According to DSM-IV-TR, dysthymic disorder cannot be fully diagnosed until the depressed mood has been present for at least 2 years. Additional criteria are specified to diagnose dysthymic disorder, and once the depressed mood criterion has been met, only some of the other criteria must be met. This is in contrast to the DSM-IV-TR criteria for diagnosing major depression. In this case, at least 5 of 9 criteria must be met.
Major diseases such as diabetes, hypertension, arteriosclerosis, and cancer often have a genetic disposition and put the client at greater risk for developing them. The number and ages of siblings is a component of the family history, as is inquiring about the client’s support network. Vaccines and immunizations would be covered in the section known as past history.
The client in the manic state is generally intrusive and insensitive to the needs of others and does not recognize boundaries, whether psychologic or physical. The client also tends to have an intense preoccupation with sexual urges and frequently touches others or positions self in socially inappropriate ways. The nurse must encourage the client to set and maintain boundaries while interacting with others. The person in a manic state is unlikely to be able to conform to the schedule in option 1 or to sustain attention for this period of time. Additionally, the client is likely to find the activity room more stimulating than a quieter area of the unit. Individuals experiencing manic affect tend toward overreaction and overdramatization in any situation, so participating in such a group would likely increase the client’s manic hyperactivity and dramatization (option 2). While physical exercising will allow the client to sublimate some of the excessive energy that is felt (option 3), the client is likely to be domineering, overbearing, and highly competitive in groups. Further, it is likely that the client’s level of mania will increase because of the extra stimulation.
The nurse must first attend to safety and physiologic needs necessary to sustain life. Considering the prior level of physical activity of the client and that the client is currently perspiring profusely, the nurse should recognize that this client could easily enter into a state of fluid and/or electrolyte imbalance. This at-risk problem will take priority over actual problems that do not involve basic physical needs or safety. Impaired skin integrity (option 3) is incorrect. The nurse should recognize that while this is an actual physical problem, it does not pose the same level of risk that the risk for injury and fluid deficit pose for this client. Like the psychological needs, this problem can be addressed after basic physiologic and safety needs are addressed. Ineffective coping and impaired adjustment (options 2 and 4) are not priority problems at this time. They are psychologic problems that can be addressed after basic physiologic and safety needs are addressed.
Clients in a manic state are vulnerable to injure self or others, either through restless hyperactivity and poor judgment, or through actions during unpredictable mood swings. Continuous and close nursing supervision of these clients to ensure safety is imperative, regardless of the type of room to which they are assigned. A room near the nurses’ station (if it is not too loud) may be advisable for the client with elevated affect (option 1), but this will not substitute for constant immediate supervision of the client. Medications (option 3) should be given orally if possible, since the manic client is likely to overreact to any physical contact, either interpreting it as a physical assault or ascribing a sexual intent to it. Being in a quiet, nonstimulating private room (option 4) is advisable for this client, but it is not as urgent as close personal supervision by the nurse.
Posttraumatic stress disorder is associated with a traumatic event. Symptoms such as nightmares and flashbacks are commonly associated with this disorder. Option 1 is incorrect as generalized anxiety disorder is associated with having a great deal of difficulty controlling unrealistic, excessive anxiety associated with common daily experiences. Option 3 is incorrect because social phobias present as fears of social occasions, and the phobic individual avoids many or most social situations because of dread of being embarrassed or humiliated. Phobic persons recognize that their behavior is irrational. Option 4 is incorrect because dysthymic disorder is a long-lasting problem of the individual that involves lowered mood and a variety of other experiences that have lasted over at least a 2-year period. Sleep pattern disturbances are common, but nightmares of a specific event are not.
Generalized anxiety disorder is characterized by chronic, unrealistic, and excessive anxiety concerning a number of different stressors. Option 1 is incorrect as agoraphobia involves anxiety and fear of places or situations, such as crowds. Option 3 is incorrect because panic attacks are characterized by sudden anxiety that may not be identifiable. Option 4 is incorrect as post-traumatic stress disorder is characterized by “flashbacks” and/or nightmares about a traumatic event.
The client’s behavior reflects a healthy response necessary for survival. Option 1 is incorrect as a phobic reaction is an excessive and unrealistic fear of a particular object or situation. Option 2 is incorrect because chronic anxiety is low-level anxiety occurring over an extended period of time. Option 4 is incorrect as in acute anxiety states, whether mild, moderate, or severe, the individual experiences specific physiologic symptoms and a feeling of uneasy dread and gloom.
This client describes dissatisfaction with both ascribed and assumed roles. Option 1 is incorrect as the client does not describe having too many roles, but rather being unable to perform the roles satisfactorily. Option 2 is incorrect because the client’s description does not include anything about thought processes. However, if the client had described thought patterns, it is not likely that they would have been described as irrational. Instead, the client probably would have described them as repetitive, persistent, and illogical. Option 4 is incorrect as the client’s statement does not describe family relationship patterns, but rather the client’s dissatisfaction with carrying out his or her own roles in the family.
The client is experiencing a repetitive irrational thought. Cognitive restructuring focuses on teaching people to change their maladaptive beliefs, self-statements, and imageries that contribute to their having an anxiety disorder. Option 1 is incorrect because what the client has said indicates repetitive thinking, not impaired coping with stress. Of course, impaired coping can be an outgrowth of preoccupation with negative thoughts, but the client’s description is very specific: thoughts are bothersome. Option 2 is incorrect as security enhancement is indicated when a client’s level of anxiety is high enough for the client or others to fear that the client’s behavior will become out of control. No indication of potential danger or lack of control is present in the client’s statement. Option 3 is incorrect because calming techniques are useful for managing the physiologic dimensions of acute or chronic anxiety. These include such things as muscle relaxation and deep breathing. This client has described a cognitive, not a physiologic, symptom of anxiety.
Severe anxiety must be reduced to a tolerable level before any other goals can be achieved. Option 1 is incorrect as the presence and support of the nurse is appropriate in almost all instances involving client care. However, in situations where the client’s anxiety is severe, the nurse should go beyond being supportive and work actively to decrease the client’s anxiety in order to prevent untoward consequences for the client or others. Option 2 is incorrect because clients at severe levels of anxiety will be unable to identify the cause of their anxiety. The nursing priority is to reduce the anxiety to a level that is safe for the client and others. Once that has occurred, the client can be assisted to identify possible causes of anxiety. Option 4 is incorrect as clients at severe levels of anxiety will be unable to focus on learning new coping skills. The nursing priority is to reduce the anxiety to a level that is safe for the client and others. Once that has occurred, the client can be assisted to learn new coping skills.
The nurse should be aware that this is a general discussion, not a therapeutic interview. Therefore, when the client’s anxiety seems to increase, the nurse can relieve the anxiety by altering the focus of the discussion. Option 1 is incorrect because asking the client for more details in this social situation will probably increase the client’s anxiety level. Exploring possible causes of the client’s anxiety at this time would be probing, a nontherapeutic response. Option 2 is incorrect as guided imagery is used to help the client focus away from anxiety-producing stimuli and onto a positive image that feels safe. This would be inappropriate to use in a more general type of interaction with a client. Option 4 is incorrect because if the nurse physically leaves the conversation, the client can be left feeling rejected. The anxious client needs the presence of a supportive person, in this case, the nurse.
Children get the first of 20 deciduous teeth between the ages of 6 months and 5 years. Permanent teeth begin to erupt about the age of 6 as deciduous teeth fall out. All 32 permanent teeth are usually erupted in late adolescence.
Option 4 is incorrect because the symptoms of a panic attack involve acute onset of generalized and severe physiologic symptoms throughout the body and an anxiety level so high that the person fears immediate death. The symptoms of hypochondriasis, however, are more frequently limited to one or several body systems.
If the nurse speaks softly to the client, this will serve as positive role modeling for the client. Additionally, if environmental stimuli are reduced, the client is likely to be able to moderate behavior, including beginning to speak more slowly and softly. This in turn could reduce stress-related emotions and their physiologic consequences, which could reduce the client’s level of social aggression. Option 1 is incorrect because calming, deep breaths could be used at a later time. Then initial response of the nurse should be something that is simple and direct and does not require concentration. Option 2 is incorrect as the focus of the nurse’s response should be on the socially aggressive client, not on others. Option 3 is incorrect because if the nurse pointed this out to the client at this time, it is very likely that the client’s emotions and the situation would escalate. Discussing causes of an individual’s behavior should not occur in a group setting, unless it is a therapeutic group.
Anxiety can be a healthy protective response to an actual threat. When at normal levels, it motivates and increases the individual’s level of awareness and involvement in the environment. Option 1 is incorrect as defense mechanisms are unconscious psychological responses designed to diminish or delay anxiety. Used by all persons, some are considered healthy or adaptive, and others are considered to be maladaptive. The nurse should assist the client to learn to use healthy defense mechanisms. Option 3 is incorrect because it is unrealistic to strive toward experiencing no anxiety. Anxiety is a common part of the human experience. Option 4 is incorrect as it is impossible for the human being to avoid the “fight or flight” response. It is a normal reaction to the person encountering a stressor and is part of the stress response.
Combined use of benzodiazepines and other central nervous system depressants can lead to death from respiratory failure. If the alcohol has been ingested shortly before admission (which is not at all uncommon for a client experiencing anxiety), giving a benzodiazepine could put the client at risk. Social support, coping mechanisms, and motivation for treatment (options 1, 2, and 3) are all important factors to document during the examination. However, the client’s immediate risk for safety is the priority at this point and must be examined first. The other data can be compiled at a later time when the formal examination is completed.
The symptoms displayed by the client reflect an increased alertness and heightened level of arousal focused on an immediate concern or perceived threat. This is also referred to as the “fight-or-flight” response and occurs during the alarm stage of the general adaptation syndrome. Exhaustion and resistance (options 2 and 4) consist of more severe symptoms (both physical and psychological) experienced in the general adaptation syndrome. They occur in the second and third stages respectively of GAS. General anxiety (option 3) is characterized by significant difficulty controlling unrealistic, excessive anxiety associated with common daily experiences. This type of anxiety is more generalized, or free floating, and does not necessarily have a specific focus.
Impaired thought processes related to understanding directions and/or obsessive thoughts is an appropriate nursing concern for clients with severe or panic-level anxiety. This is an important nursing concern because the altered thought processes that occur at this level of anxiety are usually accompanied with overwhelming emotions and disorganization. These factors often result in a regression to more primitive behaviors, putting the client at risk for injury. Ineffective health maintenance (option 1) does not reflect the current cognitive state of the client. Option 3 is an at-risk problem, and this client’s current emotional state and risk for danger will take preference over any risk diagnosis. Impaired communication (option 4) does not reflect the current cognitive state of the client.
Clients with generalized anxiety disorder should be able to demonstrate effective coping with mild anxiety. Clients with generalized anxiety disorder do not generally have dissociative experiences or perform ritualistic behaviors (options 1 and 4). Dissociation and compulsive behaviors occur with more severe levels of anxiety. Neither of these symptoms are in the diagnostic criteria for GAD. Anxiety related to traumatic events is associated with posttraumatic stress disorder (option 3).
Anxiolytic medications alleviate or reduce symptoms of anxiety so the client can learn to identify stressors and effective coping mechanisms. Anxiolytics allow the client to benefit from individual and group therapy. Anxiolytics cannot change the source of the anxiety. While the statement in option 1 is true, it does not provide the information that the client needs at this time. Option 3 is an inaccurate statement. Anxiolytics are not curative. Persons with anxiety disorders need to change their coping behaviors. They cannot rely on drugs to address the underlying source of the anxiety. It is during group therapy that effective coping mechanisms can be introduced and practiced. The statement in option 4 is inaccurate. The chemical effect of the anxiolytics can be realized whether the client is in group or not; however, the combination of anxiolytic and group therapy is considered to be more effective than either alone.
Ritualistic behaviors are related to heightened anxiety. The compulsive behaviors increase in intensity and/or frequency as the anxiety level escalates. The nurse should allow the client to complete the ritual in as reasonable and timely a manner as possible. Interrupting or stopping the ritual will increase anxiety, which in turn will increase the client’s need to engage in the ritual. Exploring childhood experiences (option 2) cannot be expected to bring about reductions in anxiety or ritualistic behavior. Clients who display compulsive behaviors need support and encouragement to manage their daily lives by modifying the environment and allowing time for the behaviors. Assigning solitude (option 3) cannot be expected to decrease the client’s need for the ritual. What causes the client to have a need to perform the ritual is not from the actual environment. Hence, remaining in the room will not necessarily decrease the urge to recheck and recheck compulsively. The nurse should recognize that the client’s motivations for the rechecking arise from within the psyche and are not related to environmental events (option 4). While keeping others out of the room may spare the client from feelings of embarrassment, it will not necessarily decrease the compulsive behavior.
At panic-level anxiety, the individual will not be able to process complex ideas (option 3). Using short, simple sentences will provide the best way to communicate information, directions, and support. Additionally, the nurse’s highest priority is to reduce the client’s anxiety to a more tolerable level. Anxiety is “contagious” in interpersonal situations. If the nurse conveys anxiety to the client, the client’s anxiety will escalate further. Speaking calmly and projecting an image of competence may have a calming effect on the client (option 4). The nurse should avoid communicating <i>loudly and firmly</i> (option 1). Speaking to the client in this manner would most likely further increase the client’s fearfulness, anxiety, and agitation. The client in panic level of anxiety has an urgent need for physical activity. Attempts to prevent or restrict the activity (option 2) will result in increased agitation. The physical hyperactivity should be allowed, but in a protected and nonstimulating environment in which the nurse is physically present and attending to the client’s safety needs. Clients in panic-level anxiety are not able to learn (option 5), because they cannot concentrate and have a very narrow self-focus. Learning best takes place when anxiety is at a mild or moderate level. Cognitive restructuring is appropriate for clients with chronic, lower-level anxiety.
The single most important measure of brain growth in infants is head circumference, so it should be measured at every examination.
Loss of control is a major concern for clients who have OCD. Goals related to control of unwanted thoughts and behaviors are appropriate for these clients. Clients with OCD are aware that their compulsive behaviors are not normal (option 2). Knowing this does not mediate or change their ability to manage or control the unwanted thoughts and behaviors. This statement only reflects the client’s awareness of his or her disorder; it does not indicate control over the behaviors and thoughts. The compulsive behaviors are utilized to reduce anxiety, not to reward self for good behavior (option 3). The statement in option 4 does not indicate control over behavior.
Hypnotic and anxiolytic agents should be taken for as short a period of time as possible. Physical dependence on these drugs can develop in a very short period of time. Additionally, anxious clients should be assisted to improve their coping mechanisms without relying on medication. The statement in option 1 shows awareness of correct drug information. Triazolam (Halcion) has both anxiolytic and sedative effects. Its primary use is as a nighttime sedative. The statement in option 2 shows awareness of correct drug information. Since clients can become physically dependent on benzodiazepines in a very short period of time, abrupt discontinuation can precipitate a withdrawal response. The statement in option 3 shows awareness of correct drug information: Driving or operating heavy machinery is not recommended when clients take benzodiazepines or other drugs that have sedating effects.
Suppression of feelings requires energy and will lead to increased anxiety. Clients need to talk about their feelings. The client’s statement in option 1 does not suggest insight, which is the development of understanding of one’s motivations. It suggests that instead of addressing and managing worries, the client will use avoidant behaviors. Generalized anxiety is characterized by worrying. The client will not be able to independently reduce this behavior and improve coping (option 2). However, if the client is taught the technique of cognitive restructuring, this might help to reduce the worrying behaviors. The nurse–client relationship should be maintained, because the client continues to require guidance and support (option 4).
