by the church to provide nursing services and perform referrals Parish nursing is not limited to nurse practitioners Nursing Process Step Evaluation Client Needs Category Health Promotion and Maintenance Client Needs Subcategory Prevention and or Early Detection of Health Problems Cognitive Level Application The mother of a severely handicapped child states she is exhausted and voices the need to take a break to the nurse What type of referral would best benefit the client A respite care provider Hospice care agency Home care Ambulatory clinic Answer Rationale Individuals who are faced with caring for ill or handicapped family members might need to have a break The best option would be for a respite care provider Respite care offers short in-home services in which the care provider would be freed from her duties for a short time Hospice care is designed to assist the dying client and family members Home health care is best for clients who are unable to leave their home for care services Ambulatory clinics are used for clients who are in need of limited point-of-care medical services Nursing Process Step Implementation Clients Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Application The client who lives alone indicates concerns about their ability to perform the necessary dressing changes after discharge Which action by the nurse is indicated at this time Explain to the client that she will need to seek the assistance of a friend or neighbor to help as needed Make a referral to the home healthcare agency preferred by the client Contact the hospital social worker Discuss the client s anticipated needs with the physician Answer Rationale The client will likely need home health care Home care requires a physician s order The nurse will need to initiate the referral process In some facilities a discharge planner might be involved The services of the hospital social worker are not indicated by the information provided The client has already indicated the absence of assistance If the client lacks the social resources for it it will be up to the healthcare team to locate community-based resources Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application The nurse is evaluating a group of clients for referral to a home health agency Each of the clients is on the Medicare program Which client is most likely to qualify for home health services The postoperative client needing reevaluated by the physician six weeks postoperatively The client having a moderate-sized stage III pressure ulcer requiring daily dressing changes The bedridden client who s physician has prescribed oral antibiotic therapy for two weeks The client having large stage I pressure ulcer Answer Rationale Home care is indicated for clients for whom travel to the healthcare provider would be impossible or quite difficult A large stage III pressure ulcer would be painful for the client during travel Daily dressing changes would not be a typical function of the physician s office and would ideally be completed in the home The client requiring a postoperative assessment in six weeks does not appear to have any limitations presented Oral antibiotic therapy does not present challenges to the client that signal the need for home care The stage I pressure ulcer does not have skin breakdown or require professional healthcare services Nursing Process Step Planning Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Analysis During a home care visit the nurse notices the client s dressing supplies are not being kept in a readily assessable environment The nurse has discussed this with the client and family in previous visits What action by the nurse is indicated Document the activities relating to the situation Continue to discuss the issues each visit Notify the physician Take the supplies and arrange to bring them back with each visit Answer Rationale The nurse has attempted to address the concerns with the client and family The client s failures to make changes in routine indicate a lack of intent to change Continued discussion likely will prove futile There is no need to notify the physician at this time Taking custody of the supplies carrying them around and bringing them back each time is not feasible for the nurse Goals of the nurse are not necessarily shared by the client Nursing Process Step Planning Client Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Application While conducting a home health care visit the nurse is asked to administer insulin to the client s ailing husband What action by the nurse is indicated The nurse should refuse to administer the medication The nurse may agree to assist with the administration of the insulin this time only but should caution the client and family that this is not the purpose for their visit The nurse should contact the physician for the husband for an order for the medication The nurse should contact his supervisor to obtain permission to administer the medication Answer Rationale The home healthcare nurse is there to care for the client Providing nursing services for the other members of the household is not appropriate Legal issues would preclude the nurse from providing care without an order Making contact with the physician is not appropriate as the client s husband is not a client of the home health agency Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Analysis The home health nurse observes several small round bruises on the back side of an elderly client s arms What action by the nurse is indicated first Question the client about the cause of the bruises Discuss the bruises with the client s spouse Document the bruises with plans to review them for changes on the next visit Contact the home health supervisor to report the findings Answer Rationale The client should be asked about the cause of the bruises Nurses suspecting abuse are legally required to report it Pending the client s response the supervisor will likely require notification The client s spouse should not be the first contact concerning the bruises as he might be the source of the injury Documentation about the findings is indicated Delaying action until the next visit does not meet the legal responsibilities of the nurse Nursing Process Step Assessment Client Needs Category Safe Effective Care Environment Client Needs Subcategory Safety and Infection Control Cognitive Level Analysis A home health nurse is preparing to begin a series of visits with a client Based upon the client s condition the client is expected to require home care visits weekly for the next two months Which of the following tasks should take place first Set priorities Assess the home environment Establish trust and rapport Promote learning Answer Rationale The basis for a successful long-term relationship between the nurse and the client is founded in trust Once a rapport is established it will be possible to begin to identify priorities that are of mutual interest A review of the home environment will be needed to determine needs for all aspects of care and to promote and maintain safety Learning is an ongoing process The client will be more receptive to interventions by the nurse once a rapport is established Nursing Process Step Planning Client Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Application A postoperative client is preparing for discharge A home health nurse has been scheduled to call on the client in two days The client tires easily and voices an inability to concentrate on all of the information the nurse is attempting to review Which of the subjects concerning the client s condition and home care may be deferred for the home health nurse The recommended diet after discharge The activities that will take place during the four-week checkup with the physician Potential adverse reactions of the prescribed medications The actions of the prescribed medications Answer Rationale The client must be discharged with the needed information to safely manage until the home healthcare nurse has the first visit in two days Information concerning prescribed medications and the recommended diet are of the greatest priority as they will require action by the client prior to the health nurse s visit A discussion involving activities planned four weeks in the future can wait until the client is better able to tolerate the information Nursing Process Step Evaluation Client Needs Category Physiological Integrity Client Needs Subcategory Physiological Adaptation Cognitive Level Analysis The home health nurse has identified a series of concerns while providing services to a client During one of the visits the nurse becomes concerned about criminal activity in the home What initial action by the nurse is most appropriate Dial to obtain assistance in removing the client from the home Contact the physician to discuss the situation Leave the home Advise the client to leave the home as soon as possible Answer Rationale The nurse working in the client s home must always be aware of personal safety Leaving the home in the presence of criminal activity would be the safest alternative Removing the client from the home is beyond the scope of the nurse s responsibility Contact with the physician might be indicated but it does not have a higher priority than leaving the scene to ensure personal safety Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Analysis The nurse is teaching the client about ways to increase personal safety in the home During the interaction the client advises the nurse that he has no plans to make the recommended changes What response by the nurse is most appropriate You might not get well if you do not follow my recommendations I will need to tell your physician the home is not safe enough If you need more information about what we have discussed please let me know I might not be able to continue my visits if you do not conform Answer Rationale When providing patient teaching the nurse must be aware that not all recommendations considered important by the nurse will be held at the same priority by the client A failure to have the same goals does not mean the interaction is without merit Telling the client he might not recover might not be true At no time should the client feel threatened by the nurse s responses Implying that the visits will stop or that the physician will be called could be considered threatening Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Safety and Infection Control Cognitive Level Analysis During a home health visit the client indicates he feels he might need physical therapy to facilitate his recovery What action by the nurse is indicated The nurse should contact the client s insurance carrier to determine benefit eligibility The nurse should provide the client with the contact information for a local agency that offers physical therapy services The nurse should contact the physician to discuss the client s concerns The nurse should advise the client to contact the physician to discuss his concerns Answer Rationale The home health nurse is responsible for making contact with needed agencies Contact with the physician will be needed to initiate physical therapy Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application The nurse is assessing the client s perception of safety issues in the home Which of the following questions and statements will best assist the nurse in obtaining the needed data Do you feel safe at home Can you see room for improving safety at home Please tell me some safety concerns you have Have you ever fallen at home Answer Rationale Open-ended questions or statements will yield the most information Encouraging the client to share safety concerns will allow the greatest exchange of information directly related to the identified topic Asking the client about feeling safe at home is broad and might not yield the desired information Nursing Process Step Assessment Client Needs Category Safe Effective Care Environment Client Needs Subcategory Safety and Infection Control Cognitive Level Application CHAPTER When preparing a client for surgery the nurse observes that the client has been crying When the nurse asks the client to sign the surgery consent form the client states I guess I should just go ahead and sign it even though I m not really sure about doing this The best response by the nurse would be a Most people are usually nervous before surgery b The surgeon is waiting so you should decide c What concerns are you having d Should we just cancel your surgery Correct answer c Rationale The nurse has a responsibility to assess further what the client is upset concerned about prior to surgery If the nurse was present when the physician gave informed consent he can reinforce any information If he was not present or there are still questions the surgeon should be notified to make any other clarifications The surgery should not just be cancelled Telling the client that others are usually nervous does not address this client s individual