The client’s complaints indicate the “fight-or-flight” response that occurs at the severe level of anxiety. Mild anxiety (option 1) is associated with the tension of everyday life; the person is alert, the perceptual field is increased, and learning is facilitated. In moderate anxiety (option 2), the perceptual field is narrowed, and low-level sympathetic arousal occurs. Panic anxiety (option 4) is associated with dread and terror, and physiological arousal interferes with motor activities.
Obsessive-compulsive (OC) behaviors represent attempts to relieve anxiety and decrease fear or guilt through controlling and ritualizing activities. People with obsessions and compulsions engage in a kind of magical thinking and believe that something terrible will happen if they do not act on their compulsion. If deprived of opportunity and adequate time to carry out a ritualistic compulsion, the person’s anxiety will escalate significantly, resulting in an increased need to carry out the compulsive behavior. It is best to schedule a therapeutic activity just after the client has completed a ritual. The client with OC symptoms is likely to have been socially isolated prior to admission and should be encouraged to participate in therapeutic and social activities on the unit (option 1). Instead of a diary connecting feelings experienced if unable to carry out the ritual, it would be more useful for the client to understand the relationship of feelings to the initiation of the ritual (option 3). The client should be allowed to use personal products (option 4), but this is not as important as allowing the client extra time to prepare for unit activities.
Because of shame or difficulty organizing thoughts, clients may be reluctant to talk about anxiety. Questions should be specific, direct, and individualized to the client. Option 1 is incorrect because when a client is experiencing anxiety, abstract thinking is impaired. Options 2 and 3 are incorrect because the nurse should ask direct questions about the client’s anxiety.
Safety needs have a higher priority than psychosocial needs, even when they are intense. Options 1, 2, and 3 are applicable nursing diagnoses for anxious clients, but safety has the highest priority.
The goal of teaching calming techniques such as relaxation therapy is to assist the client to learn to experience anxiety without feeling threatened and overwhelmed. Relaxation therapy (option 1) does not assist a client to confront sources of anxiety, but rather to reduce the level of intensity of the anxiety. Keeping a journal (option 3) is a self-monitoring technique but is not used to measure the outcome of relaxation. The goal is not to suppress anxious feelings (option 4) but to make them more manageable.
Long-term goals for moderate anxiety should focus on assisting the client to understand the causes of anxiety and learn new coping strategies. Mild anxiety (option 1) does not require nursing intervention. Clients at high (severe or panic) levels of anxiety (options 3 and 4) have very narrowed attention and cannot focus on learning.
To promote safety, the nurse should stay with extremely anxious clients. It is important for the nurse to remain calm and serene, use simple communication, and convey an attitude of calm, authoritative competence. During a panic attack a client is unable to focus on teaching (option 2). The priority of the nurse is to provide safety, as clients at panic-level anxiety are frantic and extremely disordered cognitively. Their judgment is impaired, they feel frantic, and they are therefore at high risk for injury if left alone (option 3). The client at panic-level anxiety tends to be very overactive and restless. Assisting the client to engage in a simple, repetitive task like deep breathing can be useful. Exploring possible sources of anxiety is appropriate when intervening in lower levels of anxiety (option 4).
The cover-uncover test examines coordination of eye muscle movement. In strabismus, one muscle is weaker and the eye wanders rather than focusing forward. Undetected and untreated strabismus can lead to amblyopia.
Beta blockers are effective in reducing cardiovascular symptoms (increased pulse and blood pressure, possible palpitations) associated with anxiety because they target the beta-adrenergic receptors in the sympathetic nervous system (fight-or-flight response). Options 1, 2, and 3 are not cardiovascular symptoms and reflect symptoms that beta blockers will not relieve.
Abrupt withdrawal from a benzodiazepine may lead to symptoms associated with hyperarousal. Benzodiazepine use can quickly lead to physical dependency. Although the client’s symptoms could be related to anxiety (option 1), the nurse notes that these symptoms began after the client refused a benzodiazepine. Benzodiazepine use can quickly lead to physical dependency. Manipulation (option 2) is a purposeful behavior aimed at getting one’s needs met at the expense of someone else. No data is given to suggest manipulation on the part of the client. Signs of benzodiazepine overdose (option 3) include severe drowsiness, ataxia, and impaired coordination.
People with PTSD often avoid interactions and develop an isolated lifestyle that prevents them from working and socializing with others. Clients are likely to feel victimized by the traumatic event (option 1). Options 3 and 4 reflect symptoms of PTSD, indicating the client is not yet showing improvement.
Somatoform disorders are anxiety-related disorders in which the individual has physical symptoms for which there is no underlying physical basis. The five somatization disorders include somatization, conversion, pain disorder, hypochondriasis, and body dysmorphic disorder. These clients are obsessively interested in bodily processes and diseases and unconsciously use physical symptoms to attempt to reduce conflict and anxiety. They generally have great fears of abandonment and loss of love but are unable to express their feelings directly. Interventions that assist with anxiety reduction are therapeutic for these clients, who tend to develop more and more symptoms as their level of anxiety increases. Options 1, 3, and 4 are all incorrect because each of them would provide secondary gain and increase the likelihood of the client’s continuing to express physical symptoms instead of expressing needs and feelings more directly.
Conversion disorders, like other somatoform disorders, result when individuals cannot express their needs (often to be loved) and feelings (often fear of abandonment) directly. They learn to have physical symptoms (loss of a bodily function in the case of conversion) to manage their anxiety. If the client can learn to express needs verbally, the need for using physical symptoms to avoid acknowledging conflict or anxiety will be minimized. Option 1 is incorrect as the client is not imagining the presence of the symptoms. The symptoms are real, but there is no objective physical reason for them. A more appropriate goal would be for the client to connect the physical symptoms to emotions being felt. Option 3 is incorrect because participating in adjunctive therapies like art and music therapy will be beneficial to the client and help reduce anxiety, but these therapies are not nearly as important as therapies which aim toward helping the person develop some level of insight into the meanings of the conversion symptoms. Option 4 would encourage dependency on the nurse, which would be a form of secondary gain. The client should be encouraged and guided toward being as independent as possible.
Since the client is experiencing physical symptoms that do not have an objective physical basis, it is vital for the client to begin to view the physical symptoms differently. The nurse should work toward assisting the client to see that the symptoms are related to life circumstances, interpersonal relationships, and unmet needs of the individual. Teaching about the relationship between mind-body reactions and stress is one way of doing this. Options 1, 2, and 4 are inappropriate because, in varying ways, each of them focuses on the physical symptom without connecting the physical and psychological spheres of the individual’s functioning. They would reinforce the client’s erroneous assumption that a physiologic disorder is present.
Conversion disorder, which is the most common of the somatoform disorders, is characterized by deficits in voluntary motor or sensory function. The dysfunction does not correspond with current scientific understanding of the nervous system, nor does the dysfunction present in usual ways, such as stumbling into things when blind from organic causes. Conversion blindness is not the result of a physical change in structure or function; rather, it is an unconscious attempt to avoid conflict and anxiety. The client’s expression of symptoms is a reflection of the client’s particular way of understanding blindness. Option 1 is incorrect as there is no evidence that other senses are heightened when conversion symptoms such as blindness are present. Option 2 is incorrect because the term “faking” indicates conscious awareness and deliberateness. When these are present, the individual is malingering. Option 4 is incorrect as the client has unconscious awareness of environmental hazards. On the conscious level, the client is blind.
Body dysmorphic disorder is a psychological disorder that requires mental health treatment. Clients usually have a normal appearance but are preoccupied with imagined defective body parts, often of the face, skin, genitalia, thighs, hips, and hair. Thoughts about this body part become obsessional, and the client engages in compulsive behaviors such as mirror checking, camouflaging, and other “corrective” measures. Because of the intense preoccupation and embarrassment about the imagined defect, the client is apt to be socially isolated and seeks medical treatment for relief. Option 1 focuses on the skin, not the underlying psychological issues. This focus will reinforce the client’s idea that the skin requires “fixing.” Of course the nurse should teach the client about ways to maintain the integrity of the surgical wound, etc., but this should be done matter-of-factly without undue emphasis. Option 2 is incorrect as the client is already prone to solitary activities because of fear of others seeing the “defect.” The nurse should encourage resuming social contact with others, but it is very likely that the client will have difficulty doing this. Option 4 suggests that the skin near the hairline has not been “fixed.” The client is now likely to see this as confirmation of a continuing “defect.”
In any nursing care situation, safety and maintenance of life always take precedence over psychologic issues, even when these issues are intense and lead to other problems, such as depression. The client’s statement indicates that a nurse has engaged the client in a no-self-harm contract, which is an appropriate intervention with a suicidal client. In options 1 and 3 the client indicates a continued focus on the appearance of the face. Reactions to or preoccupations with facial appearance are psychological experiences of the individual and are therefore secondary in importance to physiologic and safety needs. Option 2 indicates that the client is not utilizing therapeutic supports to assist with resisting urges for self-harm. Either the nurse has failed to offer the client a no-self-harm contract, or the client agreed to the contract but did not comply with its stipulations when feeling suicidal.
This client is showing typical physiologic manifestations of anxiety at this time. If this client has somatoform disorder, as the symptoms should suggest to the nurse, the anxiety was probably precipitated by receiving news of the negative gastroscopy findings. Somatization symptoms arise from underlying anxiety and exist for the purpose of reducing the anxiety and allowing the person to avoid the causes of the anxiety. For this reason, rather than relieving anxiety, hearing news of negative physical findings would increase the client’s anxiety. Option 1 is incorrect because, although the client is experiencing pain, the priority concern is the current presentation of anxiety, which is also the cause underlying the pain. Option 3 is incorrect as there is no indication of hopelessness in the situation described. Option 4 is incorrect because there is no indication of disturbed body image in the situation described, although clients experiencing chronic pain of any sort are subject to having body image changes.
The lead value of 12mg/dL is high. Lead levels below 10mg/dL are acceptable. Levels of 10–19mg/dL require an environmental history. Levels above 20mg/dL require a full medical evaluation. Asking a question regarding the child’s address is the first step in evaluating the environment. Older homes may have lead paint and lead in the plumbing. Option 1 is inaccurate because the level is high (not normal), and options 2 and 3 are unrelated to lead poisoning.
By the time a child is 7 years old, the nurse can appropriately ask questions of the child. A 7-year-old would not be expected to have problems with night vision or glare and should know colors. Problems in school could be a sign of vision problems and warrant a thorough visual examination.
One of the most frequent reasons for people to seek medical attention is pain. When testing rules out any organic basis for pain and significant impairment in functioning exists because of the pain, pain disorder may exist. When it does, the client usually focuses on the pain and is controlled by it, thus being relieved of awareness of underlying anxiety. Pain disorder, like other somatoform disorders, is classified as an anxiety disorder. Option 1 is incorrect because clients with somatoform pain are at very high risk for excessive use of narcotic or sedative medications. This is especially true if there are comorbid conditions like depression and personality disorders. Option 3 is incorrect as persons with pain disorder generally have a significant disability and are unable to perform ascribed or assumed roles. Option 4 is incorrect because when somatoform pain disorder exists, there is no structural damage at the site of the pain, and no organic reasons can be established for the pain.
When an individual has many somatic complaints that do not have an identifiable origin in physiologic functioning, it is appropriate to consider possible causative factors from the person’s psychologic functioning. Generally it is thought that such persons are expressing anxiety and problems in living through their somatic complaints. The person, however, is consciously unaware of contributing stressors and stress and is therefore unable to use other means to cope with anxiety. Option 2 is incorrect as hopelessness may develop in the person with chronic somatoform symptoms, but it is not generally recognized as a basic part of somatoform disorder. If it does occur, it is secondary to the continuing and unrelieved physical symptom, which itself is secondary to anxiety. Option 3 is incorrect because clients with somatoform disorder do have impaired ability to communicate. Organs involved in the communication process are intact and functioning. The unconscious mind interferes with the client’s communication style, and the client expresses his or her messages symbolically and nonverbally through the particular physical symptom the client has. Option 4 is incorrect as pain is a possible manifestation of somatoform disorder, but it is not a universal experience in all clients in this diagnostic group.
Physical exercise, within the client’s ability level, reduces muscle tension and pain. Additionally, exercise creates a feeling of greater self-efficacy. Option 2 is the second best response. Music therapy could result in reduced anxiety, which would be therapeutic for this client. However, an activity that would result in relaxation of muscles would be expected to be more beneficial for this client. Option 3 is incorrect as persons with chronic pain problems are at high risk for abuse or dependency on narcotics and sedatives. Nonchemical means of pain control are preferable for these clients. Option 4 is incorrect because individuals with chronic pain should continue to be as active as possible. Placing the client on bed rest will prevent additional psychologic and physiologic problems.
Chronic pain interferes with social and occupational functioning, prompting further stress and anxiety. The concerns in options 2, 3, and 4 do not address the long-term homebound status and unemployment of the client.
This response describes unconscious avoidance of responsibilities or conflicts (competing in the recital) as a primary gain. The client’s anxiety is reduced, and the client does not have to take personal responsibility for not playing; rather, the client can “blame” symptoms. Glove anesthesia does not have an organic basis and follows a pattern that is neither anatomically nor neurologically possible. The client’s symptom does not indicate unnatural fear of an actual object or situation, which is what occurs when a person has a phobia (option 1). Carpal tunnel dysmorphia is an organically caused problem and follows specific nerve tracks (option 3). Somatic delusions are fixed, false thoughts about the body that are sometimes present in persons with certain types of psychoses. This client is not psychotic. Conversion responses are considered to be a type of anxiety disorder (option 4).
Option 4 suggests that the client examine this interrelationship of personal emotion and body image. Additionally, it sets the stage for other interventions to deal with preoccupation with imagined physical defects. These include cognitive-behavioral approaches like (1) identifying and challenging distorted perceptions of the client and/or (2) interrupting self-critical thoughts. A crucial early intervention is to help the person to identify and express feelings. Option 1, along with option 2, would support the client’s preoccupation with appearance of the ears and would likely increase the client’s level of anxiety and dissatisfaction. Option 3 suggests that the client consider theory, but the theory mentioned is maturation. The option does not suggest that the client should examine the interrelationship of personal emotion and body image.
Option 2 indicates accurate awareness of mind–body interaction and shows that the client no longer persists in (1) identifying illness as physical in origin and (2) feeling that medication is necessary to control the symptoms. Both of these are characteristic of somatization disorder. Option 1 indicates that the client still sees symptoms as something to medicate. Option 3 suggests that the client is receiving secondary gain from the family. A sign of progress would be a statement indicating recognition of secondary gain and its part in the chronicity of the symptoms. Option 4 indicates that the client is still focused on the idea of having an undiagnosed, untreatable problem.
The nurse should provide physical care for the client in a matter-of-fact manner and, at the same time, should help the client note how symptoms increase at the time of stress and can be a way of coping with stress. Option 1’s statement is confrontive and interpretative and will likely cause the client to feel frustrated and angry, which can increase the intensity of the headache. Option 2 would focus further attention on the physical aspects of the client’s functioning without helping the client to move toward developing an awareness of the interrelationship between pain and emotions. It also suggests that the nurse requires physician guidance before intervening. The nurse should know that it is appropriate to provide physical care in a matter-of-fact manner, while at the same time helping the client to understand how symptoms increase in a time of stress and can be a way of coping with stress. Option 3 is a critical statement that will likely cause the client to feel frustrated and angry, which can increase the intensity of the headache.
This client is preoccupied with the appearance of the body, not the health of the body. Body dysmorphic disorder is characterized by preoccupation with imagined defects, usually on the face or head, that prompt the client to seek medical treatment. In option 1 the client’s behavior does not suggest health-seeking behavior, but rather relief from feelings that the body is defective. In option 3 this client’s history and statements show a preoccupation with the appearance of the body, not with personal identity. In option 4, although great dissatisfaction with the appearance of the body is expressed, there is nothing in the client’s statement to suggest immediate threat for self-mutilation.
The pain of somatization disorder often begins after trauma or injury. The client with pain disorder continues to express discomfort even after medication is given, does not respond well to medication, and exhibits no insight into the role of stress on pain perception. Individuals with pain disorder generally do not show a good response to analgesics and are at high risk for substance abuse and dependency (option 1). In pain disorder, the client is not indifferent to the pain. Instead the client is consumed by the pain experience (option 2). Indifference to pain is most associated with pain of the conversion type. Clients with pain disorder see pain as something that is imposed on them (option 4).
An irregular heart rate that increases with inspiration and decreases with expiration is a sinus arrhythmia, which is common in children. It requires no action on the part of the nurse. Further evaluation is not necessary (options 1 and 4), and a determination of caffeine intake (such as in carbonated beverages) is not indicated.
Focusing on the effects of the symptoms may help the client understand the relationship between symptoms and stressors and would help to identify secondary gains the client might be experiencing. Conversion symptoms are thought to represent unconscious attempts to solve a stressful dilemma or set of circumstances. The person “gets” two things from having the symptom: primary gain (avoiding a stressful or conflicted activity) and secondary gain (support from others because of having the conversion symptom). Options 2, 3, and 4 will not assist the client to understand the relationship between symptoms and life circumstances.
Option 3 shows that when the nurse shows empathy by verbalizing the implied feeling of the client, an opportunity is created for the client. Specifically, the client can now express feelings and begin to connect these feelings to anxiety-producing situations and the symptoms being experienced. Option 1 leaves the client feeling that a misdiagnosis has occurred. It will not assist the client to verbalize feelings, nor will it assist the client to learn to express self in nonsomatic ways. Option 2 focuses totally on the physical aspect of the client’s functioning and makes no effort to assist the client to recognize the interrelationship of emotions and the symptoms. Option 4 shows a lack of concern for the client and can lead to feelings of rejection, which can increase the client’s anxiety and therefore the preoccupation with own physical health.
Option 4 shows that the client has profited from the opportunity to talk and gain support from others, both of which free up energy associated with unexpressed emotions. Unexpressed emotions and the energy associated with them play a significant role in the development of nonsomatically caused pain. Option 1’s statement gives no indication that the group therapy has been effective. Instead, the client is still focused on the perceived pain. Option 2’s statement suggests that the client does not recognize commonalities between other clients and self. Instead, the client is still focused on the perceived pain. Option 3 suggests that the client has not participated fully in group therapy and cannot therefore be expected to have received full benefit from the therapy.
Secondary gains are unintentionally sought benefits that result from an illness, such as support that otherwise might not be available. These benefits serve to reinforce illness behavior. The family’s response (cooking and cleaning for the client) can be viewed as a secondary gain for the client. Primary gains (option 1) are symbolic resolutions of unconscious conflict that decrease anxiety and keep the conflict from awareness. Attention-seeking behaviors (option 3) are not indicated in the question. Attention-seeking behavior directly calls attention of others to the individual who has experienced lack of satisfaction of either conscious or unconscious needs. Malingering (option 4) is motivated by deliberate conscious decisions of the individual. The individual offers a complaint, but has no actual dysfunction or symptom. Malingering is used to achieve secondary gain, but in this question, the client has actual back pain.
This response offers empathy and information about the spouse’s illness. Family members must understand the mechanism of somatization disorder and have their own needs addressed. The chronic nature of the physical complaints is very frustrating and disruptive of family functioning. The nurse must be responsive to this. Option 1 suggests an approach that would be confrontational and therefore likely to increase relationship difficulties between the spouses. Option 2 fails to offer empathy to the spouse. In fact, it could make the spouse feel defensive. In essence it says, “You aren’t attentive enough.” While the statement in option 4 is perhaps factual, it does not offer empathy to the spouse. The nurse should be ever mindful that the chronic nature of the client’s physical complaints is very frustrating and disruptive of family functioning.
Option 1 indicates beginning development of insight, which is a desired outcome for nursing intervention. Understanding the relationship between physical symptoms and stress helps the client to gain control of outcomes. Physical activity and limited use of pain medications (option 2) are indicated when the client has pain disorder. The client tends to allow the pain to dominate all spheres of functioning. Relaxation techniques (option 3) are most effective when practiced on a regular, not episodic, basis, although they can be employed when pain levels are just beginning to rise. Clients with chronic pain disorders are at high risk for dependency on drugs, whether prescribed or nonprescribed (option 4). These clients should be taught nonpharmacologic methods of pain relief.
Somatization disorder is characterized by chronic, multiple, vague physical symptoms in multiple body systems that impair role performance. The disorder usually begins before age 30 (option 1), and symptoms are a major source of concern throughout the client’s life. The client reports significant distress and usually seeks out multiple providers for health care. Clients with somatization disorder do not generally have dissociative experiences (option 2) or ignore their symptoms (option 3). Instead, they focus obsessively on their body. When one somatic complaint is managed, another emerges.
Discharge criteria for clients with somatoform disorders, which are associated with anxiety, include understanding the relationships between symptoms and anxiety-provoking events. The nurse should focus on assisting the client to understand this relationship. When the client has hypochondriasis, it is important to avoid focusing on the client’s past and associated physical conditions or complaints (option 1). These actions would likely increase the client’s anxiety and increase the preoccupation with symptoms. The client with hypochondriasis usually has a number of care providers in succession, going from one to another in a search for a cure, so encouraging a second opinion may suggest the presence of a serious problem, thus increasing the client’s anxiety and further intensifying symptoms (option 2). When the client has a somatoform disorder, family members must learn not to reinforce physical symptoms or illness behavior of the client (option 4).
Clients with a conversion disorder have no physiological basis for the symptoms. Options 1, 2, and 4 have physiological bases. Recall that conversion symptoms represent deficits in voluntary motor or sensory functioning for which there are no objective explanations or findings.
The nurse should be aware that the client with somatization disorder is indeed experiencing pain, although physical diagnostic results may be negative. The client’s pain should be relieved in a matter-of-fact manner. Prompt reduction of pain is the priority. Confronting the client with the negative physical findings (option 2) will likely increase the client’s anxiety level and therefore the level of pain. Once the client’s pain is reduced, then the client can be taught relaxation techniques, like deep breathing (option 3). Teaching should not be attempted when the client is experiencing pain. The nurse should respond matter-of-factly to the client’s request for medication and give the medication as ordered (option 4). Unnecessary delays will increase the client’s anxiety and therefore the pain level.
Vital signs in an infant are best taken when the infant is quiet early in the exam. Counting respirations by observing the abdomen is least intrusive, followed by the heart rate and temperature.
The statement in option 3 indicates some basic level of understanding about the meaning of hypochondriacal concerns. Education for a client with hypochondriasis is effective if the client is aware that the symptoms present no real danger. Giving up the preoccupation with the serious nature of the symptoms is a gradual process of cognitive restructuring. Option 1 suggests that the client believes that the illness is too serious to be identified. Option 2 indicates that the client feels ill and misunderstood by the family. Option 4 suggests that the client is searching for reasons to explain symptoms being experienced.
Depersonalization, which is probably underdiagnosed, is often not responsive to therapy or medications. Characterized by persistent feelings of being detached from one’s body and feeling as if in a dream, depersonalization disorder is thought to relate to emotional abuse in childhood. The primary symptom, which results from the defense mechanism of dissociation, is the feeling of being detached or living outside one’s own body. Option 1 is incorrect because, while in a depersonalized state, individuals are oriented and in contact with reality. They know they are not living in a dream, even though the world seems dreamlike to them. Option 2 is incorrect as clients who are depersonalized can communicate well verbally. Option 4 is incorrect because self-mutilative behavior is not associated with depersonalization disorder. Rather it is more common in persons experiencing dissociative identity disorder. In these persons, one or more of the “alters” can be hostile and destructive toward the primary personality, which is seen as the occupier of “the body.”
This intervention is called grounding the client. Grounding involves having the client focus on real, concrete things that can be seen or heard and redirects the client’s attention from the depersonalization experience. This in turn interrupts the anxiety response. Option 1 is incorrect because when the client is depersonalizing, the nurse should remain with the client and use the grounding technique to interrupt the depersonalization process. Option 2 is incorrect as the client who is depersonalizing should be helped to focus on something that is happening outside of the self in the external world. If the client were left alone with closed eyes, this could accelerate the depersonalization response. Option 3 is incorrect because it is the second best response. The nurse’s intent in this intervention is probably to reduce anxiety, but taking deep breaths calls for an internal focus. The client who is depersonalizing should be assisted to develop an external focus.
Support groups held for survivors of natural disasters are a form of crisis intervention. They are intended to help the survivor create meaning of the event, obtain emotional and material support, and reinforce positive coping efforts. Option 1 suggests that the client is denying, rather than coming to terms with the event. Option 2 indicates that the client feels more impacted than others and has not experienced a feeling of oneness with the group. Option 4 is incorrect as the client’s statement indicates rejection of the potential value of a support group and suggests that the client is rationalizing his or her lack of participation.
Clients with DID often describe the experience of amnesia for events when another personality is dominant, as “lost time.” Option 2 is incorrect because when DID is present, the principal personality may or may not be aware of the presence of other personalities, or “alters.” Option 2 is incorrect because the amnesia of the client with DID is not restricted to nonawareness of alter personalities. Indeed memories of large parts of the client’s life experiences may be lost. Option 3 is incorrect as the amnesia associated with DID may take any form: localized, selective, generalized, or continuous. When situations of specific abuse have overwhelmed the individual and led to development of DID, the primary personality does not have memory of the specific events. Some “alters” may have this memory. Option 4 is incorrect because when DID is present, if the primary personality experiences amnesia, these memories remain submerged and outside of the individual’s awareness.
Option 4 suggests a method for external “grounding” of the client. While not merely being around other people prevents the individual from dissociating, any person who is near can implement this technique when the client appears to begin dissociating. Grounding helps help to give the client a focus on external reality and decrease anxiety being experienced. A reduction in the anxiety level can then avert the dissociation in process. Option 1 is incorrect as merely being around other people does not help prevent dissociation. A more active approach must be used to bring about that end. Option 2 is incorrect because it implies that dissociation is a willful act of the individual. This is inaccurate, as dissociation is called into play by the unconscious mind of the individual. Option 3 is incorrect as it is dismissive and somewhat critical of the spouse’s concern.
All family members are affected by dissociative identity disorder (DID). Children must also find ways to understand and deal with what is occurring to a parent, rather than denying what is obvious or proceeding on incorrect assumptions that are not challenged by accurate information. Options 1, 3, and 4 are incorrect because they each fail to recognize that all family members, including children, are affected by DID in the family unit.
Dissociative fugues, which last for varying periods of time, are characterized by wandering or moving away from one’s familiar place with an amnesia for the complete past, including self. The person often assumes a new identity for the duration of the fugue. Fugues are most often precipitated by subacute, chronic stress, so prevention of future episodes of fugues involves examining life circumstances and issues of the client before the fugue started. In a very real way, a fugue state is a psychologic escape from a life circumstance or intense feeling that the individual feels unable to handle. Option 1 is incorrect as it is impossible to plan for prevention of future fugue responses without knowing what might have precipitated this one. Option 2 is incorrect because spending more time in solitary activities is not expected to benefit this client. People live in a world involving others, and withdrawing from others in a time of stress is a mechanism that has already caused difficulties for this client. Option 4 is incorrect as recalling events that occurred during the fugue (many clients never are able to do so) is not as valuable as recalling events that happened before the fugue. This is important because fugues generally follow an overwhelming environmental or psychological stressor.
Option 3 indicates that the client is beginning to make connections between stress, anxiety, and dissociation. This will enable the client to modify stressors or personal response to them, thus preventing the dissociative process. Options 1, 2, and 4 are incorrect. Each of them shows a lack of insight into the connection between stress, anxiety, and dissociation, as well as a continuing tendency to engage in behaviors that are likely to bring about dissociation.
Although all of the options are dissociative responses, only localized amnesia is the inability to recall events in a circumscribed time period. Options 1, 3, and 4 are examples of various dissociative states, but they do not show amnesia that is limited to a specific, or circumscribed, period.
A 6-month-old should be able to babble as well as localize sounds by turning head toward sounds. Failure to turn toward sound is an indication that further hearing examination is necessary. The Moro reflex should not be present in a 6-month-old, and an infant that young would not be forming words yet.
Dissociative disorders result from using the defense mechanism of dissociation. This dissociation prevents anxiety about traumatic events or stressors from entering conscious awareness. Dissociation is not consciously employed and does not involve a gradual loss of memory (option 1). The process of changing alters generally occurs very quickly. Regressive behaviors (option 2) are common in dissociative states, but dissociation is intended to reduce anxiety, not avoid adult responsibilities. Use of hallucinogens can result in dissociation in persons who are prone to “trance states” or spacing out, but when this occurs, current use of the drug is most likely to have occurred (option 3).
Dissociation occurs when anxiety is high; thus, a calm, safe, and supportive environment is essential to decrease emotional arousal. Increasing sensory stimulation (option 2) will increase psychological arousal and can lead to increased dissociation. Working through past trauma (option 3) is not an immediate priority. Even if a history of trauma is a causative factor, anxiety must be reduced to a level compatible with verbal exploration. Social skills (option 4) may or may not be problematic when the client is dissociating. This is dependent on the alter that emerges and its “function” within the group of personalities.
Clients with DID often have particular physical problems including headache, irritable bowel syndrome, and asthma. Elated mood (option 2) could be a comorbid condition associated with one or more of the alters. However, it is not a universal symptom of dissociative identity disorder (DID). Memory is discontinuous in states of DID (option 3). Each personality has a memory of its own. Stocking or glove anesthesia is not characteristic of DID (option 4).
The client needs to have critical physical needs met, including physical comfort, as the first priority. Creating a sense of safety after an assault is essential, as anxiety may fluctuate. The nursing interventions in options 1, 3, and 4 are relevant, but not a priority and can be deferred to a later time.
The change in the client’s voice indicates a change to a child alter. Reasons for this change include regression, resistance, needing sustenance, wanting to be understood, or other possibilities that are connected to severe underlying anxiety. Persons with DID do not dissociate in order to gain attention (option 1). Dissociation is an unconscious mechanism used to reduce overwhelming anxiety. Depersonalization (option 2) involves a person’s feeling disengaged and removed from one’s surroundings, as if viewing things in a dream state. The person remains aware of personal identity during the time of depersonalization. Dissociation is not shown in this situation. Malingering (option 4) is a consciously motivated behavior in which the individual behaves as if ill or feigns an emotion. Malingering is not shown in this situation.