needs The client has a right to have all questions answered prior to signing a consent for surgery and should not be pressured for any reason Application Implementation Safe Effective Care Environment Upon review of the medical history prior to surgery the nurse notes that a client has a history of alcoholism The nurse makes a point to bring this to the surgeon s attention when informed consent is being provided The rationale for this action would be a The client could be at risk for depression postoperatively b The client will be at greater risk for respiratory complications postoperatively c The client could be dehydrated d The client might require more general anesthesia Correct answer d Rationale Clients need to be assessed for surgical risk factors preoperatively for planning There is no reason to anticipate depression respiratory complications or dehydration simply due to a history of alcoholism Damage to the client s liver might have occurred and this could affect how the client metabolizes medications Analysis Planning Safe Effective Care Environment The nurse is providing preoperative teaching to a client with diabetes The client states I know I won t need as much insulin after surgery since I haven t had anything to eat or drink since midnight Which response by the nurse would be most appropriate a You are right the insulin need will be less postoperatively b Your insulin need will be adjusted and most likely will increase due to the stress of surgery on your body c We will give you your usual dose of insulin just prior to surgery d You will be given insulin during surgery to avoid complications postoperatively Correct answer b Rationale The stress of surgery not of being n p o preoperatively often increases rather than decreases blood sugar and thus insulin needs Insulin is not typically given just prior to or during surgery Analysis Implementation Physiological Integrity A client has a history of malignant hyperthermia A bowel resection with colostomy placement surgery is scheduled The nurse anticipates which type of anesthesia will be used with this client a Regional anesthesia b Inhaled anesthesia c Conscious sedation d Total intravenous anesthesia Correct answer d Rationale The client is having a major surgery General anesthesia would be indicated Inhaled and total intravenous anesthesia are general anesthesia options The use of inhaled anesthesia in a client with a history of malignant hyperthermia would be avoided as it can trigger malignant hyperthermia Total intravenous anesthesia would be used in this situation Analysis Planning Physiological Integrity A client reports a pain level of on a pain scale The nurse offers to review the orders for additional pain medication The client states I really don t want to take any more pain medication because I am afraid I will become addicted The nurse s response should focus on which concept a Physical dependence on pain medication is uncommon during the short-term postoperative use b This client already might have an addiction problem c This client might benefit from a placebo dose d The physician should be notified to discuss pain management Correct answer a Rationale Clients might fear addiction or physical dependence on pain medications especially opioids postoperatively The duration of use is typically short-term and this concern should be discussed but is not anticipated to occur The client who already has an addiction problem most likely would be requesting more medication not refusing it The client is verbalizing pain so administration of a placebo is unethical against client rights for pain management and should not be administered It is within the scope of the nurse to review and make decisions with the client regarding safe use of pain medications that have been ordered by the physician The physician does not need to be called at this time unless the nurse s interventions with the client are unsuccessful Analysis Implementation Physiological Integrity The nurse has many teaching responsibilities preoperatively From the following list select all topics that would be within the nurse s scope to provide instructions about preoperatively a Diaphragmatic breathing b Positioning turning in bed c Coughing exercises d Potential risks of the surgery Correct answers a b c Rationale Measures to ensure respiratory circulatory and gastrointestinal functioning are important for the nurse to teach the client preoperatively The physician would discuss the potential risks and benefits of the surgery during the informed consent process Application Implementation Physiological Integrity Assessment findings that would alert the nurse that a client might be at greater risk for deep vein thrombosis include Select all that apply a Client is years old b Client has varicose veins c Client is obese d Client is on an anticoagulant medication Correct answers b c Rationale The development of a blood clot is an increased risk in the client with an impaired circulatory system as evidenced by varicose veins a client who is obese and over the age of years has an infection or malignancy Anticoagulant medications are given to dissolve clots and do not increase the risk of development Analysis Planning Physiological Integrity Following a coughing episode a client who is hours postoperative from abdominal surgery notifies the nurse of a feeling of pressure in the surgical wound The nurse observes that the surgical wound is open The initial response by the nurse should be a Check the client s vital signs then notify the physician b Cover the wound with a sterile dressing moistened with normal saline then notify the physician c Notify the physician d Place the client in the Trendelenburg position Correct answer b Rationale When the wound dehiscence occurs the site must be covered immediately and be kept sterile The physician should then be notified The client will be returning to surgery Vital signs can be taken after the wound is covered and the physician notified Client positioning is not the priority Analysis Implementation Physiological Integrity Chapter The hospice nurse is working with the family of a -year-old client who is dying The client voices concerns about how her death will be perceived by her -year-old child What advice from the nurse would be most beneficial Advise the client that children that age emotionally distance themselves from the death Explain to the client that children of this age recognize death is permanent Encourage the client to begin to prepare the child by explaining that death is permanent as the child fears separation and might lack comprehension of permanent separation Advise the client that children at this age fear death Answer Rationale Age is a great determinant of beliefs about death Children at this age understand the finality of death At the age of children do not have the emotional maturity to distance themselves from death The ability to understand separation has been mastered by the age of The fear of death is typically seen in children this young Nursing Process Step Implementation Client Needs Category Psychological Integrity Client Needs Subcategory Cognitive Level Application A client has reported to the physician s office with complaints of an inability to sleep at night During the data collection the client reports her estranged husband died a little over a year ago She states I am not sure why this is so difficult I really couldn t stand him near the end Which response by the nurse is most appropriate You seem angry You should contact a therapist Sometimes a rocky relationship with someone at the time of their death can impact your ability to grieve You are just entering the grief process things will get better Answer Rationale Unresolved conflict at the time of death can impact the ability of survivors to successfully grieve the deceased The client s demeanor does not seem angry It is inappropriate for the nurse to refer the client to a therapist Referrals must be initiated by the physician The death occurred more than a year ago The client s continued inability to sleep indicates impaired grieving Nursing Process Step Implementation Client Needs Category Psychological Integrity Client Needs Subcategory Cognitive Level Analysis After suffering a massive cerebral hemorrhage a client of American Indian descent is not expected to survive The family arrives at the hospital In conversation with the family they report they observe most of their religious and cultural traditions Which of the following interventions by the nursing staff would be most appropriate Offer the family a private room to sit together Discourage the family from sitting with their loved one prior to death Discuss the possibility of transferring the client home for the death Encourage the family to assist in the care of the dying client Answer Rationale Traditional American Indians prefer to mourn in private They often will mourn away from the dying client While the American Indian culture might not encourage the family to be with the dying individual it is not appropriate for the nurse to discourage the family from having time with the client at this critical point The severity of the client s condition does not allow for transfer at this time Traditional American Indian rituals associated with death do not encompass assistance with the care Nursing Process Step Planning Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application A competent elderly client has a living will The living will expressed the desire to avoid resuscitation and heroic life support measures The family members are not supportive of this directive Which of the following actions by the nursing staff is most appropriate Contact the Social Services department Notify the hospital attorney Place the document on the chart Explain to the client that the conflict could invalidate the document Answer Rationale The client is competent The wishes of the client must take priority The document should first be placed on the chart and the physician notified If there are concerns about the authenticity of the document the Social Services department or the unit supervisor will need to be contacted A lack of support by the family does not invalidate the document Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application At the time of admission the client is asked if he has a healthcare directive The client reports that his daughter will be allowed to make health-related decisions if he becomes incapacitated Based upon your knowledge the client has a n Living will Healthcare surrogate Durable power of attorney Advanced directive Answer Rational The healthcare surrogate is an individual who will make medical decisions in the event the client becomes unable to do so The living will provides written directions about life-prolonging decisions The power of attorney delegates the decision maker concerning business matters Nursing Process Step Evaluation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application While preparing for the discharge of an elderly terminally ill client the family asks for information concerning the most appropriate time to become involved with a hospice agency What action by the nurse is most correct Assist the family with making contact with hospice at this time Determine the client s expected life expectancy to gauge when the contact should be made Encourage the family to hold off making the contact until death is very close Determine what expectations the family has of the hospice agency Answer Rationale Hospice agencies provide vital services to clients who are facing death and to their families Information concerning available services should be met with facts This is an indication of willingness to embrace the supportive service Referrals for elderly clients should be prompt It is inappropriate to determine life expectancy This is an inaccurate measurement of the degree of services needed Waiting until the time of death nears does not leave much time for the hospice agency to assist the family Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application The client is diagnosed with Huntington s disease While at a follow-up visit with the physician the client breaks down and questions her ability to cope with the situation What response by the nurse will be most beneficial to the client You are certainly facing a difficult road ahead Unfortunately your prognosis is bleak How have other members of your family coped with this diagnosis You should contact a support group Answer Rationale The client is facing a terminal illness The illness is characterized by a continual and increasing loss of function and control The client needs to have validation of her feelings The client realizes the prognosis is bleak and will not benefit from the nurse s restating the obvious Certainly Huntington s disease is inherited and the client might have family members who have faced the disease but this line of questioning will not