Changing alters often occurs with increases in anxiety. Asking the client to explain more will help the nurse understand what is happening on a system level, and why the child alter was emergent. Option 1 would increase the client’s anxiety level. Option 2 would not help the client become aware of feelings that preceded the dissociation. It is somewhat critical and represents a sort of private musing of the nurse that should not be verbalized to the child alter. Option 4 would also increase the client’s anxiety level.
Feeling detached, as if in a dream, is characteristic of depersonalization disorder. Multiple personalities or alters (option 1) are not part of depersonalization disorder. Indifference to the symptoms (<i>la belle indifference</i>) and amnesia (option 3) are usually related to conversion disorder. In depersonalization, the client remembers the event and usually is distressed by the experience (option 4).
Reducing anxiety through the use of stress management techniques will prevent depersonalization that is a reaction to high levels of anxiety. There is no data to support suicidal thoughts (option 2) or multiple identities (option 3). Improving self-concept is helpful (option 4), but is not a priority when anxiety leads to dissociation.
This client is showing localized amnesia. The client’s memory loss began a few hours after a disturbing event. Further, the client is unable to recall all memories of the event, and the memory loss is confined to this particular sphere of the individual’s functioning. Suppression (option 1) is a consciously motivated response of an individual to a stressful event. When suppression is used, the individual is fully aware of what is taking place and refuses to acknowledge it. This client does not evidence this type of awareness. Confabulation (option 3) is the replacement of gaps in memory with imaginary information. This client is not showing this behavior. Continuous amnesia (option 4) is the type of memory loss in which the individual forgets successive events as they occur. This type of amnesia includes loss of memory of present events and affects orientation.
Fugue states usually begin abruptly after a major stressor, such as war or natural disaster, and end abruptly. The client experiencing a fugue state may or may not have a history of childhood trauma or depression (option 1). During the fugue state the person either appears totally normal to others or appears dazed and confused. Depression (option 2), if it occurs, is likely to precede or follow the fugue state. If the stressor is severe enough, the client can enter a fugue state without ever having had other dissociative responses (option 4).
The auditory canal of children over age 3 is like that of adults, narrower and more curved; therefore, the pinna should be gently pulled up and back.
At this time the client needs an opportunity to work through the disaster event, acknowledge its reality, and reduce anxiety. This will best occur in a disaster survivor support group in which other survivors of disaster and the client will talk about the reality of the loss. If this does not happen, the client is at risk for experiencing a crisis response. Feelings of depression (option 1) and anger (option 2), while a part of coping with loss, may occur later than 2 days after an event and will take more than a few days to resolve. It is too early to consider whether job retraining is necessary (option 3) or whether funds are available for rebuilding.
Trust is the basis of a therapeutic relationship, and the client should proceed at a self-determined rate, particularly if the subject is painful. Self-pacing avoids flooding the client with severe anxiety. This self-disclosure should be accepted nonjudgmentally by all persons with whom the client has contact. Option 2 would result in flooding the client with anxiety, which is not recommended. Additionally, the nurse should recognize that a nursing assistant is not properly prepared for this sort of intervention. Option 3 could interfere with trust and the client’s readiness to disclose. Option 4 is nonaccepting and demeaning to the client.
Hypnosis may be effective to access memories and, if present, other personalities that result from dissociation. Option 1 is incorrect because ECT does not enhance recovery of memories. Instead, it can interfere with recall and memory, particularly of recent events. While overwhelming anxiety is associated with dissociative identity disorders, normal relaxation techniques (option 3) do not enhance memory retrieval. While overwhelming anxiety (option 4) is associated with dissociative identity disorders, antianxiety medications are symptomatic measures to reduce anxiety and are not directly associated with retrieval of memories.
Objects or surroundings can be used to reorient the client by promoting concentration and an external focus. Internal focusing only augments dissociation (option 4). Taking an antianxiety medication at the time of dissociation (option 1) will not be an effective deterrent, since the dissociation has already begun. It is also unlikely that the person can actually take the medicine, because dissociation will already be interrupting integrated functioning. Beginning a relaxation technique at the time of dissociation (option 3) will not be an effective deterrent, since the dissociation has already begun. It is also unlikely that the person can focus on the relaxation technique because integrated functioning has already been interrupted by the dissociation.
This is a supportive response. Many clients with DID have lack of awareness of events because another personality was present when these events were discussed. Thus, the host personality has no knowledge of them. Although the client eventually must be accountable for all actions of the personalities to the greatest extent possible, this may not initially be under the client’s control. The style of option 2 could be construed as somewhat condescending. The information is true, but there is no attempt to be supportive of this individual client. The nurse should not look upon the client’s lateness as resistance (option 3). Many other causative possibilities exist, including emergence of an alter personality that emerged and controlled the individual’s behavior. Also, this response is somewhat accusatory.
The client who has experienced a fugue is generally unable to remember events occurring during the fugue state (option 1), despite encouragement (option 2). During fugue states, clients are generally reclusive and quiet, so their behavior rarely attracts attention. Amnesia for the events occurring during the fugue state can be predicted (option 3). The client does not have the ability to alternate personal identity with the partial identity assumed during the fugue state (option 4).
Changing from one alter to another is manifested in a variety of ways including blinking, facial changes, and changes in voice and train of thought. Orthostatic hypotension (option 1), dystonic reactions (option 3), or pallor (option 4) are not usually associated with changing from one alter to another.
Option 2 is correct because dichotomous thinking is one of the prevalent cognitive disturbances of individuals with borderline personality disorder. This type of thinking results in persons seeing the world in extremes—all good or all bad, totally perfect or totally horrible, etc. This type of thinking permeates their interpersonal relationships and their views of themselves, which can involve rapidly shifting roles ranging from victim to victimizer, dominant individual to submissive individual, etc. Option 3 is correct because clients with borderline personality disorder are intense and unstable affectively. They have difficulty tolerating anxiety and moderating feelings. An emotion that would be of low-grade intensity in others rapidly escalates to the level of a catastrophe for the client with borderline personality disorder. Option 4 is correct because, due to intense shifts in emotion and frantic attempts to avoid abandonment, persons with borderline personality disorders often attempt to manipulate others to meet their needs. Depending on the emotion they are feeling, the manipulation can be aimed toward any number of purposes, ranging from having dependency needs met to suffering humiliation or injury. Option 1 is incorrect as persons with borderline personality disorder have intense needs to be loved and cared for. This leads them to seek relationships with others in intense, often desperate-seeming, manners. The relationships are typically conflicted and short-lived, but the individual with borderline personality disorder continues to seek the company of others in the vain hope that the perfect friend or lover will be found. Option 5 is incorrect because clients with borderline personality disorder tend to be impulsive, unpredictable, and manipulative.
Individuals with paranoid personality disorder interpret the motives of others as malevolent; thus, they perceive the world as threatening rather than boring, exciting, or interesting. Their distrust and suspiciousness of others is reflected in DSM-IV-TR diagnostic criteria for paranoid personality disorder and must be considered in the planning and delivery of care. Additionally, they tend to be secretive, guarded, and aloof. Option 1 is incorrect as the paranoid individual is hyperalert to all environmental stimuli, often ascribing a harmful intent to neutral people and situations. Options 2 and 3 are incorrect because instead of finding the world exciting or interesting, the individual with paranoid personality disorder sees it as hostile and dangerous.
Limit setting provides a structured environment rather than an unstructured environment. This decreases the client’s opportunities to manipulate and is a small step in disrupting a maladaptive communication pattern. Option 1 is incorrect as justifying rather than stating rules and regulations may be perceived by the client as a sign of discomfort or defensiveness on the part of the nurse and may result in increased efforts at manipulation. Options 2 and 4 are incorrect because they would allow the client a wide range of opportunities to manipulate other clients or staff in an effort to have their needs met.
The normal head circumference of a full-term infant is 32 to 38 cm, about 2 cm greater than the chest circumference. In the toddler, both measures are about equal; after the age of 2, the chest circumference exceeds that of the head.
Persons with borderline personality disorder do not manage anxiety well and are unable to tolerate and moderate strong feelings. Their interpersonal relationships are intense and unpredictable, as they have intense needs for acceptance and love, as well as unrealistic expectations of others. They are frequently self-mutilative and can become actively suicidal, as well as psychotic. It is estimated that 15-25% of the population of psychiatric clients has borderline personality disorder. Option 1 is incorrect because, while histrionic and borderline personalities are both part of Cluster B disorders in DSM IV-TR, individuals with histrionic personalities are most characterized by behaviors designed to seek stimulation and excitement in life. These individuals are often the center of attention and use attention seeking and/or seductive behaviors in order to seek attention and approval from others. Option 2 is incorrect as suicidal ideation is not an Axis II diagnosis. Axis II diagnoses either refer to personality disorders or mental retardation. Option 4 is incorrect because a motivational syndrome is associated with certain other long-standing mental health problems, such as chronic schizophrenia.
Responding to the client in a businesslike, nonpunitive fashion decreases the tendency of the client to try to engage in a power struggle with the nurse. Justifications are not offered, but rather facts are presented simply and directly. Options 1 and 4 are incorrect as they would allow the client to gain control of the situation through manipulation. Both options would reinforce the client’s tendency to see himself as special and deserving of unique considerations. Option 4 suggests that the nurse and the client will engage in a cooperative act of secrecy. Option 2 is condemning of the client. The nurse should respond calmly and matter-of-factly when refusing the client’s request for special privileges.
Personality disorders are typified by pervasive, inflexible, and enduring patterns of behavior that lead to distress or impaired functioning in all areas of the client’s life, beginning with adolescence. Major characteristics include inflexible and maladaptive responses to stress, disability in loving and working, and ability to evoke interpersonal conflict and/or “get under the skin” of others. These clients, however, generally lack the ability to recognize that their behavior contributes greatly to their unsatisfactory interpersonal relationships and their problems in living. Option 1 is incorrect as only some clients with personality disorders show intensely ritualistic behaviors. They are most likely to be those with obsessive-compulsive personality disorder. Option 2 is incorrect because, while it is true that individuals with personality disorders are often dually diagnosed with other psychiatric problems, there is not a specific correlation with chronic pain disorder. Option 3 is incorrect as people with personality disorders are not psychotic. Therefore, their thinking, while disturbed, will not be autistic and they will not experience delusions. Some clients with personality disorders develop psychotic symptoms, but when this occurs, the client is dually diagnosed, and the personality disorder is the Axis II diagnosis.
Clients who are diagnosed with a personality disorder most frequently perceive their personality patterns as ego-syntonic or a natural part of themselves rather than as ego-dystonic, or foreign and distressing to the self. Option 2 is incorrect because this is one reason it is difficult to motivate individuals with personality disorders to try to change their maladaptive behavioral patterns. Individuals with personality disorders display problems in living rather than clinical symptoms. Option 3 is incorrect as clients who are diagnosed with a personality disorder most frequently perceive their personality patterns as ego-syntonic or a natural part of themselves rather than as ego-dystonic, or foreign and distressing to the self. Option 4 is incorrect because due to their dissatisfactions and problems in living, clients with personality disorders are strongly predisposed to abuse of substances.
It is difficult for individuals diagnosed with dependent personality disorder to make decisions on their own; rather, they try to get others to make decisions for them. This characteristic is reflected in DSM-IV-TR diagnostic criteria. Options 1 and 3 are incorrect as they indicate that the client can readily make independent decisions. Option 2 is incorrect because clients with dependent personality disorder are not likely to make critical remarks about others. Instead, they will go out of their way to agree with others to avoid rejection.
To the person with paranoid personality, the world is a hostile place in which people are not to be trusted. Ever on the alert for misdeeds, this individual prefers solitude and emotional distance from others. When this is not possible, the person tends to react with harsh criticism or anger directed toward others. For these reasons, the client can be least anxious and function best if allowed to have a private room. Option 1 is incorrect because as persons with paranoid personalities have a strong fear of losing power and control to others, the client would be likely to view this sort of therapy with suspicion and disdain. Option 2 is incorrect because due to intense self-preoccupation and suspiciousness, the person with paranoid personality disorder is not sensitive to the needs of others. Because of this and the fact that the client holds emotions under tight control (except for episodic hostile outbursts), this client is not a good candidate to lead a client group. Option 4 is incorrect as being introduced to all clients may or may not be helpful to this client, who is likely to feel that others have secret roles or missions and that information is being withheld from the client.
Individuals diagnosed with paranoid personality disorder frequently are critical or argumentative to maintain a safe distance between themselves and others related to their inability to trust others. This, coupled with their aloofness, makes it difficult for others to feel comfortable with them. Option 2 is incorrect as people who are considered shy are likely to have schizoid personality disorder. They are considered to be “loners” who have restricted ranges of feelings. Staff would also probably find it frustrating to work with these clients. Option 3 is incorrect because persons with paranoid personality disorder are not likely to be dependent. They would fear being overpowered psychologically by the other person. Indecisive, clinging behavior is more likely to be seen in persons with dependent personality disorders. Staff would also probably find it frustrating to work with these clients. Option 4 is incorrect as checking and rechecking behaviors are associated with compulsive personality disorder, not paranoid personality disorder.
Clients diagnosed with personality disorders view their personality patterns as natural, or ego-syntonic. They think their behavior is normal, and it is neither painful nor uncomfortable to them. For this reason, they rarely seek treatment. This view is directly opposite that of ego-dystonia, in which the individual is greatly distressed by behaviors and symptoms. Narcissistic responses (option 1) involve a grandiose sense of entitlement and focus on the self. Schizotypal individuals demonstrate eccentricities in behavior and avoidant responses (option 3). Avoidant behaviors involve social inhibition and feelings of inadequacy (option 4).
Verbalizing rather than suppressing one’s fear of abandonment is the first step in recognizing its effect on the self and on interpersonal relationships. A fear of abandonment often drives significant others away as it may be reflected in extremes of emotion, extremes of idealization, or devaluation of the other. It can be associated with impulsivity and a heightened risk of self-mutilation. Thus, verbalizing this fear realistically is a sign of progress that is consistent with decreasing the risk of self-mutilation. Expressing rage reflects emotional volatility and may be associated with a heightened risk of self-mutilation (option 3). Vowing never to get involved in another relationship (option 2) reveals lack of insight into the desire and need for a close relationship and the related fear of abandonment. Suppressing one’s fear of abandonment (option 4) is not therapeutic. Verbalizing this fear can help with the development of insight about the self and interpersonal relationships.
In returning the focus of the conversation to the client, the nurse intervenes in the attempts at manipulation. The manner in which the nurse does this is professional and businesslike without appearing uncomfortable. The responses in options 3 and 4 make the nurse seem uncomfortable. Sensing this, the client will feel in control of the interaction and use even more manipulative behaviors. Option 1 is defensive and shows the client that the manipulative attempt has “gotten under your skin.” This will encourage the client to continue with other manipulative efforts.
The Moro reflex is also known as the startle reflex, and it may cause the infant to cry. For this reason, it should be performed at the end of the exam.
The client’s pattern of attention-seeking behavior reflects DSM-IV-TR diagnostic criteria for histrionic personality disorder. Dramatic attention-seeking behaviors (option 1) are not as common in borderline personality disorders as are those in which the individual is unstable and impulsive because of fears of abandonment. Dramatic and theatrical attention-seeking behaviors are not characteristic of narcissistic personality disorders (option 2). Narcissistic individuals show a sense of entitlement and lack of empathy for others. Dramatic attention-seeking is not a common behavior associated with antisocial personality disorders (option 4). Instead, even though they may be superficially charming and sociable, they have utter disregard and lack of consideration for the rights of others and often violate the rights of others if it is to their own personal advantage.
Individuals diagnosed with antisocial personality disorder frequently attempt to play one staff member against another. This behavior is referred to as splitting. Their goal in doing this is to manipulate others or control their environment. Individuals diagnosed with antisocial personality disorder have no regard for others and lack the capacity to empathize. Their behavior is not driven by attempts to gain acceptance or attention or create guilt (options 1, 2, and 3). Rather, it is to gain control by manipulation.
Individuals diagnosed with antisocial personality disorder rarely take responsibility for their behavior. Statements of this nature are likely to be insincere. They feel their behavior is justified and typically blame others in an irritable fashion for their socially unacceptable actions. In addition, they feel that their physical aggression toward another is not only justifiable but even deserved by the other person (option 4). They are not remorseful, and it would be very unlikely that they would apologize. They characteristically assign blame to others.
Individuals diagnosed with borderline personality disorder frequently display a tendency to dichotomous thinking, or splitting. They perceive the self and others as all good or all bad. The client may be seeking secondary gain from the nurse (option 1), but the manipulative behavior itself is not a manifestation of secondary gain. Acting-out behavior (option 2) involves displacing anxiety from one situation to another in the form of some observable response like crying or being violent. Passive aggression (option 3) involves behaviors that appear passive on the surface but are actually motivated by unconscious anger. Examples are being obtuse, arriving late, and making “mistakes.”
Being encouraged to acknowledge attempts at manipulation is a small, but important step in recognizing maladaptive communication patterns and their effect on relationships. Spending more time alone (option 1) cannot be expected to lead to a decrease in manipulative behavior. The manipulative person should be taught ways to have social interactions without manipulating and taking advantage of others. The manipulative person will have a great deal of difficulty sustaining lasting relationships (option 2). Working toward a change in this area would be a long-term goal. Exploring childhood experiences (option 3) is not a short-term goal.
Change is reflected in action and behavior. Even if stated clearly and with apparent conviction, plans, promises, and words do not reflect actual behavioral change. Statements of plans and promises (options 1, 2, and 4) indicate intentions. In order to evaluate actual change, behavior must be observed.
DSM-IV-TR criteria for schizoid personality disorders indicate that such individuals are aloof and remote when interacting with others, as they have no desire for close relationships. The nurse should accept this behavior pattern with calmness. To the schizoid client, helpful and nurturing (option 1), light and playful (option 3), and warm and friendly (option 4) approaches might seem like the nurse is attempting to be interpersonally close. This feeling would make the client uncomfortable and could be experienced as overwhelming.
To meet DSM-IV-TR diagnostic criteria for a personality disorder, behavioral patterns must be pervasive and maladaptive, resulting in functional impairment or subjective distress. The other behavioral patterns (options 1, 2, and 3) are associated with some but not all personality disorders.
Growing up in a multigenerational enmeshed family system and failure to separate/individuate the self are associated with the development of borderline personality disorder. Conflict in the area of separation/individuation can result in splitting or dichotomous thinking—perceiving the self and others as all good or all bad. Although each of the other etiologic factors in options 1, 2, and 3 are associated with the development of personality disorders in general, none of them are associated with the development of dichotomous thinking.
All four options indicate Cluster B disorders, as defined in DSM-IV-TR diagnostic criteria. However, the disregard for others, lack of guilt and remorse, and involvement in illegal actions are specific behaviors associated with antisocial personality disorder. The client’s behaviors do not indicate narcissism (option 1) because there is no indication of grandiosity or need for admiration. Histrionic qualities (option 2) are absent because there is a lack of emotion rather than heightened emotionality. There is no indication of borderline personality (option 4) because the client is not showing a pattern of instability in interpersonal relationships, self-image, and affect.
With iron-deficiency anemia, it is important to select dietary items that are high in iron to counteract the deficit. Red meat tends to be high in iron, as do some green, leafy vegetables. Although options 1 and 4 contain salad greens (and therefore are green, leafy vegetables), the other components of these meals are not as high in iron. Lasagna and carrots (option 3) are not as high in iron as the other choices.
According to DSM-IV-TR criteria for avoidant personality disorder, the individual will show a pattern of social inhibition, feelings of inadequacy, and avoidance of interpersonal contact and new situations related to fear of rejection and embarrassment. Avoidant personality disorder is a Cluster B disorder, while schizotypal (option 1), paranoid (option 2), and schizoid personality disorders (option 4) are Cluster A disorders in DSM-IV-TR.
Individuals diagnosed with antisocial personality disorder display decreased impulse control, can be irritable and aggressive, and lack remorse for their actions. Recognizing the potential risk for violence and maintaining client safety is the first priority of nursing care. Clients with antisocial personality disorder do not have personal identity disturbance (option 1), which is an anxiety disorder. Clients with antisocial personality disorder do not show excessive fearfulness (option 2), which is a characteristic of Cluster C disorders in DSM-IV-TR. Instead of being socially isolated, the client with antisocial personality disorder often has a wide range of social contacts and activities, although they occur at a superficial level without regard for the feelings of the other persons (option 4).
Since individuals diagnosed with schizoid personality disorder have no desire for interpersonal relationships and are indifferent to the opinions of others, individual rather than group therapy would be the treatment of choice. If this client were placed in group therapy (options 1 and 3), it is unlikely that the client could tolerate the interpersonal closeness of the group. A support group might be useful to the client after discharge (option 4), but the client might find the interpersonal closeness threatening.
A sense of entitlement, or believing that one is so special that others should defer to his or her needs, is included in the DSM-IV-TR diagnostic criteria for narcissistic personality disorder. Additionally, these clients lack empathy and have very disturbed interpersonal relationships due to their arrogance and selfish focus on self. Splitting (option 1), or dichotomous thinking, is associated with borderline personality disorders and involves seeing the world, the self, and others in extremes: all good or all bad; totally perfect or totally awful, etc. Hypersensitivity (option 2), especially when combined with suspiciousness (option 3), is more associated with paranoid personality disorder.
Because the behavioral patterns of individuals diagnosed with antisocial personality reflect a tendency to test and manipulate others, it is important to establish the parameters of acceptable behavior upon admission through limit setting. The interventions in options 2, 3, and 4 result in an unstructured environment with no consistent limits on behavior. This would increase rather than decrease an individual’s tendency to test and try to manipulate others in the environment.
Individuals with obsessive-compulsive personality disorder tend to become aggressive and argumentative when someone is stressing the importance of routine, rules, and regulations. Learning to communicate more assertively (option 1) would be useful for these individuals. Obsessions and compulsions are attempts to control anxiety; therefore anxiety management (option 3) would be useful. Because persons with obsessive-compulsive personalities need perfection and control, they usually have trouble making decisions, which can negatively affect their occupational functioning. Learning that decisions do not always have to be perfect and that they can be changed may be a first small step toward improvement (option 2). Twelve-step programs (option 4) are appropriate for treating individuals with addictive disorders. Distraction techniques (option 5) are not likely to be effective with persons with obsessive-compulsive symptoms. Their attention is riveted to the obsessions and accompanying compulsions.
Tangential speech occurs when the topic of conversation is changed to an entirely different topic. A permanent detour follows. It is considered a disturbance in associative thinking. There may be a logical progression, but it causes a permanent detour from the original focus. Option 1 is incorrect as circumstantial speech pattern includes many unnecessary and insignificant details before arriving at the main point. Option 2 is incorrect because a word salad is an incoherent mixture of words or phrases. Option 3 is incorrect as loose association is a vague, unfocused, illogical flow or stream of thought.
Hypervigilance is a state of readiness with the expectation that something is about to happen. Generally the expectation is that a negative event will occur. Option 1 is incorrect as hypervigilance and aggression are different phenomena. Hypervigilance can be thought of as hyperalert and hyperwatchful behavior. Aggression is forceful, often harmful, behavior aimed at another person or object. Hypervigilant individuals may or may not progress to being aggressive. Option 2 is incorrect because persons who are attending to internal stimuli will not be focused on the environment, but rather on their own experience. They will generally appear distracted and minimally aware of the environment. Option 3 is incorrect as hypervigilance is associated with heightened anxiety.
Delusions are false, fixed beliefs that cannot be changed by logical reasoning or evidence. These beliefs arise from an incorrect appraisal of external reality. They are firmly maintained even in the face of clear evidence to the contrary. Option 2 is incorrect as a hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; they are real only to the person experiencing them. Option 3 is incorrect because an idea of reference is a cognitive distortion in which a person believes that what is in the environment is related to him or her, even when no obvious relationship exists. Option 4 is incorrect because loose association is a vague, unfocused, illogical flow or stream of thought.
The principle of communicating with a client who is paranoid is to express doubt about paranoid content and not to attempt to convince him or her through arguing. Option 1 is incorrect as paranoid clients can not comprehend or accept logic. Option 2 is incorrect because providing an anxiety-free environment may decrease a client’s paranoid episodes but will not necessarily assist the nurse in communicating with the client. Option 4 is incorrect as encouraging ventilation of anger must be done in a controlled environment because paranoid clients may react to false beliefs by placing themselves or others in harm’s way.
The oral anticoagulant drug is sodium warfarin (Coumadin), and its action can be limited by excessive intake of foods containing Vitamin K. Since green, leafy vegetables are high in Vitamin K, the nurse needs to counsel this client about the possible antagonistic effect of these foods with the medication. Walking, rural living, and spending time alone pose no particular risk to the client.
Daily walks will allow the client to work off energy and possibly decrease agitation and anger. Option 1 is incorrect as volleyball would allow the client to dissipate his or her energy but may allow or encourage aggressive, competitive behavior toward others. Options 2 and 3 are incorrect because Scrabble, bingo, and other board games do not allow a client to work off pent-up energy. Additionally, each of them requires concentration, which will be difficult for a client in a heightened state of emotionality.
The client is describing a tactile hallucination. Hallucinations are false sensory experiences that can occur in any of the special sensory functioning areas: olfactory, gustatory, tactile, visual, or auditory. There is no external stimulus to the corresponding sensory organ; but the experience is perceived as real by the individual having the hallucination. Option 1 is incorrect as believing falsely that everyone is talking about the client is an example of a delusion. Option 3 is incorrect because mistaking stimuli such as shadows is an illusory experience. Illusions are increased in states of heightened anxiety. Option 4 is incorrect as delusions are false thoughts without a basis in reality.
Arguing or attempting to disprove a client’s delusional or suspicious thoughts will be ineffective and can lead to increased mistrust. The nurse should respond to the underlying feelings rather than the illogical nature of the delusion. Option 1 is incorrect as a consistent program schedule will cut down on the number of surprises for the client and help develop trust in the staff. Option 3 is incorrect because orienting the client to the unit and introducing him or her to the staff will enable the client to start developing therapeutic relationships. Option 4 is incorrect as communicating clear expectations will prevent the client from being confused.
After making an empathetic comment (shown in the stem of this question), the nurse matter-of-factly informs the client of the nature of the substance and its general purpose. Clients have a right to know the names and purposes of all medicines ordered for them. The nurse avoids arguing that the medicine is not poison and does not try to force the client to take the medication. Following this statement, the nurse should offer the medication to the client again. The client has the right to refuse the medication. Only if the client’s behavior is clearly dangerous (and a specific physician’s order is in place) can the nurse give the medication without the client’s consent. Option 1 is incorrect as this option would not persuade the client to take the medication. The client has stated a firm, but delusional, opinion that the medicine is poison. The nurse should also recognize that the client’s delusion probably relates to anxiety and lack of trust in the reliability and competence of the staff. If this is the case, an attempted reassuring remark from the nurse will most certainly be rejected by the client. Option 2 is incorrect because this option implies punishment. Legally, this can be considered an assault of the client. If the nurse then gives the medication forcefully, this would be considered client battery. Option 3 is incorrect as the nurse and client have not yet established a relationship of trust, so this statement is rather inane on the part of the nurse. Additionally, the nurse should not be apologetic or defensive with the client.
Ideas of reference or misinterpretation occurs when the client believes that an incident has a personal reference to one’s self when, in fact, it is not at all related. Option 1 is incorrect as a hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; it is real to the person. Option 2 is incorrect because delusions are false beliefs that cannot be changed by logical reasoning or evidence. Option 4 is incorrect as loose association is a vague, unfocused, illogical flow or stream of thought.
When a client first mentions hallucinations, it is imperative for the nurse to examine for the possible presence of command hallucinations, or hallucinations that give the client an instruction. If command hallucinations are present, the risk of physical danger for the client or others is great. Note also that the nurse does not refer to the “voice” as a voice, because this could lead the client to believe that the “voice” is indeed an actual voice. Option 1 is incorrect as this response could be appropriate later, once the nurse has established the content and nature of the hallucinatory experience. At this point, the client is newly admitted, and the nurse must examine for command hallucinations. If the client feels commanded to harm self or others the nurse must implement appropriate safety measures. Option 2 is incorrect because the nurse should know that the client who is hallucinating perceives the experience as being real. What is important is for the nurse to examine for the possible presence of command hallucinations. Option 4 is incorrect as it is inappropriate to try to educate the person at this point. More data is needed so that appropriate interventions can be planned. Specifically, the nurse must examine for the presence of command hallucinations.
This client is most likely experiencing a visual hallucination. First, it is important for nurses to know the content of the hallucination so they can assist the client to process the experience and prevent any aggressive behavior. After this intervention is completed, then the client should be oriented back to reality. Ending the conversation (option 1) would not promote trust with the client or allow the nurse to determine content of the hallucination. Trihexyphenidyl (option 2) will not prevent hallucinations. The nurse should not redirect the conversation (option 4) until the nurse has evaluated for hallucinations.
Akathisia is an extrapyramidal side effect of antipsychotic medications that may manifest as subjective and objective restlessness and increased motor movement. Akinesia (option 2) is also an extrapyramidal side effect, but it is not shown in this client’s behavior. Akinesia is decreased activity or motor movement. Dystonia (option 3) is also an extrapyramidal side effect, but it is not shown in this client’s behavior. Dystonia presents as sudden and often painful contractions of muscles, especially of the head and neck. Tardive dyskinesia (option 4) is also an extrapyramidal side effect, but it is not shown in this client’s behavior. Tardive dyskinesia presents as involuntary muscle movements, strange tics, and repetitive motor movements in persons who have taken antipsychotics for a long period of time. The situation gives no past history of the client.
The nurse should know that the client has the right to have information about medications being taken. This information should be accurate and given in manner that the client is likely to be able to understand. The nurse’s answer should be based on the understanding that haloperidol (Haldol) is a traditional antipsychotic and that valproic acid (Depakote) is a traditional anticonvulsant that is also used for the nontraditional purpose of mood stabilization. Option 1 contains inaccurate information about expected drug effects. Option 2 is a nonspecific response and does not provide the client with the requested information, and option 4 is an inaccurate statement because this sort of combination is not old—FDA approval for administering certain anticonvulsants (including valproic acid) was not approved until the early 2000s.
Paranoid schizophrenic clients are very suspicious and potentially dangerous. It is best to avoid any physical contact, as well as any symbolic or actual invasion of the client’s personal space, because the client may feel threatened. Offering a back rub (option 2), shaking hands (option 3), and placing a hand on the client (option 4) involve physical contact. It is unlikely that the client could tolerate this without becoming aggressive.