provide comfort for the client A support group might be helpful but suggestions about joining should follow supportive statements by the nurse Nursing Process Step Implementation Client Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Analysis The client age dies after an unsuccessful resuscitation attempt What nursing action is indicated first Notify the funeral home Document the time of death Contact the physician Contact the orderly for transport to the morgue Answer Rationale After death the time must be recorded in the client s record After documentation is completed the attending physician will require notification Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family s wishes Transportation of the body to the morgue can take place after the family members have been notified and allowed to see their loved one Nursing Process Step Implementation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Application The client has been diagnosed with chronic sorrow related to her husband s recent diagnosis of terminal cancer Which action by the nurse would be most helpful to the client Question the client about her knowledge of cancer treatment options Question the client about her husband s prognosis Determine the means used by the client to cope with loss in the past Encourage the client to identify potential sources of emotional support Answer Rationale Chronic sorrow is a recurring sense of overwhelming sadness in response to a loss The best means to assist the client is to assist the client to discuss her feelings The use of emotional supports will enable the client to manage these seemingly all-encompassing emotions The client is attempting to discuss her own feelings Turning the conversation s focus to the client s knowledge about her husband s illness would not meet the needs presented Past coping does not influence the needs accompanying chronic sorrow Nursing Process Step Implementation Client Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Analysis A client hospitalized for diagnostic testing reports an intense fear of being found to have a terminal condition What response by the nurse will be most therapeutic There is no indication you are going to die I am not sure why you feel that way What has your doctor told you about your condition What types of symptoms lead you to feel this way Answer Rationale The client is demonstrating signs of death anxiety This involves a fear of dying The nurse s responsibility will be to determine what has caused this belief Telling the client that the feelings are unfounded will do little to ease the client s anxiety Further this might not be entirely true Expressing to the client a lack of understanding about his feelings will not gain much data or promote a rapport between the client and the nurse Nursing Process Step Evaluation Client Needs Category Psychological Integrity Client Needs Subcategory Coping and Adaptation Cognitive Level Application A group of students is attending an in-service about do-not-resuscitate orders Which of the following statements by one of the students indicate the need for further teaching Select all that apply Do-not-resuscitate orders are a form of euthanasia My nursing license will not be in jeopardy if I follow do-not resuscitate orders If a client does not have completed do-not-resuscitate orders I can just participate in a slow code Do-not-resuscitate orders may be rescinded if the client wishes Answer Rationale Do-not-resuscitate orders outline the plans for a patient who stops breathing Euthanasia refers to the process of initiating actions to cause or promote a death The concepts are not the same Participation in a slow code is malpractice The nurse is legally bound to make every effort to revive any client who does not have valid do-not-resuscitate orders Nurses who follow the policies of their facilities regarding the use of do-not-resuscitate orders will not face legal action The client retains the right to change her perspective concerning their code status Nursing Process Step Evaluation Client Needs Category Safe Effective Care Environment Client Needs Subcategory Management of Care Cognitive Level Analysis Chapter During a class for teens a participant states she frequently overindulges in numerous activities including eating She questions her likelihood for becoming addicted to alcohol as a result of her addictive personality What information should be provided to the client a There are no data to support the existence of an addictive personality although individuals who become addicted to substances frequently display an affinity for engaging in risky behaviors b It is true the addictive personality does have a greater incidence of becoming addicted to a variety of substances c There is no relationship between addiction and personalities who are prone to overindulgence d The client is not at an advanced enough age to make this determination Answer a Rationale Certain personality traits are associated with risk-taking behaviors and addiction There is a relationship between personality type and addiction Age does not play a factor in this scenario NURSING PROCESS STEP Implementation CLIENT NEEDS CATEGORY Health Promotion and Maintenance CLIENT NEEDS SUBCATEGORY Prevention and or Early Detection of Health Problems COGNITIVE LEVEL Application After surgery the nurse notes a client is unable to achieve pain relief from the analgesics prescribed A review of the client s medical records reveals a history of alcohol abuse What inferences can the nurse make The client has an unreported addiction to the pain medication being prescribed The client has a history of using this medication at home The client is likely cross-tolerant to the prescribed analgesic The client has a dual diagnosis relating to alcohol and drug addiction Answer Rationale Cross-tolerance results when tolerance to one substance also results in a tolerance to another drug The client s heavy use of alcohol likely has resulted in a tolerance to alcohol and by association to the prescribed analgesic There are no data to support a suspicion that the client takes the medication at home or is addicted to the medication NURSING PROCESS STEP Diagnosis CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Pharmacological and Parenteral Therapies COGNITIVE LEVEL Analysis A client is being treated for alcohol dependency During the treatment the client reports having been treated and undergone detoxification three times in the past The client states that this time has been more difficult than the previous detoxification experiences What information can be provided to the client Aging can impact the ability of the body to handle detoxification from alcohol and drugs Increased difficulty with alcohol detoxification is likely the result of an addiction to another substance at the same time The dependency might have been greater this time With each subsequent episode detoxification becomes more difficult Answer Rationale The body responds more harshly with each episode of detoxification Aging does not play a role in the process There is no evidence to support addiction to additional substances or an increased degree of dependence NURSING PROCESS STEP Assessment CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Basic Care and Comfort COGNITIVE LEVEL Application During a routine physical the nurse asks the client about alcohol use The client denies alcohol use The client reports having alcoholic parents and wonders about the likelihood of becoming an alcoholic as well What response by the nurse is most correct You are right to avoid alcohol use You will likely become an alcoholic There are studies that support a genetic link for developing alcoholism You should be fine to drink Answer Rationale Studies have identified a link between biologic factors and the development of an addiction Although the client does have an increased risk advising the client he is right to avoid drinking or that he will become an alcoholic is inappropriate Giving the client permission to drink does not address the question being posed by the client NURSING PROCESS Implementation CLIENT NEEDS CATEGORY Psychosocial Integrity CLIENT NEEDS SUBCATEGORY Coping and Adaptation COGNITIVE LEVEL Application A client involved in a minor accident reports having used crank an hour ago The client denies having used the drug before Based upon your knowledge what manifestations can be anticipated The client might report feelings of increased strength and intelligence The client will display increased strength and cognition The client will be drowsy The client will exhibit hallucinations and paranoia Answer Rationale Crank is a form of methamphetamine It will promote the client to feel as if she has increased strength and intelligence These are simply the client s impressions and are not present in reality Drowsiness is not anticipated for this client Hallucinations and paranoia might be seen in an individual who has been using crank for a long period of time NURSING PROCESS Assessment CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Physiological Adaptation COGNITIVE LEVEL Application A teen client is brought to the Emergency Department by parents The client s mother reports the client reported taking goofballs and hootch before refusing to communicate further Based upon your knowledge which of the following will be the greatest concern for this client The client will require close observation for seizure activity The client will require close observation for respiratory depression The client will require close observation for signs of withdrawal The client will require close observation for signs of hallucinations Answer Rationale Goofballs are barbiturates These are central nervous system depressants Hootch is a street term for alcohol Barbiturates and hootch are a lethal combination The client who has ingested both items is at risk for varying degrees of sedation up to coma and death Seizure activity signs of withdrawal and hallucinations are not the greatest risks for this client NURSING PROCESS STEP Assessment CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Basic Care and Comfort COGNITIVE LEVEL Analysis A client is admitted to the Emergency Department after taking PCP phencyclidine piperidine The physician has determined that the client overdosed on the drug You are anticipating the care that will be provided to this client What actions can be anticipated Select all that apply Induce vomiting Obtain materials to assist with lavage Initiate seizure precautions Initiate an IV Administer Narcan as prescribed Answer Rationale The client has taken an overdose of phencyclidine piperidine PCP which can produce an adrenaline-like response or speed reaction PCP overdose is associated with possible hypertensive crisis respiratory arrest hyperthermia and seizures The client will require an IV line The client will need to have seizure precautions such as padded side rails initiated Vomiting is induced for overdoses of alcohol barbiturates and benzodiazepines Narcan is a narcotic antagonist administered for opiate overdose NURSING PROCESS STEP Planning CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Pharmacological and Parenteral Therapies COGNITIVE LEVEL Analysis The nurse is colleting data from a client regarding past alcohol use history What question will provide the greatest amount of information Are you a heavy drinker How often do you use alcohol Drinking doesn t cause any problems for you does it Is alcohol use a concern for you Answer Rationale Open-ended questions will elicit the greatest amount of information Asking closed questions will limit the information obtained NURSING PROCESS STEP Assessment CLIENT NEEDS CATEGORY Psychosocial Integrity CLIENT NEEDS SUBCATEGORY Coping and Adaptation COGNITIVE LEVEL Application A new nurse orienting to the unit is preparing to assist with obtaining data for a screening tool to review the likelihood that a client is addicted to methamphetamine Based upon your knowledge which of the following tools will be used B-DAST The CAGE questionnaire MAST CIWA-ar Answer Rationale The B-DAST Brief Drug Abuse Screening Test is used to assess for addiction to substances other than alcohol The CAGE questionnaire MAST Michigan Alcohol Screening Test and CIWA-ar Clinical Institute Withdrawal Assessment of Alcohol Revised are all used to assess for alcohol-related problems NURSING PROCESS STEP Assessment CLIENT NEEDS CATEGORY Psychosocial Integrity CLIENT NEEDS SUBCATEGORY Psychosocial Adaptation COGNITIVE LEVEL Comprehension The client with a history of alcohol abuse is being discharged The physician has prescribed disulfiram Antabuse The client asks about the action of the medication Which of the following statements by the nurse is most correct The medication will help curb your craving for alcohol The medication will reduce the anxiety you might experience during this difficult time The medication will prevent