The client in renal failure needs balanced nutrition, and fish is often acceptable to clients who do not eat red meat. Option 3 is less appropriate because crackers are not nutrient-dense foods. Options 1 and 2 contain high amounts of sodium or potassium, which are not helpful to the client in renal failure.
Residual-type schizophrenia manifests with socially withdrawn behavior, an inappropriate affect, and an absence of prominent psychotic symptoms. The most likely and common nursing concern would be social isolation. Impaired verbal communication (option 1), self-care deficit (option 2), and anxiety (option 4) are less likely to be seen in a client with residual schizophrenia than is social isolation.
This client is actively responding to internal stimuli and could easily react aggressively to others, especially if experiencing command hallucinations or if responding to actual or perceived intrusions of others into the client’s own personal space. The described behaviors do not suggest that this client is disoriented (option 1). Instead the nurse should recognize indications that the client is experiencing hallucinations. The client is likely to respond aggressively to moving hand gestures (option 3), which will be perceived as a physical threat. If the nurse offered the kind of verbal statement to the client as in option 5, it is highly unlikely that the client would feel reassured. Indeed, this action might provoke further suspiciousness, as the client’s hyperalertness and mistrust will lead to misinterpretation of environmental events.
The AIMS (abnormal involuntary movement scale) is used to screen for signs of tardive dyskinesia, which is a possible side effect associated with long-term use of an antipsychotic, particularly of the traditional type. It is characterized by involuntary, repetitive, and often bizarre movements of the mouth, face, trunk, and extremities. It is considered irreversible, so early recognition is imperative. The AIMS test does not include tests for muscle weakness (option 1), which would indicate acute EPS (extrapyramidal side effects) rather than tardive dyskinesia. The AIMS test excludes regular repetitive rhythmic tremors (option 2). These are indications of acute EPS (extrapyramidal side effects), not chronic tardive dyskinesia. The AIMS test does not measure slowed body movements (option 4), which would indicate acute EPS (extrapyramidal side effects), not chronic tardive dyskinesia.
Blurred vision is an anticholinergic symptom/side effect that usually resolves in a few weeks. If there is no improvement with time, then the doctor should be notified. It is too early to schedule an appointment (option 1), as the client can be expected to accommodate to this side effect within a matter of days. However, if the client also complains of pain in the eye, the physician should be notified immediately, as the client may be experiencing glaucoma as a result of the pupillary dilation that caused the blurred vision. There is no indication of pain with the blurring of vision, so the nurse does not have to respond urgently (option 3). Permanent blurred vision is unusual (option 4). The client can be expected to accommodate to this side effect within a matter of days.
Agranulocytosis is the most dangerous common side effect of clozapine and can lead to death if not detected and treated early. In addition to the requirement that weekly analysis of WBCs must be completed before clozapine can be reordered, it is important that the client, family, and nursing staff understand that changes in the WBC could occur during the time period between two laboratory testings. Therefore, reporting any observations of suspected infection is an urgent priority. Feeling more energy and interest (option 1) probably indicates a decrease in the intensity of negative symptoms of schizophrenia, and notification of the physician can be delayed. Sensitivity to ultraviolet rays (option 2) is a potential side effect of clozapine that is generally more bothersome than dangerous. Interference with a normal sleep pattern (option 3) is a problem that should be reported to the physician, but urgent reporting is not necessary.
Improvement in motivation and volition and ability to experience pleasure indicate a reduction in negative symptoms. While option 1 indicates improvement, the improvement is in the positive symptoms of schizophrenia: auditory hallucinations. Options 3 and 5 indicate improvement in the positive symptoms of schizophrenia: delusions.
Safety is always the highest priority when caring for any client. This is particularly true when the client has paranoid schizophrenia. These clients are extremely suspicious and distrusting of the environment and feel that others have harmful intent toward them. They maintain an alert and watchful hypervigilance and are at high risk for aggression and/or violence. Interrupted thought processes (option 1), social isolation (option 2), and impaired verbal communication (option 3) are appropriate for the client’s care plan but are not given highest priority, as they are not as important as safety.
The client is experiencing a delusion and indeed believes that the nursing staff members are secret police. Understandably, the client will be distrusting, suspicious, and frightened of all actions of the staff. The nurse should show awareness of the feelings of the client (“That must be a frightening thought.”) and present reality about the role of the nursing staff (“We are nurses who work at this hospital.”). Option 1 demeans the client and fails to allow the client to know the staff’s role. Option 3 attempts to respond to the client’s feeling and present reality, but it does not tell the patient about the role of the staff. Option 4 attempts to be reassuring, but it fails to give reality-based information that might assist the client to feel more comfortable with the staff. It also could suggest to the client that torture will occur, but not at this location.
Diminished pleasure (option 2), blunted affect (option 3), and difficulty making decisions (option 5) all represent a loss or lack of normal skills and functioning of the individual, which is the definition of negative symptoms of schizophrenia. First-generation antipsychotic drugs typically do not improve these symptoms, but second-generation antipsychotic drugs do. Positive symptoms of schizophrenia, such as abnormal thoughts (option 1) and hallucinations (option 4) are symptoms that, if present, clearly and certainly indicate the presence of psychosis.
This client is exhibiting signs and symptoms of possible neuroleptic-induced malignant syndrome (NMS), which is a potentially lethal side effect of antipsychotic medications that requires immediate medical care. The care cannot be delayed, as the NMS may progress rapidly and lead to client death. The client is not simply experiencing extrapyramidal effects (EPS), which would indicate the need for a prn anticholinergic (option 1). While orthostatic hypotension (option 2) may occur as a side effect to many antipsychotic medications, making this the priority intervention at this time would ignore the possibility that NMS is present. Suspected NMS should be considered an immediate medical emergency. Failing to recognize the urgency of the situation and arranging for a physician’s visit later in the day (option 4) could put the client at grave risk for negative consequences, possibly including death.
A child restraint system should always be in the back seat and rear facing. After a child is 1 year of age and 20 pounds, the seat may be in the rear and front facing. Although bright colors are stimulating to an infant, the color of the system does not matter.
The client who has diabetes needs to have regular meals that are evenly spaced throughout the day and may need to supplement meals with snacks. Eating six meals per day is excessive and could lead to inadequate glucose control. Options 1 and 2 pose no risk as long as they are in the client’s meal pattern. Option 3 is acceptable as long as the client ensures that the fruit is packed in water instead of syrup.
The precise cause of schizophrenia is unknown. The general consensus is that schizophrenia results from the interaction between a variety of biologic and psychosocial factors that have been correlated with schizophrenia. Research has correlated genetic factors with schizophrenia, but more research is needed (option 1). Poor parenting skills (option 3) and early age trauma (option 4) have not been documented as exact causes of schizophrenia.
This option recognizes that the client is not likely to initiate interpersonal or social activity independently. It is also a measurable goal that is reasonable to achieve in a short time. Clients need to meet short-term goals during hospitalization to promote a sense of accomplishment, which may increase their self-esteem. Leading a unit community group by the time of discharge (option 2) is a possible long-term goal; however, this could be an unrealistic goal for the time of discharge. Option 3 is not written in measurable terms, even though it specifies a short time frame for accomplishment. It fails to indicate how the nurse can know that a client is “more comfortable.” Option 4 is not written in measurable terms, even though it specifies a short time frame for accomplishment. It fails to indicate how the nurse can know that a client “enjoys participating.”
Option 1—Catatonic schizophrenia is characterized by two phases: nonresponsive hypoactivity and unpredictable hyperactivity and aggression that may be dangerous to self or others. The nurse must always anticipate that the aggressive stage may occur. Option 2—Constipation is possible because of the psychomotor retardation and relative immobility of the client. This client will likely be receiving antipsychotic medications, most of which have anticholinergic side effects, including constipation. Unless the staff assists the client and allows extra time for meals, the likelihood of nutritional deficiency (option 4) is increased because of the client’s psychomotor retardation and inability to verbally report any feelings of hunger. Option 3—The client is actually experiencing impaired individual coping, as expressed through the presenting behaviors. Option 5—Many clients who have had catatonic episodes are able to recall details and events occurring during a period of stupor.
Clang associations are association disturbances in which schizophrenic clients rhyme words in a sentence that seems nonsensical to the listener. Echopraxia (option 1) is meaningless imitation of motions made by others. Echolalia (option 2) is involuntary parrotlike repetition of words spoken by others. Associative looseness (option 4) does not involve rhyming, but rather lack of integration or logical connection between thoughts.
Increase in body weight and body mass index (BMI) can occur very quickly when clients take olanzapine (Zyprexa). Baseline data about these should be obtained before the client begins to take this drug. Determining the client’s sleep pattern (option 1) is not an urgent consideration, although the nurse should recognize that daytime somnolence might be an early side effect of the olanzapine (Zyprexa). Food and fluid preferences (option 2) are important considerations when the nurse teaches the client about usual side effects, but this can be done later. While some clients do have digestive disturbances (option 4) while taking olanzapine (Zyprexa), this is not nearly as common as the side effect of rapid weight gain.
Thought insertion is a thought disorder of schizophrenia that is defined as the client believing that others are putting thoughts in his or her mind against the client’s will. Thought broadcasting (option 1) is the belief by a client that he or she can broadcast his or her thoughts to others. Thought blocking (option 2) occurs when a client’s thoughts stop in midstream. Thought control (option 4) is the belief that others can control one’s thoughts against his or her will.
Persons with dementia may exhibit confabulation, in which they fill in a memory gap with a detailed fantasy that they believe. This process allows preservation of self-esteem. Option 1 is incorrect as perseveration consists of repetitive behaviors such as lip licking, finger tapping, pacing, or echolalia. Option 2 is incorrect because agnosia is an inability to recognize familiar situations, people, or stimuli. Option 4 is incorrect as hyperorality is the need to taste, chew, and examine any object small enough to be placed in the mouth.
If the delirious client is very agitated or restless, physical restraints may be necessary to keep tubes and lines intact and functioning. The restraint should be used only if absolutely necessary and the disoriented client should never be restrained and left alone. Clients who are restrained can be expected to resist the restraints. Family members are likely to be alarmed and fearful about the safety of their family member. The nurse’s response to the family should be sensitive to that. Option 1 is incorrect as the nurse should not have to wait for the physician to explain the purposes of the restraints. At the time that the family expresses concern, the nurse should give compassionate and accurate information to the family. Option 2 is incorrect because, although it begins in an appropriate way by attempting to show empathy, the second part of the statement is inaccurate. Delirious clients who are restrained, like other restrained individuals, are generally aware of and resistive to the restraints. Option 3 is incorrect as this option begins by trying to respond to the feelings of the family, but it ends with a poor attempt at reassurance, which will not comfort the family at all.
Clients in stage 3 of Alzheimer’s disease experience severe impairments usually requiring total dependent care. The client is often incontinent and mobility is severely impaired. As the disease progresses, a more realistic goal for these clients is that they remain clean and dry. Option 1 is incorrect as the client in stage 1 dementia might be able to meet this outcome with assistance. However, in stage 2, behavior deteriorates markedly and the client begins needing assistance with ADLs. When stage 3 is reached, total care becomes necessary. Option 2 is incorrect because in stage 3 dementia, the client is confused and easily overwhelmed by unfamiliar situations and persons. He or she may become unable to identify even very familiar persons, such as a spouse. The client is also prone to wandering, so attending therapeutic outings would present a safety issue for the client. Option 4 is incorrect as the client in stage 3 dementia easily becomes agitated and even violent. He or she has poor impulse control and is prone to behavioral outbursts. Nurses and other staff members should make every effort to manage these situations and to keep anxiety at a manageable level, but maintenance of physiologic functioning is the priority.
The client may not have the ability to read posted signs or the verbal ability to ask for help. An appropriate nursing intervention is one that will directly assist with orientation, thereby reducing confusion that may indirectly lead to wandering that can compromise the client’s safety. Wandering may be an attempt to avoid stress and tension in the environment. Sensor devices can provide a warning if the confused client wanders through an outside door. Within a safe environment wandering can be beneficial, as it promotes exercise and stimulates oxygenation and circulation. Option 1 is incorrect as wandering behaviors usually begin in stage 3 dementia. At that point, the client will not be able to remember information such as addresses and phone numbers. Option 2 is incorrect because by the time dementia has progressed sufficiently to cause wandering, the client will have lost the cognitive skills for reading and understanding a map. Option 5 is incorrect as, due to significant cognitive impairment, the client will not be able to verbalize an explanation of reasons for wandering.
By the third postoperative day, the suture lines from the teeth extraction should be beginning to heal, and the client should be able to manage soft foods. With this in mind, option 2 provides the client with carbohydrates and a protein source for healing in a soft form. Options 1 and 3 contain items (bacon and cereal, respectively) that could be scratchy and irritate the suture lines. Option 4 would be appropriate the day after surgery while the suture lines are still new.
Families of clients in the early stages of DAT may need assistance in providing 24-hour care for clients. If families are not available during the day, adult daycare centers are available in some communities. Options 1 and 3 are incorrect as skilled nursing facilities and hospitalization are options usually reserved for clients with more advanced stages of DAT. Option 4 is incorrect because the laws providing for involuntary treatment of clients in hospital settings require that the client’s behavior be clearly and immediately dangerous to self or others and gravely disabled. The client in stage 1 dementia would not meet these criteria.
Withdrawal delirium symptoms develop after reduction or termination of sustained, high-dose use of certain substances such as alcohol. Due to forced abstinence during hospitalization, clients with chronic alcoholism may experience withdrawal symptoms 2 to 3 days following their admission. Alcohol withdrawal delirium is considered a medical emergency and can result in death even if treated. When the nurse knows that the client has an established history of alcohol use, the nurse should be alert for earlier signs of alcohol withdrawal such as hyperalertness, subjective distress described as “shaking inside,” and heightened anxiety. These are among the many manifestations of alcohol withdrawal that the nurse should report promptly to the physician. If alcohol withdrawal is properly treated, the client is not expected to progress to the more dangerous situation of alcohol withdrawal delirium. Alcohol withdrawal symptoms may begin as early as a few hours after the last intake of alcohol cessation or reduction of intake of alcohol and can progress to alcohol withdrawal delirium, which will usually peak 48-72 hours later. Options 1, 2, and 4 are incorrect as these conditions are usually associated with a sustained long-term pattern of heavy drinking of alcohol.
Option 1 is incorrect because, while it is true that clients experiencing alcohol withdrawal delirium are disoriented and confused, reality orientation is secondary to interventions to preserve life and physiologic functioning. Option 2 is incorrect as restraints should not be applied routinely when clients are delirious. Other safety measures should be attempted first, and restraints should be used only to provide safety and allow physiologic, life-preserving actions. Application of restraints generally leads to increased agitation and physically resistive behaviors. Option 3 is incorrect because referral to Alcoholics Anonymous is an appropriate later intervention. The client who is in alcohol withdrawal delirium is at grave physiologic risk, and the priority interventions are those designed to preserve life.