seizures and other symptoms of withdrawal The medication will prevent your body from breaking down alcohol Answer Rationale Disulfiram Antabuse is used in the management of clients with alcohol dependence The medication will prevent the body from breaking down alcohol and will cause illness if taken and alcohol is then ingested The medication does not reduce the craving for alcohol reduce onset of seizures or lessen anxiety NURSING PROCESS STEP Implementation CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Pharmacological and Parenteral Therapies COGNITIVE LEVEL Comprehension A nurse is concerned about potential substance abuse by a coworker Which of the following behaviors warrants further investigation The nurse in question frequently requests the largest patient care assignment for the shift The nurse in question prefers not to be the medication nurse on the shift The nurse in question declines to take scheduled breaks The nurse in question frequently wastes medications Answer Rationale Excessive medication wasting could be a sign that a nurse is using or diverting drugs The nurse might be wasting erroneous amounts of medications The nurse who is unable or unwilling to manage a patient care assignment could be a substance abuser Taking frequent or lengthy breaks might signal substance abuse NURSING PROCESS STEP Diagnosis CLIENT NEEDS CATEGORY Safe Effective Care Environment CLIENT NEEDS SUBCATEGORY Safety and Infection Control COGNITIVE LEVEL Analysis A formerly homeless client has been treated for alcoholism The client s physical examination reveals the client is underweight and malnourished Which of the following medications prescribed by the physician is intended to manage the client s nutritional status Folic acid Magnesium sulfate Methadone Sertraline Zoloft Answer Rationale Folic acid may be prescribed to manage the alcoholic client s nutritional imbalances and correct the associated vitamin deficiencies Magnesium sulfate is used to control seizures Methadone is prescribed to manage heroin cravings Sertraline Zoloft is used to reduce anxiety and stabilize the mood NURSING PROCESS STEP Diagnosis CLIENT NEEDS CATEGORY Physiological Integrity CLIENT NEEDS SUBCATEGORY Pharmacological and Parenteral Therapies COGNITIVE LEVEL Application The client reports to the Emergency Department with signs of drug use The client reports having ingested mellow yellows Which of the following medications will be indicated to manage a potential overdose Narcan Diazepam Haldol Vitamin B Answer Rationale Mellow yellows are a type of hallucinogen Diazepam can be prescribed to manage signs of an overdose Narcan is used to treat an overdose of opiates Haldol can be administered to manage an overdose of phenocyclidine piperidine PCP Vitamin B is used to manage the neurologic symptoms that might accompany a nitrate overdose NURSING PROCESS STEP Planning CLIENT NEEDS CATEGORY Physiologic Integrity CLIENT NEEDS SUBCATEGORY Pharmacologic and Parenteral Therapies COGNITIVE LEVEL Analysis Chapter A nursing coordinator is being briefed on a situation that needs special attention A school bus transporting a local university s basketball team has just crashed in the rain on the side of the road The bus was transporting approximately people Which classification would most closely describe the situation Hint Types of Disasters Answer Choices A natural disaster A multiple-casualty incident A manmade disaster A mass-casualty incident Answer Rationale Disasters are typically called multiple-casualty incidents if more than but fewer than people are injured Mass casualties refer to incidents where more than people are injured Natural disasters are caused by acts of nature or emerging diseases Manmade disasters are either accidental or intentional Nursing Process Assessment Client Need Safe Effective Care Environment Cognitive Level Application Objective Distinguish the difference between an emergency and a disaster Strategy Look at each type of disaster or emergency listed Determine which one best describes the situation outlined in the stem of the question An Emergency Department nurse is working when a dirty bomb detonates at a nearby shopping mall Which types of injuries should the nurse expect to see in the victims Hint Types of Disasters and Common Injuries Answer Choices Fractured limbs and spinal injury Radiation sickness Thermal burns Overexertion and exhaustion Answer Rationale Radiation sickness commonly occurs with a radiological dispersion bomb dirty bomb blast Fractured limbs and spinal injury can occur with blunt trauma Thermal burns occur with nuclear detonation Overexertion and exhaustion occur in snowstorm-related injuries Nursing Process Diagnosis Client Need Safe Effective Care Environment Cognitive Level Analysis Objective Describe the types of injuries or symptoms that are associated with biological chemical or radiological terrorism Strategy Examine each answer choice for the correct injuries that might be present in bomb victims Since there are multiple injuries in each answer choice eliminate the answer with at least one incorrect injury All injuries must be correlated to this type of attack A new-to-practice nurse is caring for a client who suffered a blast injury to the eye Which nursing intervention performed by this new-to-practice nurse would require follow-up by the preceptor Hint Disaster-Related Eye Injuries Answer Choices The nurse encourages the client to rub the eye to get out specks of dust The nurse uses eyewash to flush the client s eye The nurse stabilizes the eye with a rigid shield The nurse tapes a plastic bag full of crushed ice to the client s forehead Answer Rationale Clients should be cautioned not to rub the eye that has specks of dust or debris in it They should instead use eyewash flushing the eye with copious amounts of water The eye should be stabilized with a rigid shield without pressure A plastic bag full of crushed ice can be taped to the forehead to rest gently on the injured eye Nursing Process Planning Client Need Safe Effective Care Environment Cognitive Level Analysis Objective Evaluate nursing interventions related to the treatment of injuries related to biological chemical or radiological terrorism Strategy Consider each nursing action Eliminate any correct actions Choose an incorrect action for an eye injury as the correct answer An Emergency Department nurse is working when two school buses carrying children each collide in route to an out-of-state field trip The Emergency Department nurse knows that reverse triage will need to be instituted Which principles come under reverse triage Select all that apply Hint Casualty Management Answer Choices When there is a mass casualty event with greater than victims reverse triage may be instituted A very basic reverse triage system is to categorize or label victims needing the most support and emergency care as red so they can be treated first Victims most likely to survive are color-coded black and are treated first Reverse triage works on the principle of the greatest good for the greatest number Reverse triage works on the principle of the greatest good for the most critically ill Answer Rationale During a disaster nurses may be expected to perform triage Triage means sorting A mass casualty is an event with more than victims thus necessitating reverse triage Victims least likely to survive or who are already dead are color-coded black Reverse triage works on the principle of the greatest good for the greatest number Nursing Process Planning Client Need Safe Effective Care Environment Cognitive Level Application Objective Explain the rationale for reverse triage in disasters versus conventional triage in emergencies Strategy Read each answer choice to decide which statement correctly depicts the concepts of reverse triage Multiple answers will be correct An Emergency Department nurse is informed of a nearby bombing at the World Trade Center This nurse needs to be aware of the principles of triage and decontamination In which zone does decontamination usually occur Hint Casualty Management Answer Choices In the hot zone In the warm zone In the cold zone In the artic zone Answer Rationale The site of the disaster where a weapon was released or where the contamination occurred is called the hot zone It is considered contaminated and only those persons in the appropriate personal protective equipment may enter this zone The warm zone is adjacent to the hot zone Another name for this area is the control zone This area is where the decontamination of victims or triage and emergency treatment takes place The cold zone is considered to be the safe zone Nursing Process Planning Client Need Safe Effective Care Environment Cognitive Level Application Objective Discuss situations requiring the need for client isolation or client decontamination Strategy Determine in which zone it is safe to decontaminate clients who were exposed to either a weapon release or contamination A nurse is working during a routine scheduled disaster drill The nurse is reviewing the stages and phases of a disaster with a new-to-practice nurse Which answer choice if provided by this new-to-practice nurse correctly lists the order of the stages of a disaster Hint Disaster Planning Response and Mitigation Answer Choices The nondisdaster stage the predisaster stage the impact stage the emergency stage and the reconstruction stage The predisaster stage the nondisaster stage the impact stage the emergency stage and the reconstruction stage The emergency stage the predisaster stage the nondisaster stage the emergency stage and the reconstruction stage The impact stage the nondisaster stage the predisaster stage the emergency stage and the reconstruction stage Answer Rationale The five stages of disaster preparedness are the nondisaster or interdisaster stage the predisaster stage the impact stage the emergency stage and the reconstruction or rehabilitation stage Nursing Process Planning Client Need Safe Effective Care Environment Cognitive Level Application Objective Discuss the role of the nurse in disaster planning response and mitigation Strategy Determine the correct sequence of the stages and phases of a disaster A nurse is teaching a seminar on disaster preparedness to a group of senior citizens at an assisted living facility Which statement if made by a client demonstrates the need for further teaching Hint Special Considerations Older Adults Answer Choices I need to keep a list of names and phone numbers of significant persons or relatives to be notified in a secure place in case of an emergency I need to keep a -hour supply of medications and the style and serial numbers of medical devices in a secure place in case of an emergency I need to keep a list of allergies blood type checkbook credit cards and dietary needs in a secure place in case of an emergency I need to keep a blanket sturdy shoes warm clothes hearing aids and hearing aid batteries in a secure place in case of an emergency Answer Rationale Teaching about disaster preparedness is important in all communities A current list of medications doses and times of administration should be kept in an easily accessible secure place The names and phone numbers of significant persons relatives those with power of attorney healthcare providers or any others to be notified in case of an emergency should also be kept in an easily accessible place Additionally the following materials should be considered essential in keeping with the person should evacuation to a shelter be necessary eyeglasses and eyeglass prescriptions style and serial numbers of medical devices such as pacemakers healthcare policies and numbers identification list of allergies blood type checkbook credit cards insurance agent s name and number driver s license -hour supply of medications dentures list of special dietary needs sturdy shoes warm clothing blankets incontinence briefs prostheses hearing aids hearing aid batteries extra wheelchair batteries oxygen and other assistive devices Nursing Process Planning Client Need Safe and Effective Care Environment Cognitive Level Analysis Objective Identify ways that nurses are able to provide care to clients with special considerations Strategy Determine if each statement is correct with regard to planning disaster preparedness for the older adult client Choose the incorrect statement as the answer choice Chapter Question The nurse is educating a group of nursing students regarding parents who are carriers of certain genetic conditions The nurse understands that carriers are Results of an altered gene on the X chromosome A problem on the Y chromosome Parents who have a single gene alteration on one chromosome or a pair of chromosomes Diseases that occur in spite of the fact that there exists one unaltered gene Answer Rationale The definition of a carrier is an individual with a recessive condition who has inherited one altered gene from his mother and one from his father In most cases neither parent is affected therefore each of the parents must have a single gene alteration on one chromosome of a pair Cognitive Level Application Client Need Health Promotion and Maintenance Nursing Process Assessment Question The nurse is educating a group of parents about the cause of Turner s syndrome The nurse explains to the parents that Turner s syndrome is due to a variation in chromosomal number called Monosomy Trisomy Euploidy Polyploidy Answer Rationale Turner s syndrome results from the loss of a single chromosome from a pair known as monosomy Trisomy is the gain of a single chromosome making a total of three copies of a certain chromosome This can result in trisomy or Down syndrome Euploidy is the presence of the normal number of chromosomes and polyploidy is the condition where more than two pairs of all of the chromosomes are present Cognitive Level Comprehension Client Need Health Promotion and Maintenance Nursing Process Assessment The nurse is developing a teaching plan for a group of parents who need genetic counseling Which statement by a parent would indicates the need for further education We understand that half of the sets of chromosomes come from the mother and the other half come from the father We understand that the rd pair of chromosomes will determine if our child will be male or female We understand that a chromosome called a karyotype is a chromosomal profile We understand that are all the chromosomes are the same size in males and females alike Answer Rational A basic understanding of the cell DNA cell division and chromosomes is important for young families receiving genetic counseling The cell nucleus contains about feet of DNA that are tightly wound and packaged into pairs of chromosomes making a complete set of chromosomes The structure and number of chromosomes can be shown by karyotype or picture of an individual's chromosomes There are two copies of each chromosome One copy or half of the complete set of these chromosomes is inherited from the mother and the other copy is inherited from the father For example an individual will have two chromosomes one inherited from her mother and one inherited from her father These two copies or pairs of inherited chromosomes are called homologous pairs Chromosomes are numbered according to size with chromosome being the largest and chromosome being the smallest The first pairs of chromosomes known as autosomes are alike in males and females The rd pair the sex chromosomes determines an individual's gender A female has two copies of the X chromosomes one copy inherited from each parent and a male has one X chromosome inherited from his mother and a Y chromosome inherited from his father These X and Y chromosomes are known as sex chromosomes The remaining pairs of non-sex chromosomes are alike in both males and females and are called autosomes Cognitive Level Analysis Client Need Health Promotion and Maintenance Nursing Process Assessment CHAPTER Discharge teaching is being done by the nurse for a client who had a myocardial infarction The client asks why the pain he experienced prior to the event was felt primarily in his left arm The nurse s best response would be a Cardiac pain is generally unexplainable b Were you doing some physical activity with your arm just prior to the event c What you are describing relates to psychogenic pain d Pain in the arm related to cardiac tissue damage is a type of referred pain Correct answer d Rationale Pain in a spinal nerve can be felt over the skin in any body area where neurons share the same spinal nerve route This is known as a dermatome Cardiac pain is explainable as referred pain Pain in the arm did not trigger the cardiac event Psychogenic pain occurs in the absence of a diagnosed physiological cause or event Application Implementation Physiological Integrity A nursing student is teaching her peers about pain Which teaching point supports the idea that each person s pain response should be assessed individually in each situation a Everyone has the same pain threshold b Everyone has a unique tolerance to pain c Everyone perceives painful stimuli at the same intensity d Most people have the same the pain response to surgery Correct answer b Rationale Each person s pain tolerance is different and will need to be assessed on an individual basis Everyone has the same pain threshold and perceives pain at the same intensity Even though the same surgery is performed on different people each individual might have a different pain response Application Implementation Physiological Integrity Which response by the nurse would be most appropriate to the client comment I know I won t feel as much pain with this knee surgery as I did with the other one when I was years younger a You are most likely correct b It should not be quite as bad with the newer technology c You need to consider that you are getting older and might experience more pain d Your pain response might be the same since one s pain sensitivity does not decrease with age Correct answer d Rationale There is no evidence that normal aging decreases sensitivity to pain This is a common misconception The client did not anticipate feeling as much pain compared with a prior surgery but the nurse needs to explain this concept Application Implementation Physiological Integrity Each client s response to pain may be influenced by multiple factors Select all that apply a Age b Past experience with pain c Cultural influences d Knowledge Correct Answers a b c d Rationale All factors listed can influence a client s response to pain Application Implementation Physiological Integrity A client has returned to the unit following surgery The nurse knows that which intervention will provide the most pain relief for the client a Offer pain relief before the client complains of pain b Wait until the client can describe the pain specifically c Assess the pain level every four hours around the clock d Allow the client to sleep off the anesthesia and then offer pain medication Correct answer a Rationale Anticipating a client s pain will ensure a more manageable pain experience than will waiting until the client complains of pain Pain management need to be implemented prior to the client describing specific postoperative pain or sleeping off anesthesia If the client is asleep she should not be awakened simply to assess the pain every four hours unless there are other significant nonverbal signs during sleep that indicate the client is in pain These can include grimacing moaning thrashing or guarding of a surgical site Analysis Planning Physiological Integrity During the discharge teaching process the nurse explains the physician s order for the client to take Motrin ibuprofen at home for any further discomfort Since this is an NSAID nonsteroidal anti-inflammatory drug what other teaching will be done with this client who also has diabetes a NSAIDs can increase the effect of hypoglycemic medications b NSAIDs can decrease the effect of anticoagulant medications c NSAIDs cause minimal gastrointestinal side effects d NSAIDs have no effect on fever Correct answer a Rationale The diabetic client needs to be taught that NSAIDs can cause an increased response to hypoglycemic medications The client s hypoglycemic medications might need to be altered to adjust for this NSAIDs can increase the effect of anticoagulant medications not decrease them NSAIDs could cause gastrointestinal bleeding and should be taken with meals milk or a full glass of water to decrease gastric irritation NSAIDs have anti-inflammatory analgesic and antipyretic fever-lowering effects Analysis Implementation Physiological Integrity A client is receiving a narcotic for severe acute pain Which of the following should the nurse encourage the client to consume on a greater level due to the pain medication a Vitamin D b Fiber c Protein d Carbohydrates Correct answer b Rationale Clients who are administered narcotics are a risk for constipation Increasing fiber in the diet will help to decrease this effect Increasing vitamin D protein and carbohydrates is not needed specifically related to the effect of a narcotic medication Analysis Implementation Physiological Integrity An extensive spinal surgery was performed on a client five days ago The client continues to have pain despite around-the-clock dosing of a narcotic When assessing the client s pain the nurse discovers that the client s pain level is not decreasing significantly between doses This is an example of which of the following a Pseudoaddiction b Psychologic drug dependence c Drug tolerance d Addiction Correct answer c Rationale Over a period of time a person s body might require a progressively greater amount of a drug to achieve the same results Pseudoaddiction involves drug-seeking behavior as a result of inadequate pain relief Psychologic drug dependency is seen with psychologic drug withdrawal symptoms Addiction is a compulsive use of a drug despite negative consequences Application Evaluation Physiological Integrity An elderly woman is complaining of lower leg pain Which information found in her medical history would be the most likely indicator of this pain a History of cardiovascular disease b History of shingles c History of smoking for years d History of alcoholism Correct answer b Rationale Post-herpetic neuralgia following shingles is an example of a chronic neuralgia type of pain There has been damage to a peripheral nerve which has resulted in the current pain Cardiovascular disease a history of smoking and alcoholism are not the likely direct causes of this pain Application Assessment Physiological Integrity Pain in the elderly is subject to many misconceptions Which of the following are common misconceptions related to aging Select all that apply a Opioids will cause excessive respiratory depression b Aging decreases a person s sensitivity to pain c Older adults are likely to become addicted to narcotics if used d Pain is an expected part of the aging process Correct answers a b c d Rationale All are common misconceptions that the nurse must be aware of when caring for older adults There are basic truths to each misconception that must be explored and discussed Application Implementation Health Promotion and Maintenance Pain can be managed by classes of medications Which class is also used to treat migraine headaches a Antidepressants b Local anesthetics c Anticonvulsants d Narcotics Correct answer c Rationale Some seizure medications are effective with peripheral pain such as with migraine headaches This is a type of neuropathic pain and can be treated with an anticonvulsant Analysis Assessment Physiological Integrity The nurse is planning to administer a pain medication to a client who is two hours postoperative following bowel resection surgery The client has four standing orders for pain medication The nurse should administer which medication based on this situation a Select the one that will be given intramuscularly IM to work quickly b Select the one that is ordered on a p r n basis c Select the one to be administered intravenously by patient demand and under patient control d Select the one to be administered orally Correct answer c Rationale Patient-controlled analgesia allows self-management of pain and is a common postoperative method of administering pain medication The advantages to this method are dose precision timeliness and convenience Selecting an oral medication or a p r n medication two hours after a major surgery would not be the most effective The medication that is administered IM is not typically recommended for moderate-to-severe pain that will require more than one dose Analysis Implementation Physiological Integrity A client is receiving intraspinal analgesia Nursing care will focus on a Decrease in heart rate b Increase in heart rate c Increase in urine output d Decrease in urine output Correct answer c Rationale Intraspinal narcotics can block the micturition reflex causing urinary retention A Foley catheter might need to be inserted The respiratory rate not the heart rate would be another focus directly related to intraspinal anesthesia Analysis Assessment Physiological Integrity CHAPTER What is a primary concern regarding fluid and electrolytes when caring for the older adult who is intermittently confused a Risk of kidney damage b Risk of stroke c Risk of bleeding d Risk of dehydration Correct answer d Rationale As an adult ages the thirst mechanism declines This in a client with an altered level of consciousness can increase the risk of dehydration and high serum osmolality The risks for kidney damage stroke and bleeding are not specifically related to aging or fluid and electrolyte issues Application Planning Health Promotion and Maintenance A client is experiencing a multisystem fluid volume deficit Symptoms present include tachycardia pale cool skin and decreased urine output These signs are most likely a direct result