Elderly clients have slower metabolism and elimination of drugs causing an increased susceptibility to side effects. Haloperidol is a first-generation, high-potency antipsychotic that frequently causes extrapyramidal side effects (EPS), either of an acute or a chronic nature. In younger clients, EPS are more likely to be acute, but elderly clients may be more at risk for tardive dyskinesia (TD), which is generally irreversible. Option 2 is incorrect as constipation is a common side effect of antipsychotic drugs. Unmanaged constipation can lead to fecal impactions, especially in the elderly. However, these are considered preventable or treatable problems, while tardive dyskinesia is irreversible. Option 3 is incorrect because pseudoparkinsonian side effects are one of the extrapyramidal side effects associated with antipsychotics, especially traditional ones like haloperidol. They are generally reversible and treatable. While not as likely as tardive dyskinesia in the older client, acute extrapyramidal side effects (EPS) can occur. Option 4 is incorrect because, as one of the more potent of the first-generation antipsychotics, haloperidol is not likely to cause sedation as a side effect.
Initially, the delirious client is dazed and drowsy with disturbed perceptions and difficulty sustaining attention. Further, the client is expected to experience alternating periods of disorientation, confusion, and lucidity. These symptoms place the client at risk for injury, so an absence of them indicates that the client’s safety is less threatened. Options 1, 2, and 4 are incorrect as these outcomes could be appropriate at a later time after the client has been stabilized physically. Drug overdose and delirium place the client at significant medical and physical risk, and the priority at this time is to preserve physiologic functioning and reduce risk for injury.
This statement addresses the client by name and gives a simple statement indicating why the nurse is at the client’s bedside. This is important because when the client has dementia, addressing the person by name can help the client to focus on the speaker and retain personal identity. The nurse should also speak in a low, warm, respectful voice and identify self to the client by name. Option 1 is incorrect as this statement addresses the client by name, but it asks the client to make a decision (a difficult task for a person with dementia) and uses an unusual term (“your sleeping accessories”), which the client may have difficulty understanding. Option 3 is incorrect because this option inappropriately tests the client’s memory and fails to give the client information about the purpose of the nurse being at the bedside. Option 4 is incorrect as this option addresses the client by name, but fails to be simple, direct, and informative.
This response uses a method of reality orientation that increases self-worth and personal dignity. It also allows client reminiscence, which is useful to persons with dementia as their remote memories are more intact than recent ones. In option 1, the nurse is attempting to present reality, but in a nontherapeutic manner. The statement is made in a demeaning and belittling manner. The nurse should present reality and provide orienting stimuli in a manner that preserves the client’s self-esteem. In option 2, the response of the nurse promotes further disorganization in thinking and orientation in this client with dementia. The client’s statement in option 3 indicates disorientation and disorganized thinking that is very common in persons with dementia. There is nothing to suggest that this behavior requires a prn medication (such as aggression toward others) is present.
Clients with early dementia should be allowed to provide their own ADLs as independently as possible for as long as possible. They will need extra time to perform tasks. It is premature to provide ADLs to the client with early dementia (option 1). This will likely be necessary at a later stage of the illness. Having the client develop a written schedule for ADLs (option 2) may be overwhelming to the client and increase confusion and uncooperativeness. Giving the client an ultimatum about the time in which ADLs must be completed (option 4) may be overwhelming and therefore increase confusion and/or uncooperativeness.
Client safety and security are nursing priorities for clients with the disorientation, confusion, and memory deficits seen in dementia. Option 1 is stated illogically. Dietary choices will not stimulate appetite. Additionally, recall that clients with dementia should not be expected to make choices, as this can overwhelm them. Client safety and security are nursing priorities for clients with dementia rather than social isolation (option 2) or low self-esteem or anxiety (option 3).
The highest priority is given to nursing interventions that will maintain life; therefore, basic physiological needs must be addressed initially with baseline vital signs. Checking the level of orientation (option 2) is important but does not provide any new information to the nurse. Nutrition and fluid balance (option 3) may be maintained by IV therapy once vital signs are evaluated and a physician’s order is obtained. Sedative medications (option 4) may complicate an attempt to identify the original cause of the client’s symptoms.
Problems with vision may be attributed to vitamin deficiency, especially Vitamin A. This finding could adversely affect the client’s health status and requires follow-up by the nurse. Options 1 and 2 will not adversely affect health status. Option 3 has a lesser chance of adversely affecting health status, since it is a familial risk and not a personally identified problem.
The client is experiencing tactile hallucinations. The most appropriate response is option 3, which orients the client to the reality of being sick and reassures the client of safety. By making statements that essentially agree that the bugs exist (options 1, 2, and 4), the nurse is communicating that the hallucinated objects are real. This could make the client feel even more frightened.
Catastrophic reaction is the human response of overreacting to minor stresses that often occurs in demented clients. Pseudodementia (a medical diagnosis) is a reversible disorder that mimics dementia (option 1). Pseudodelirium (a medical diagnosis) is characterized by symptoms of delirium without any identifiable organic cause (option 2). Clients with dementia rather than delirium also often experience extreme agitation at the end of the day (option 4), probably as a result of tiredness and fewer orienting stimuli such as planned activities and contact with people. This human response of restless and agitated behavior worsens at night and is commonly referred to as sundown syndrome.
Recent memory loss is a common problem found in dementia; therefore, the client may be frustrated when constantly confronted with evidence of failing memory. Pictures of family members can encourage a discussion of remote memories that will help the client feel less anxious while promoting a sense of pleasure from discussing past experiences. Options 2, 3, and 4 rely on recall of recent memories rather than remote memories and can cause increased anxiety and confusion.
When working with a confused client, the most effective nursing action is simple, direct, and unambiguous. This option assigns responsibility to the nurse and specifies the frequency of the nursing intervention. The nurse should vary the type of fluid offered and limit the number of choices for the client to make, since making choices can be confusing to the client. The nurse should not assume that the client will drink water placed at the bedside (option 1). The nurse should actively offer the water to the client at regular planned intervals. Option 3 does not show a planned sequence for offering fluids. The term <i>frequently</i> does not have universal meaning. Further, no one person has responsibility to offer the fluids. Option 4 is incorrect because it removes the responsibility from the nurse to the family. It also does not specify a time period for offering the fluids. The family’s presence may be helpful to both the nurse and the client, but the responsibility for increasing hydration should remain with the nurse.
A Mini-Mental State Examination score of less than 20 usually indicates the presence of dementia or delirium and requires further investigation. When responding verbally to the client, it is important that the nurse use simple words, rather than medical terms. The Mini-Mental State Examination does not measure education, bipolar disorder, or self-esteem (options 1, 2, or 4). These components are investigated in a Mental Status Examination.
In every instance, physiologic and safety needs take precedence over psychological needs. Therefore, of the options given, assuring adequate hydration is the highest priority. If hydration is not maintained, the delirium will intensify, and the client will become at risk for various physiologic complications, ultimately even death. Anxiety and fear (option 1) are common experiences when the client is delirious. When present, they complicate management of delirium. However, these are psychological experiences and have lesser priority than basic physiologic or safety needs, such as hydration. Turning and repositioning the postoperative client (option 3) is very important to prevent future problems, but this physical measure is not a basic requirement for maintaining life. Maintaining adequate hydration is critical to continuation of life and therefore takes priority. The client who is delirious is generally disoriented, and the nurse should make frequent attempts to reorient the client (option 4). However, providing basic safety and maintaining basic physiologic needs are always of highest priority.
This question describes a symptom called hyperorality, which is common in stage 2 of Alzheimer’s disease. Clients experiencing this symptom have a need to place objects in the mouth so they can taste or chew them. They cannot discriminate between hazardous and nonhazardous items. Hyperactivity (option 1) is a behavior characterized by decreased attention span, increased impulsivity, and emotional liability. Hyperetamorphosis (option 2) is the need to compulsively touch and examine every object in the environment. Hyperphagia (option 4) occurs when the individual eats, or ingests, excessive amounts of food.
Because the physical consequences of alcohol withdrawal can be lethal, they therefore take precedence over any psychological considerations. The client in a delirious state associated with alcohol withdrawal typically varies between hyperalertness and underreactivity to the environment (option 1). Such fluctuations are unpredictable and can occur very rapidly. Presenting signs and symptoms of delirium caused by withdrawal from alcohol also include hyperactive behaviors such as restlessness and irritability (option 4). When coupled with unpredictable changes in level of awareness and impaired judgment, these symptoms place the client at risk for injury. Clients in active withdrawal, including withdrawal from alcohol, are at high risk for having seizures (option 5). One reason for using benzodiazepines as the cross-tolerant agents for medically supervised withdrawal is that most of them have anticonvulsant effects. The nurse should recognize that the physical consequences of alcohol withdrawal can be lethal and therefore take precedence over any psychological considerations, including self-esteem enhancement (option 2) or coping (option 3).
Wandering behavior poses a potential risk for injury or trauma because clients experiencing dementia get lost easily and are unable to retrace their steps back home. Although the nursing diagnoses in options 1, 2, and 3 apply, maintaining the safety of these clients is of utmost importance.
It is most important for the nurse to recognize that this spouse, like others providing care to persons with DAT, is at high risk for caregiver role strain. Having to provide constant care to a person with declining cognitive and physical capacity can exhaust and overwhelm the caregiver. The nurse should not assume that the spouse’s spiritual belief system (option 1) includes worship in a church. The nurse should determine the spouse’s belief system before making any recommendation for spiritual support. Reminiscence therapy (option 3) is more likely to be useful to the client in early stages of dementia. While it may be useful to the spouse as part of anticipatory grieving, it is most important to recognize the high risk for caregiver role strain. While a predictable daily routine (option 4) is generally helpful to the spouse, it is most necessary for the client.
The older adult client has more years of living to increase risk of skin cancer from exposure to the sun. In addition, the farmer wears a cap, but no mention is made of protectant sunscreens or long-sleeved shirts and pants. The clients in options 2, 3, and 4 have lesser risk because there are physical barriers to the sun identified in each option: sunscreen, umbrella, and ski outfit.
Clients experiencing acute episodes of delirium will have periods of lucidity and will regain full orientation when the underlying cause of the delirium is identified and treated. Suicidal ideation (option 2) may be seen with dementia but is not usually associated with delirium. When the client is delirious, injury is more likely to be the result of impulsive, nonintentional acts. Low self-esteem (option 3) and tactile agnosia (option 4) are commonly seen with dementia but are not usually associated with delirium.
When the nurse is attempting to increase the level of orientation of the client with dementia, nonverbal stimuli may be more effective than verbal stimuli. It is important that the decorations be traditional, as the client is more likely to have intact remote memory that allows for recognition of objects from the distant past. The nurse should not assume that the client with dementia has a hearing deficit (option 1); what is present is a cognitive deficit. When telling the client the day of month and time, it will be more important for the nurse to speak simply and to repeat reorienting stimuli frequently. Except in emergency situations where client safety is compromised, the nurse should avoid giving the client with dementia untruthful or nonrealistic information (option 2). Instead of reorienting the client, the news station (option 3) would likely increase the client’s disorientation, because the client would not be able to process the events in a normal cognitive manner. Additionally, the constant stimulation would probably be overtaxing to the client.
Donepezil (Aricept) is a cholinesterase inhibitor that appears to slow down cognitive deterioration in individuals with mild to moderate dementia. When the activity of cholinesterase is inhibited, the amount of acetylcholine in the synapse is increased. Options 1, 2, and 3 all indicate medications that may be prescribed for clients with dementia, but none of these medications is known to directly bring about improved cognitive function.
Short-term memory loss is a sign of depression in the older adult that can be caused by a deficit of serotonin in the brain. Paroxetine (Paxil) blocks the reuptake of serotonin resulting in elevated levels of serotonin in the brain. Also, the nurse should keep the communication as simple as possible because the listeners may not know or understand human anatomy or commonly used medical expressions. Options 1, 2, and 4 convey inaccurate information about the effects of paroxetine (Paxil).
Spending nonstressful time with the client helps diminish feelings of resentment, isolation, and alienation in the caregiver. Since remote memories are less diminished than recent memories, there is also the possibility that it will increase the client’s self-esteem by allowing reminiscence of past pleasurable life events. Because safety of the client is an urgent consideration, close supervision of the client should be provided at all times. However, if one caregiver remains with the client 24 hours a day, that person is at high risk for developing caregiver role strain with feelings of resentment, isolation, and alienation (option 1). Regular periods of respite are necessary to help prevent this occurrence in caregivers. While assistance to personal hygiene and establishing a routine are important when providing care to the person with dementia (option 2), there is no prescribed time that personal hygiene should occur. Because safety of the client is an urgent consideration, close supervision of the client should be provided at all times. However, regular periods of respite are necessary for caregivers (option 3).
DSM-IV-TR specifies that substance dependency can be diagnosed if the behaviors of the client over the past 1-year period are consistent with three or more of seven specific criteria. This option describes one of the criteria. Option 3 is incorrect as this option is not included among the DSM-IV-TR criteria. These criteria recognize that alcohol dependency can follow many different patterns, including episodic drinking to excess. The only time frame mentioned in the criteria is 1 year, and this is because persistent patterns of use are necessary to establish the diagnosis of alcohol dependency. Option 5 is incorrect because this option is not included among the DSM-IV-TR criteria. Also, confabulation is not considered one of the characteristic defense mechanisms of the alcohol-dependent individual. These are denial, rationalization, and projection.
Option 3 is correct. For the client who is dually diagnosed with alcohol dependency and another psychiatric-mental health problem, he or she must receive treatment for both illnesses in order to have the optimal chance of recovering. Options 1, 2, and 4 are incorrect because treatment of only one of the disorders is incomplete and can lead to relapse.
Options 1, 2, and 4 are correct. The substance-dependent client must recognize that relapse is common among substance abusers. Clients need to be taught how to prevent relapse so that they can gain confidence and the expectation of being able to cope without using a substance. It can be useful for the client to learn to apply the HALT mnemonic, which teaches avoidance of situations that are known to promote relapse. These include being: Hungry, Angry, Lonely, and Tired. Other relapse prevention skills include involvement in an active recovery program, often a 12-step program that considers recovery to be a lifelong process that is best accomplished with the support of peers with the same addiction. Option 3 is incorrect as treatment programs emphasize the need to be open and honest about having urges to return to use of the substance. Suppressing feelings is considered to be an addictive behavior. Option 5 is incorrect because the recent social network of the client is most likely to be that of a group of substance users. Relapse prevention skills include developing a new social network of persons who will support efforts toward sobriety.
Substance-dependence clients should be taught to have structure and routine in their lives, as well as to avoid boredom and loneliness. Option 3 suggests that the client feels overly confident, which can lead to unwise behaviors that test the recovery. Option 4 indicates dissatisfaction and impatience with others and can lead the client to feel justified in returning to the “solace” of using a substance. Option 5 indicates that the client is putting self into a situation of high risk to return to alcohol use. Also, the client is showing complacency rather than cautiousness. Option 2 is incorrect as this statement indicates that the client has an awareness of a high-risk situation that could lead to relapse. After developing the awareness, the client can then make a conscious decision as to how to cope with the situation without using a substance.
Most substance use treatment programs encourage clients to acknowledge that they are unable to maintain sobriety of their own accord. Accepting the need for help and asking for it are fundamental to the recovery process. Most 12-step programs teach the concepts of powerlessness, surrender, acceptance, and asking for help as primary to recovery from the disease. Options 1, 2, and 3 are incorrect as dealing with existential issues such as “who am I,” feelings of loss, and anger are important parts of the recovery process, but this question is specifically asking for a response regarding independence issues.