of a The body s natural compensatory mechanisms b Pharmacological effects of a diuretic c Effects of rapidly infused intravenous fluids d Cardiac failure Correct answer a Rationale The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited The body naturally attempts to conserve fluid internally specifically for the brain and heart A diuretic would cause further fluid loss and is contraindicated Rapidly infused intravenous fluids would not cause a decrease in urine output The manifestations reported are not indicative of cardiac failure in this client Analysis Evaluation Physiological Integrity Clients experiencing a fluid volume deficit would most likely exhibit which of the following lab results Select all that apply a Increased serum potassium b Decreased serum sodium c Increased hemoglobin d Increased hematocrit Correct answers c d Rationale Increased hemoglobin and hematocrit are common due to loss of intravascular volume and hemoconcentration A decreased not increased potassium level is common in fluid volume deficits Serum sodium levels can be within normal limits with an isotonic fluid deficit or increased when the loss is water only Analysis Assessment Physiological Integrity Which of the following tests would be indicated when a client who has a history of cardiovascular disease is receiving intravenous fluids a Cardiac catheterization b Echocardiogram c Fluid challenge d Central venous pressure monitoring Correct answer c Rationale A fluid challenge may be performed to evaluate the cardiovascular and renal function related to fluid volume capabilities This can prevent fluid volume overload Cardiac catheterization and echocardiogram are directly related to evaluating cardiovascular disease Central venous pressure monitoring is a method of evaluating fluid volume status Analysis Planning Physiological Integrity A postoperative client has an indwelling urinary catheter in place Which -hour urine output total volume would necessitate a primary healthcare provider to be notified a milliliters b milliliters c milliliters d milliliters Correct answer d Rationale A urine output of less than milliliters per hour must be reported to the primary healthcare provider This indicates inadequate renal perfusion placing the client at increased risk for acute renal failure and inadequate tissue perfusion A minimum of milliliters over a -hour period is desired milliliters multiplied by hours equals milliliters per hours Application Assessment Physiological Integrity A client is receiving intravenous fluids postoperatively following cardiac surgery Nursing assessments should focus on which postoperative complication a Fluid volume deficit b Fluid volume excess c Liver failure d Seizure activity Correct answer b Rationale Antidiuretic hormone ADH and aldosterone levels are commonly increased following the stress response before during and immediately after surgery This increase leads to sodium and water retention Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system Liver failure is not anticipated related to postoperative intravenous fluid administration Seizure activity would more commonly be associated with electrolyte imbalances Application Assessment Physiological Integrity Clients with severe hyponatremia will need which specific intervention once the diagnosis is made a Infection precautions b Seizure precautions c High-risk fall precautions d Neutropenic precautions Correct answer b Rationale Severe hyponatremia can lead to seizures Seizure precautions such as a quiet environment raised side rails and having an oral airway at the bedside would be included Infection or neutropenic precautions and high-risk fall precautions are not specifically indicated Application Implementation Physiological Integrity A client is admitted with hypokalemia Which medication that the client has been prescribed might have contributed to this problem a Thiazide diuretic b Narcotic c Corticosteroid d Muscle relaxer Correct answer C Rationale Excess potassium loss through the kidneys is often caused by such medications as corticosteroids potassium-wasting loop diuretics amphotericin B and large doses of some antibiotics Analysis Assessment Physiological Integrity Chapter A client is admitted to the ICU intensive care unit after sustaining multiple injuries The physician has ordered for the client to receive a colloid solution Which one of the following solutions would be appropriate for the nurse to infuse based on the physician s orders saline D NS dextrose in water D W albumin Answer Rationale Colloid solutions contain substances that should not diffuse through capillary walls Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum causing fluid to move into the vascular compartment from the interstitial space As a result plasma volume expands Colloid solutions used to treat shock include albumin albumin hetastarch plasma protein fraction and dextran Crystalloid solutions contain dextrose or electrolytes dissolved in water they are either isotonic or hypotonic All crystalloid solutions increase fluid volume in the intravascular and the interstitial space Cognitive Level Comprehension Client Needs Physiological Integrity Nursing Process Implementation A client is admitted to the medical intensive unit after being involved in a motor vehicle collision During the nurse s initial assessment the client develops hypotension and severe jugular distension with a tracheal deviation What does the nurse suspect has occurred Hemorrhage Tension pneumothorax Compensatory shock Hypovolemic shock Answer Rationale A tension pneumothorax is a special type of pneumothorax that is life-threatening and requires immediate intervention On inspiration air enters the pleural space does not escape on expiration and increases the intrapleural pressure This pressure collapses the injured lung and shifts the mediastinal contents compressing the heart great vessels trachea and eventually the uninjured lung Cognitive Level Application Client Needs Physiological Integrity Nursing Process Diagnosis When assessing a client with a traumatic brain injury the nurse assesses the client for which of the following signs and symptoms that would be consistent with brain death Select all that apply Absence of gag or corneal reflex Toxic metabolic disorders Response to deep stimuli Absence of oculovestibular reflex Apnea with PaCO of mm Hg Answer The clinical signs of brain death criteria include apnea with a PaCO greater than mmHg no response to deep stimuli no spontaneous movement no gag or corneal reflex no oculocephalic or oculovestibular reflex and absence of toxic or metabolic disorders The diagnostic tests used to confirm brain death include electroencephalogram and cerebral blood flow studies Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment A client is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision What should be the initial action by the nurse when the client arrives in the Emergency Department ED Assess the client s abdomen for any abnormalities Assess the client s cervical spine for tenderness Assess the client for signs of neurological deficits Assess the client s airway for patency Answer Rationale Assessment of the airway is the highest priority in the trauma client Assessment includes determining airway patency If the client is unresponsive manual opening of the airway using a jaw thrust or chin lift maneuver is necessary Once the airway is opened the practitioner must identify any potential obstruction from the tongue loose teeth foreign bodies bleeding secretions vomitus or edema If the client is responsive and can vocalize that is a good indication that the airway is clear All of the other responses are important but certainly the nurse should address airway initially The nurse should assess the cervical spine area after initial ABC assessment The nurse is always concerned about the neurological assessment of a client but this client has a blunt trauma injury from a motor vehicle therefore this would not be the initial assessment for the client Cognitive Level Application Client Needs Physiological Integrity Nursing Process Analysis Which of the following interventions would be essential for the nurse to assess first for a client admitted with severe facial injuries Assess the client s level of consciousness Assess for signs of stridor cough or respiratory distress Assess the need for suctioning Assess the mouth for loose teeth or obvious problems with the mouth Answer Rationale The client with multiple injuries is at great risk for developing airway obstruction and apnea All of the choices are very important however the most important intervention for the nurse to assess is always to make sure the airway is patent and maintainable The nurse should assess for manifestations of airway obstruction including stridor tachypnea bradypnea cough cyanosis dyspnea decreased or absent breath sounds changes in oxygen levels and changes in level of consciousness Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment A client presents to the ED Emergency Department after sustaining a penetrating wound to the neck The client is dyspneic and cyanotic and has evidence of subcutaneous emphysema What does the nurse expect the physician to do initially Intubate the client because of the severe wound Notify the next of kin regarding the client s condition Order x-rays of the lumbar area to assess for fractures Administer a beta blocker to alleviate the sympathetic response Answer Rationale Penetrating trauma to the neck is associated with a high degree of morbidity and mortality Airway involvement includes dyspnea cyanosis subcutaneous emphysema hoarseness or air bubbling from the wound The key is early identification of the need for intubation before the client has no airway at all The physician will do all of the options in the question however the most important is to maintain the airway Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment A client is admitted with a traumatic injury to the spinal cord He develops marked bradycardia with a bounding pulse The client becomes extremely restless and the nurse notes that the client has developed oliguria as well The nurse would suspect Anaphylactic shock Septic shock Hypovolemic shock Neurogenic shock Answer Rationale Neurogenic shock is the result of an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle If parasympathetic overstimulation or sympathetic understimulation persists sustained vasodilation occurs and blood pools in the venous and capillary beds The manifestations of hypovolemic shock result directly from the decrease in circulating blood volume and the initiation of compensatory mechanisms Clients at risk for developing infections leading to septic shock include those who are hospitalized have debilitating chronic illnesses or have poor nutritional status Septic shock does not usually present with a client who presents with a traumatic injury Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications blood administration latex foods snake venom and insect stings Cognitive Level Application Client Needs Physiological Integrity Nursing Process Diagnosis A client presents to the trauma center after sustaining multiple injuries The client experienced severe blood loss prior to arriving at the trauma center The physician has ordered for the client to receive blood immediately The nurse understands that since there is not sufficient time for type and crossmatch the client will therefore receive O group blood A group blood B group blood AB group blood Answer Rationale Type O blood is the universal donor ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen these antibodies are called anti-A and anti-B The person with blood type B has A antibodies the person with type A has B antibodies the person with type O has both types of antibodies and the person with AB has no antibodies therefore this client is known as the universal recipient Cognitive Level Application Client Needs Safe and Effective Care Nursing Process Assessment A client who was a victim of rape six months ago presents to an outpatient clinic for the treatment of post-traumatic stress disorder PTSD Which data collected during the client s assessment would indicate a manifestation associated with PTSD The client denied anger or shock The client discussed severe nightmares related to the traumatic event The client denied the need for drug or alcohol counseling The client stated that her family is very supportive Answer Rationale Post-trauma syndrome is an intense sustained emotional response to a disastrous event It is characterized by emotions that range from anger to fear and by flashbacks or psychic numbing In the initial stage the client can be calm or might express feelings of anger disbelief terror and shock In the long-term phase which begins anywhere from a few days to several months after the event the client often experiences flashbacks and nightmares of the traumatic event The client also might call on ineffective coping mechanisms such as alcohol or drugs and withdraw from relationships Cognitive Level Application Client Needs Psychosocial Integrity Nursing Process Assessment The nurse is caring for a client in the ICU who sustained a traumatic injury several days ago During the assessment the nurse notes that the client is hypotensive oliguric and has cool pale skin and acidosis The nurse understands that these manifestations are indicative of Hypovolemic shock Cardiogenic shock Septic shock Anaphylactic shock Answer Rationale Hypovolemic shock is caused by a decrease in intravascular volume In hypovolemic shock the venous blood returning to the heart decreases and ventricular fills drops As a result stroke volume cardiac output and blood pressure decrease Hypovolemic shock affects all body systems Clients at risk for developing infections leading to septic shock include those who are hospitalized have debilitating chronic illnesses or have poor nutritional status Septic shock does not usually present with a client who presents with a traumatic injury Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications blood administration latex foods snake venom and insect stings Cognitive Level Application Client Needs Physiologic Integrity Nursing Process Assessment A -year-old male presents to the trauma center after a motor vehicle collision The nurse is assessing the client and notes the abdomen to be distended with bruising around the umbilicus Which of the following diagnostics would the nurse anticipate the physician ordering for the client Select all that apply CBC complete blood count Blood type and crossmatch Urine drug screen Thyroid profile RA factor Answer Rationale The diagnostic tests ordered once the client reaches the hospital depend on the type of injury the client has sustained Tests that might be ordered will include blood type and crossmatching for the client s serum and donor red blood cells Blood alcohol level and urine drug screen might be ordered to assess alcohol or drugs Thyroid studies should always be considered but based on the client s presenting symptoms it is not a critical diagnostic at this time Cognitive Level Application Client Needs Health Promotion and Maintenance Nursing Process Assessment A client presents to a major trauma center for evaluation after being struck by a car while riding a bicycle Identify the sequence of interventions for a rapid assessment that should be completed on the client Assessment of level of consciousness LOC and pupillary function Assessment of obvious injuries Assessment of the airway using the jaw thrust or chin lift maneuver Assessment of family support for client Assessment of circulation including pulses skin color and the temperature of the skin Answer Rationale Many different methods help healthcare providers determine the seriousness of the client s injuries and the potential for survival A rapid but comprehensive trauma assessment completed on the scene includes airway and breathing assessment first circulation assessment to palpate peripheral and central pulses assessment of capillary refill skin color and temperature and identification of any external sources of bleeding Level of consciousness and papillary function should be assessed as well Once the nurse determines that the ABCs have been assessed then the nurse can continue to assess for any obvious injuries Cognitive Level Application Client Needs Health Promotion and Maintenance Nursing Process Assessment Question Alternate Question You are the nurse caring for four clients on a medical surgical unit Evaluate the order of assessing these clients A male who was in an MVC four days ago who is preparing for discharge A female restrained passenger in an MVC three days ago who is receiving treatment for burns on of her right leg A male client admitted yesterday from an MVC who complains of severe pain in the chest when he takes a deep breath A client admitted hours ago for observation after a neck injury who complains to the nurse about numbness in the left arm Answer Rationale The nurse should always assess the client s based on the ABCs airway breathing and circulation The nurse should always assess the client with possible airway problems The client with a neck injury with numbness in the left arm could be a severe problem because this could represent a circulation problem All of these clients will require the nurse to carry out a rapid assessment The client being discharged will require extensive education therefore the nurse should assess clients in distress prior to seeing a client preparing for discharge Cognitive Level Analysis Client Needs Physiologic Integrity Nursing Process Planning Chapter Question The nurse is caring for four clients on a medical surgical unit Which client should the nurse see initially A client admitted with hepatitis A who has had severe diarrhea for the last hours A client admitted with pneumonia who is has small amounts of yellow productive sputum A client admitted with fever of unknown origin FUO who has been without fever for the last hours A client admitted with a wound infection whose WBC is mm Answer Rationale The nurse must decide which client should be seen on the initial rounds of the day The nurse must remember that the first client to be seen should be the client who needs the attention of the nurse initially A client with hepatitis A does experience diarrhea but diarrhea for the last hours could cause the client to have a problem with dehydration and experience a state of fluid volume deficit Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning Question The nurse is preparing to administer influenza vaccines to a mass drive-through clinic Which statement by a client would indicate further questioning prior to giving the client the influenza vaccine I am allergic to horse hair I try to get my vaccine every year I am not allergic to anything except eggs My husband had a severe allergic reaction after he received his influenza vaccine Answer Rationale Influenza vaccines are recommended for person at high risk for serious sequelae of influenza The nurse should be aware that clients with a sensitivity to eggs should not receive the vaccine Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment Question The nurse is caring for four clients on a medical surgical unit The secretary gives the nurse the morning labs Which of the following labs would require that the nurse call the physician and inform the healthcare provider regarding the client s abnormalities WBC mm Serum protein g dL I D incision and drainage showing no growth for the last hours Albumin g dL Answer Rationale When the nurse is caring for several clients all of the labs should be checked frequently throughout the shift to assess for any abnormalities The WBC in option is abnormal Normal WBC mm All of the other lab results are within acceptable range therefore the results should not be called to the physician Cognitive Level Application Client Needs Physiologic Integrity Nursing Process Assessment Question The nurse is orienting a new graduate The nurse is reinforcing the importance of standard precautions Which of the following observations made by the nurse would require further education regarding standard precautions The graduate nurse understands to wash hands when entering and exiting the client s room The graduate nurse wears gloves when serving breakfast trays to various clients The graduate nurse wears a gown gloves and goggles when suctioning a client The graduate nurse leaves all supplies in the room of a client who is in contact isolation Answer Rationale The nurse must have an understanding of standard precautions Prevention is the most important measure to prevent nosocomial infections Standard precautions were published in providing guidelines for the handling of blood and other body fluids These guidelines are used with all clients regardless of whether they have a known infectious disease Standard precautions are used by all healthcare workers who have direct contact with clients or their body fluids It is not necessary for the nurse to wear gloves while delivering food trays to the client because there is no contact with the client Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Evaluation Questions The admitting department alerts the nurse on a medical surgical unit that a client with active tuberculosis TB is being admitted to the unit Which type of isolation should be informed based on the client s diagnosis Standard precautions Airborne precautions Droplet precautions Contact precautions Answer In addition to handwashing and standard precautions the nature and spread of some infectious diseases require that special techniques be used to protect uninfected clients and workers The client with pulmonary tuberculosis will be placed in airborne precautions The client should be placed in a private room with special ventilation that does not allow air to circulate to general hospital ventilation mask or special filter respirators will be used for everyone entering the room Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment Question A client is receiving IV vancomycin for the treatment of Clostridium difficile The nurse understands that the client who develops flushing tachycardia and hypotension during the infusion of vancomycin indicates Ototoxicity effect Superinfection Red man syndrome Hives Answer Rationale Vancomycin inhibits cell wall synthesis and is used for serious infections It is only effective against gram-positive bacteria especially Staphylococcus aureus and Staphylococcus epidermidis The nurse should infuse this medication slowly over minutes or more to avoid red man syndrome The syndrome is characterized by erythematous rash flushing tachycardia and hypotension Clients can become dizzy and agitated Cognitive Level Application Client Needs Physiological Integrity Nursing Process Evaluation Question The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic The nurse understands that the trough should be ordered A few minutes before the next scheduled dose of medication hours after the oral administration of the medication minutes after the IV administration During the infusion of the antibiotic Answer Rationale Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication The therapeutic range that is the minimum and maximum blood levels at which the drug is effective is known for a given drug By measuring blood levels at the predicted peak hours after oral administration hour after intramuscular administration and minutes after IV administration and trough usually a few minutes before the next scheduled dose it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy increasing the likelihood of adverse effects Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Assessment Question The nurse needs to change a dressing on the client s abdomen Which of the following techniques should be implemented Contact precautions Standard precautions Droplet precautions Airborne precautions Answer Rationale Standard precautions are used on all clients regardless of whether they have a known infectious disease Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids Since the client has an abdominal dressing the nurse will use standard precautions Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning Question The physician has ordered for the nurse to obtain a sputum specimen The nurse understands that the sputum specimen should be collected Immediately after the first dose of antibiotic is administered minutes after the first dose of antibiotics is administered During the first dose of antibiotics Before the first dose of antibiotics is administered Answer Rationale When the physician orders a specimen to be collected the nurse should collect the specimen before the first dose of antibiotics is administered to ensure adequate organisms for culture Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning Question Which of the following manifestations indicate a systemic reaction associated with an inflammatory response Erythema Pain Tachypnea RR Edema Answer Rationale If the nurse observes a systemic reaction the client will exhibit manifestations including temperature increased pulse tachypnea and leukocytosis Erythema warmth pain edema and functional impairment indicate a local reaction Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment Question Alternate Question A client develops hyperthermia related to a diagnosis of pneumonia Which of the following nursing interventions would be effective in the treatment of hyperthermia Select all that apply Increase the temperature of the room environment to prevent shivering Use ice packs and a tepid bath as needed Administer antipyretic medications per physician s orders Promote frequent rest periods to increase energy reserve Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance Answer Rationale Hyperthermia is an expected consequence of the infectious disease process Fever can produce mild short-term effects and when prolonged can cause life-threatening effects The nurse should administer antipyretic medications as indicated for elevated temperatures The nurse should use ice packs cool tepid baths or a hypothermia blanket with caution The nurse should enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic heart and respiratory rates The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance Cognitive Level Assessment Client Needs Physiological Integrity Nursing Process Implementation Question Alternate Question The nurse is assessing a client s wound for signs and symptoms of inflammation Which of the following would alert the nurse that the client is exhibiting signs of inflammation Select all that apply Leg edema Leg cool to touch Severe pain from swelling Decreased peripheral pulses Severe erythema of leg Answer Rationale Regardless of the cause location or extent of the injury the acute inflammatory response follows the sequence of vascular response cellular and phagocytic response and healing Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged The cardinal signs of inflammation include erythema local heat caused by the increased blood flow to the injured area hyperemia swelling due to accumulated fluid at site pain from tissue swelling and chemical irritation of nerve endings loss of function caused by the swelling and pain Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment Alternate item format Select all that apply Which of the following manifestations would the nurse expect to see with a client who has had knee surgery and who suffered a surgical infection with signs of systemic manifestations Select all that apply Erythema WBC mm Pain at the surgical site bands Respiratory rate of Pulse Answer Rationale The client is post surgical repair of the knee The nurse should be able to distinguish between local reactions and system reactions An elevated WBC and bands are indicative of an infection Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia Local manifestations include erythema warmth pain edema and functional impairment whereas systemic manifestations include elevated temperature above F pulse greater than min respiratory rate greater than and WBC greater than mm or bands Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment Chapter A client with a history of latex allergies develops audible wheezing pruritus urticaria and signs of angioedema Which of the following would the nurse perform initially Administer epinephrine IV per MD orders Collect a detailed history from the client regarding the history of latex allergies Teach the client regarding using a kit that contains treatment for allergic reactions Administer diphenhydramine Benadryl by mouth every four hours per physician s orders Answer Rationale For mild reactions with wheezing pruritus urticaria and angioedema a subcutaneous injection of mL of epinephrine is generally sufficient The nurse should give the epinephrine first due to the symptoms Intravenous epinephrine using a concentrations may be used in the client with a more severe anaphylactic reaction The nurse does not have time to collect a detailed history because of the severity of the client s signs and symptoms Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit Cognitive Level Analysis Client Needs Physiological Integrity Integrated Process Assessment A client who is a bone marrow transplant recipient develops a maculopapular rash on the palms of both hands and the soles of the feet The client complains of severe abdominal pain with bloody diarrhea The nurse would suspect that the client is experiencing Chronic tissue rejection Graft-versus-host disease Acute tissue rejection Hyperacute tissue rejection Answer If a transplant client develops a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet it indicates GVH Graft-versus-host disease The rash can spread to involve the entire body and lead to desquamation Gastrointestinal manifestations include abdominal pain nausea and bloody diarrhea GVH that lasts longer than days is said to be chronic Chronic tissue rejection occurs from months to years after transplant of new tissue Acute tissue rejection is the most common type of rejection and occurs between days and months after the transplant Acute rejection is mediated primarily by the cellular immune response resulting in transplant cell destruction The client experiencing rejection demonstrates manifestations of the inflammatory process with fever redness swelling elevated BUN creatinine lower enzymes and elevated bilirubin and cardiac enzymes Cognitive Level Application Client Needs Physiological Integrity Nursing Process Assessment A client with AIDS is taking an antiretroviral medication The client complains of nausea fever severe diarrhea and anorexia Which of the following medications would be the most effective to relieve the anorexia as well as to stimulate the client s appetite Megestrol Megace Ciprofloxacin Cipro Zidovudine Retrovir AZT Abacavir Ziagen Answer Rationale Megestrol Megace and dronabinol Marinol are often ordered to increase the client s appetite and promote weight gain Ciprofloxacin Cipro is an anti-infective medication and zidovudine Retrovir AZT is an antiretroviral agent Abacavir Ziagen is a potent inhibitor of reverse transcriptase Cognitive Level Application Client Needs Physiological Integrity Pharmacology and Parenteral Therapy Nursing Process Implementation Question Which statement made by the client taking an immunosuppressive agent would require further teaching I know to call the physician if I start experiencing a lot of bruising I should drink plenty of water to keep me from getting dehydrated I should drink a lot of fruit juices such as grapefruit juice If I experience any joint pain I should take ibuprofen for the pain as needed every four hours Answer Rationale Immunosuppressive agents inhibit T cell development and activation They are given concurrently with a glucocorticoids and in combination with other immunosuppressants and inhibit immune system activity and organ rejection Nursing responsibilities include monitoring BUN and creatinine for evidence of nephrotoxicity The client should avoid grapefruit juice which can raise cyclosporine levels by and increase the risk of toxicity Fluids should be increased to maintain good hydration and urinary output Ibuprofen is acceptable for immunosuppressive medications but should not be taken with cytotoxic agents Cognitive Level Application Client Needs Physiological Integrity Nursing Process Implementation A client is suspected of having a reaction Which lab test would alert the nurse regarding the possibility of a hypersensitivity reaction Eosinophils of of the total WBC Indirect Coombs showing no agglutination Patch test with a one-inch area of erythema Rh antigen with negative results Answer Rationale A patch test assesses a one-inch area impregnated with the allergen which is applied for hours Absence of a response indicates a negative result Positive responses are graded from mild erythema in the exposed area to severe papules vesicles or ulcerations Direct Coombs test detects antibodies in the client s RBC that damage and destroy the cells This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs This is also part of the crossmatch of a blood type and crossmatch Indirect Coombs test detects the presence of circulating antibodies against RBCs The eosinophil count is which is within normal range Cognitive Level Comprehension Client Needs Physiological Integrity Nursing Process Assessment A client has a diagnosis of AIDS The nurse is teaching the client regarding a diet with increased kilocalories Which of the following diets would indicate that the client has an understanding of the appropriate diet Spaghetti and meat sauce raisin salad whole grain roll with butter vanilla milkshake with Ensure and a piece of pecan pie Baked chicken thigh cabbage small green salad slice of white bread dried prunes and a soda Red beans and rice slaw tomato crackers chocolate pudding and iced tea Vegetable soup small piece of cornbread banana pudding and water Answer Rationale Provide a diet high in protein and kilocalories A high-protein high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs The diet with the most kilocalories is the spaghetti and meat sauce with the vanilla milkshake made with Ensure and pecan pie Cognitive Level Application Client Needs Health Promotion and Maintenance Nursing Process Implementation Which of the following statements by the client who has HIV would require further teaching by the healthcare professional I know I have to practice safe sex with my partner I will not share my toothbrush or razor with my partner I know I can t donate blood anymore since I have HIV I know to use an oil-based lubricant to prevent spread of the disease to my partner Answer Rationale The nurse should educate the client regarding the prevention of the spread of HIV The client will need further education when he states that he will use an oil-based lubricant The client should be educated to use latex condoms for oral vaginal or anal intercourse avoid natural or animal skin condoms which allow passage of HIV The client should use only water-based lubricants not oil-based such as petroleum jelly which can result in condom damage The client is correct in stating that it is not an acceptable practice to share toothbrushes or razors The client is also correct in stating that blood donation is prohibited Cognitive Level Application Client Needs Physiological Integrity Nursing Process Implementation The home health nurse is planning the day Which of the following clients should the nurse see first A client with wasting syndrome who has end-stage AIDS who needs modifications and education regarding dietary changes A client with a long history of AIDS who is receiving IV antibiotics daily for toxoplasmosis A client with PCP Pneumocystis carinii pneumonia who called the office to report a new onset of fever cough and SOB this AM A client with AIDS who is receiving Epivir lamivudine because of a diagnosis of a low CD cell count Answer Rationale The home health nurse should see the client with Pneumocystis carinii pneumonia because of the complaint of shortness of breath with the new onset of fever All of the clients need to be seen by the nurse but based on the ABCs airway breathing and circulation the nurse should visit this client first and obtain vital signs and perform a respiratory assessment initially Cognitive Level Application Client Needs Safe Effective Care Environment Nursing Process Planning A nurse is performing an admission assessment on a client with AIDS Which of the following questions would be inappropriate for the nurse to ask the client in the interview process Have you ever experimented with recreational drugs How long have you had AIDS Does your partner have AIDS Have you had any fever diarrhea or chills over the last hours Answer Rationale During the interview process the nurse should ask questions specific to the client s history including current medications diet and signs and symptoms that the client has experienced The nurse cannot ask about the client s partner Cognitive Level Application Client Needs Psychosocial Integrity Nursing Process Assessment A client with HIV states I don t think I am going to live much longer I feel so bad The nurse determines that which of the following would be the best response You will be fine you just need to let the medication have a chance to work It must be very difficult for you right now dealing with your diagnosis You need to be more positive about your diagnosis because it will improve your chances of surviving this disease Try not to be negative You need to give yourself some time to feel better about your diagnosis Answer Rationale The nurse should be realistic with the client The nurse cannot give false reassurance or false hope about a terminal illness It is important for the nurse to express empathy for the client Cognitive Level Application Client Needs Psychosocial Integrity Nursing Process Evaluation A nurse is monitoring a client who is receiving a unit of packed red blood cells The client suddenly develops chest pains hives chills and hypotension Number the action that the nurse would take in order of priority Start normal saline at KVO keep vein open Stop the transfusion Notify the physician and blood bank Remove the blood bag and the tubing with the blood in it Obtain a urine specimen and send to the lab Answer Rationale The client is experiencing an adverse reaction to the blood transfusion The blood should be stopped immediately if a reaction occurs no matter how mild The nurse should remove the blood bag and the tubing with blood in it Flush new intravenous tubing with normal saline keeping the IV line open Notify the physician and the blood bank If a reaction