Ultraviolet light exposure greatly increases risk of skin cancer, both basal cell and melanoma types. While direct sunshine contains ultraviolet light, the amount is decreased in indirect light. The use of suncreen can reduce the risk of cancer but not “prevent” it. Option 4 is a global statement that may or may not be true depending on the disinfectant methods used.
In the contemplation stage of change the client is becoming aware of a problem but has not yet become motivated to change. Option 1 is incorrect as this reflects the preparation-determination stage of change in which the client is getting ready for a change and developing a plan to seek help. Option 3 is incorrect because stopping the gambling behavior is the action stage of change. Option 4 is incorrect as continuing the behavior of the action stage of change occurs in the maintenance stage of change, which, optimally, is a lifelong pattern.
When clients are of childbearing age, it is essential that evaluation for pregnancy occurs before active psychopharmacologic interventions are begun. This is so that substances known to be dangerous to unborn children (which includes many antidepressants) will not be given to the client. If the client is pregnant, prenatal exposure to alcohol has already occurred and the client is already at risk for delivering a child with one or more alcohol-related birth defects, including fetal alcohol syndrome. Of all substances commonly used or abused, alcohol carries the greatest risk for unborn babies. Option 1 is incorrect because, while it is true that vitamin administration is an important part of treating both pregnant women and alcohol-dependent persons, this is not as important a priority as is protecting a developing fetus from further exposure to dangerous chemicals. Option 2 is incorrect as this information is useful to evaluate the client’s overall health, but this test only assumes urgent importance if the client has significant health problems or is to begin a drug that is known to cause hematologic changes. Option 3 is incorrect because, while recording of height and weight does provide baseline data for further treatment of the pregnant and/or alcohol-dependent client, many medications can be safely begun without this data.
When the client is addicted, common elements in cognitive restructuring include making a commitment to choosing sobriety; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. Option 1 is incorrect as this response indicates that the client is projecting blame and rationalizing the drinking behavior by blaming outside circumstances. When the client is addicted, common elements in cognitive restructuring include making a commitment to choosing sobriety; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. Option 2 is incorrect because this statement indicates that the client is continuing to blame others. Additionally, it exhibits self-pity and high expectations of the behavior of others, both of which indicate relapse vulnerability. The client who makes this statement is maintaining, not changing, personal cognition. Option 3 is incorrect as this statement indicates that the client is feeling overly confident and grandiose, both of which indicate relapse vulnerability. The client who makes this statement is maintaining, not changing, personal cognition.
The definition for spiritual distress is disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biological and psychosocial nature. The lifestyle change that is necessary to recover pervades a person’s entire being and it helps explain why someone would be angry about having to make such a great change in him- or herself. Option 1 is incorrect as Ineffective denial is a disavowing of the meaning of something. This is not reflected in the client’s current status. Option 2 is incorrect because Ineffective management of therapeutic regime suggests that one is not managing the recovery process well, which is not reflected in the client’s current status. Option 3 is incorrect as Knowledge deficit suggests a lack of knowledge about the disease, also not reflected in the client’s current status.
If clients call someone when feeling depressed they are demonstrating they have learned how to use support. Reaching out to others for sobriety and interpersonal support is key to maintaining recovery from depression and addiction. Option 1 is incorrect as in recovery programs that utilize a sponsor, the sponsor’s role is to provide social and personal support, not financial support. Option 2 is incorrect because this statement indicates that the client has not accepted the importance of social support in a recovery program. Individuals who try to “go it alone” are at high risk for relapse. Option 4 is incorrect as this statement indicates an awareness of areas of commonality between the client and others, but it does not indicate that the client knows how to utilize the social network.
Alcoholism was officially listed as a disease in 1956, and Jellinek’s identification of the four phases of disease progression in 1960 reinforced the disease concept (option 2). Addiction includes behavioral habits and emotional attachment, but it is seen first as a medical disease (options 3 and 4). Although alcoholism has been recognized as a disease for approximately 50 years, many members of the general public continue to view addiction as a moral weakness (option 1). Addiction experts do not consider that addiction can be cured (option 5). Instead, they consider it a chronic medical disease that can be managed.
Taking a drink in the morning to steady one’s nerves is a sign of physical dependence and is done to avoid withdrawal symptoms. Tremors are one of the ten symptoms of alcohol withdrawal listed in the Clinical Institute Withdrawal Assessment of alcohol symptoms. People with anxiety may have tremors, but the tremors would occur throughout the day (option 1). Tolerance is not indicated because the client does not describe needing to have a larger drink in order to prevent symptoms (option 2). This client has clearly progressed from alcohol abuse to alcohol dependency (option 4).
At a blood level of 0.35%, the non-physically dependent, non-tolerant drinker would be confused, ataxic, and either semi-comatose or comatose. Death is expected when the BAL reaches approximately 0.50%. The situation suggests that this client has been drinking regularly over a long period of time and is now experiencing tolerance to alcohol (needing an increasing amount of alcohol to bring about the desired effect). Tolerance can only develop once the person is physically dependent on alcohol (option 2). This client is not acutely intoxicated, even though the BAL exceeds the normal level for intoxication (0.08% to 0.10%). This client’s body now accepts unusually high concentrations of alcohol (tolerance) and has adapted to the presence of the alcohol (physical dependence) (option 4). There is no evidence of withdrawal symptoms (option 1), such as anxiety, tremulousness, and marked elevations in vital signs. No information is given that would allow recognition of psychological dependence (option 3), which can come very early in the drinking history and precede physical dependence and tolerance.
Cravings appear to be the result of pleasurable memories engendered from the psycho-activating effect of engaging in addictive behaviors. Substances of abuse alter the brain’s reward system by artificially boosting dopamine effects, which keeps the pleasure circuit firing. In option 1, it’s true that environment and role models influence use patterns, but this is not part of the BRS phenomenon. In option 2, it is true that people employ addictive behaviors to self-medicate stress and pressure experienced, but this is not part of the BRS phenomenon. Option 3 indicates that the BRS is a positive phenomenon that assists with drug abstinence. Instead, the BRS is a negative phenomenon that assists with maintaining or returning to the substance use pattern.
Medically supervised withdrawal from benzodiazepines generally involves gradual downward titration of doses of the drug commonly used (option 3). Rapid or abrupt discontinuation of a benzodiazepine is physiologically dangerous and can lead to death (options 1 and 2). Option 4 is incorrect because most antipsychotics lower the seizure threshold and are therefore not appropriate for clients in active benzodiazepine withdrawal because they would increase the risk of seizure activity.
The priority for this client is to learn and begin to perform testicular self-exam on a monthly basis. Option 1 is insufficient in timeframe, and a physician does not need to perform the screening. Options 3 and 4 are positive but general measures and do not target the immediate need of the client for information related to detecting testicular cancer.
Alcohol withdrawal delirium (delirium tremens or DTs) is a physiologically dangerous process with potentially fatal consequences. Various medical approaches are used to treat it, and the nurse’s care must fit into the protocol of the particular agency. Priority is assigned to the client’s physical needs during this major withdrawal phenomenon. Beginning education about the disease (option 1) and encouraging development of a relapse prevention plan (option 2) are not appropriate at this time because the client is in physiologic peril. These options can be appropriate after the withdrawal period has ended. Administering anticraving medications (option 3) is not the highest current priority, as the client is actively withdrawing from alcohol and can be at risk physiologically.
The nurse should recognize possible signs of autonomic hyperactivity that is a part of alcohol withdrawal delirium. If the vital signs (also a part of autonomic hyperactivity) are elevated, the client will require a prn dose of the cross-tolerant drug that is being used as part of the withdrawal protocol. Because the client is in active withdrawal, this is not the time to teach the client (option 1). The priority is on maintaining physiologic functioning and environmental safety. Thiamine and folic acid may be ordered for the client who is withdrawing from alcohol, but they are used to treat complications of alcoholism, not to manage the acute symptoms of withdrawal (option 2). This can only be done with a drug that is cross-tolerant with alcohol. Option 3 is inappropriate, as it would not provide current data. The nurse should be able to recognize and respond to the clinical signs of increasing intensity of withdrawal symptoms.
Naltrexone (ReVia) is a narcotic antagonist that is useful for treating alcohol-dependent persons with high levels of craving and somatic symptoms. It works by blocking opiate receptors and reducing or eliminating the alcohol craving. Naltrexone does not prevent withdrawal symptoms (option 1). Since it is a narcotic antagonist, and narcotics and alcohol are both CNS depressants, it is possible that naltrexone (ReVia) could precipitate withdrawal symptoms in an individual who has had recent intake of alcohol. Naltrexone (ReVia) is not expected to prevent or reduce alcoholic blackouts (option 2) or to directly manage anxiety (option 4).
The quality of an adolescent’s recovery environment can be helpful or hurtful to someone attempting to maintain sobriety. Friends or acquaintances may encourage a recovering person to use. The recovering adolescent may want to refuse, but may not know how. Behavioral rehearsal, saying “no thanks” to an offer to engage in addictive behavior, can increase a recovering person’s confidence. Vocational skills (option 1) will not help the adolescent to refuse a drink. Problem-solving skills (option 3) and communication skills (option 4) may be useful but not as helpful as skills directly related to refusing to drink.
The definition of decisional conflict is uncertainty about a course of action to be taken when choice among competing actions involves risk, loss, or challenge to personal life values. Option 1, dysfunctional family processes: alcoholism, may apply, but it is more appropriate for the family than the individual. Ineffective management of therapeutic regimen (option 2) implies that the client has already made a commitment to recovery. Since the client probably abuses or is dependent on alcohol, risk for injury (option 3) may be present. However, what is shown in the stem of the question is behavior that indicates decisional conflict.
The key symptom of addiction is impaired control, or the inability to control, or regulate, one’s addictive behavior. In addition to loss of control, the addicted person is not able to view the addictive behaviors realistically (option 4) and frequently uses the defense mechanisms of denial, rationalization, and projection. While persons with addiction do not change their behavior because of negative consequences suffered (option 2), it is not that they do not recognize the consequences. Rather, they continue the addictive behavior in spite of consequences experienced. Acting sober when intoxicated (option 3) is an addictive behavior.
The “G” in the CAGE mnemonic represents guilt, not gulping drinks. Option 1 indicates the “C:” cutting down or reducing alcohol. Option 2 represents the “A,” being annoyed at what others say about the drinking. Option 4 represents the “E,” having an early morning drink to open the eyes and calm the nerves.
Option 2 presents reality to the client in a matter-of-fact, informative way and creates an opportunity for the nurse to help the client see that the parent–child relationship has no doubt been impacted by the addiction. Option 1 uses a judgmental and demeaning term, <i>a drunk</i>, although the information it is conveying is accurate. Option 3 offers approval or praise and allows the client to feel like a protective and good parent, instead of a parent whose behavior has impacted negatively on the son. Option 4 removes the personal focus that is necessary to help the addicted parent recognize the impact of the addiction on the son.
The most significant risk factors that lead nurses to abuse drugs and become drug dependent are: (1) exposure to substances, (2) knowledge about specific effects of certain drugs, and (3) belief that knowledge about drugs will allow them to use drugs and alcohol safely. Some nurses have grown up in a dysfunctional family (option 1), but this does not put them at more risk than those in the general public who have similar backgrounds. Most nurses know that health care providers and professionals are at a high risk for drug dependency, but they deny that this could happen to them, as they feel protected by their knowledge about drugs (options 2 and 3). Some nurses may have problems with codependency (option 4), but this does not put them at more risk than those in the general public who have similar problems.
It would not be unusual for a client who has severe addiction to come to day treatment intoxicated and deny it. Denial would cause a client to insist he or she is not intoxicated or doesn’t have a problem with alcoholism despite concrete evidence of the problem. Rationalization (option 2) is a frequently used defense mechanism of the alcoholic individual, but if it were being used, the client would offer an explanation for the odor of alcohol (such as “I spilled a bottle of cologne as I was getting dressed.”). Transference is the unconscious process of displacing feelings for significant people in the past onto the nurse in the present relationship (option 3). Countertransference (option 4) is the nurse’s emotional reaction to clients based on feelings for significant people in the nurse’s past.
Two common and key factors that increase risk of constipation are a diet that is low in fiber and fluids and inadequate exercise to stimulate bowel motility, which could lead to impaction and abdominal pain. Option 1 is partially correct; diverticulitis is something to assess for but is not as frequently an etiology as inadequate exercise and low-fiber diet. In addition, diverticulosis does not give rise to signs and symptoms. Upon diagnostic workup, the client’s symptoms could be attributed to diverticulitis, but this is not as frequently found as constipation as an etiology. Options 3 and 4 are general assessments that are either irrelevant to the client’s complaint (option 3) or too vague to be correct for this question (option 4).
Option 4 indicates one of the areas of the CAGE questionnaire that deals with expressed concern from others about the client’s drinking. Options 1, 2, and 3 would support the client’s belief that others are against her or have no right to be concerned about her. Specifically, each option would support the client’s denial, projection, or rationalization.
This client will likely be dually diagnosed with alcoholism and depression. The nurse should recognize that current standards of addiction practice call for the substance use disorder and the psychiatric disorder to be treated simultaneously. Options 1, 2, and 4 do not recognize this.
AA teaches that a client with alcoholism can never safely return to social drinking and that total abstinence is the only course in treating the addiction. When sobriety has been achieved, people don’t “graduate” (option 1); they stay and help others achieve sobriety. Acceptance and Higher Power (options 3 and 4) are active concepts in AA, but practicing these principles does not remove urges to drink and does not guarantee sobriety.
Alcohol use during pregnancy causes dysmorphic prenatal and postnatal difficulties and central nervous system dysfunction. These problems range from subtle cognitive-behavioral impairments to fetal alcohol syndrome, both of which predispose the infant to later academic and behavioral problems, as well as mental illness. Since alcohol is so widely used, many people do not recognize its dangers, as they either do not consider it a drug or think that it is a safe drug. Options 1, 2, and 4 indicate substances that can cause significant health problems for the infant, but these problems are not as pervasive as those associated with the mother’s using alcohol during pregnancy.
The adverse reaction of disulfiram (Antabuse) will occur if the person taking this drug ingests, inhales, or absorbs alcohol, even in very small doses (such as inhaling vapors from paints or wood stains, or oral ingestion in products such as mouthwash). These reactions include throbbing headache, tachycardia, diaphoresis, and respiratory distress. Death can occur. This drug is not used often, but the nurse should know about its uses and dangers. While eating improperly cooked seafood (option 2) might lead to gastric distress and/or liver problems, uncooked seafood does not precipitate a disulfiram reaction. Disulfiram does not reduce the craving for alcohol (option 3), but opioid antagonists, such as naltrexone (ReVia) do. Disulfiram works on the classical principle of conditioned avoidance. If the individual drinks alcohol while taking disulfiram, intensely unpleasant and dangerous physical reactions can occur. The effect of disulfiram (Antabuse) when combined with alcohol is not intoxication (option 4). Instead, the individual experiences intensely unpleasant and dangerous physical reactions.
This question is asking for the nurse to recognize that availability of social support, one of the balancing factors that determine whether one will enter into a crisis state, is absent. Balancing factors include how the person perceives the event, past experience in coping, available coping mechanisms, and availability of people who can be supportive. There is no indication that the client is misperceiving the event (option 1). Option 2 indicates a normal or expected response to an unexpected loss. While the nurse will observe the present state of confusion and shock in monitoring the client, this factor does not address why the client is in a crisis state at this time. Going to the crisis clinic for assistance (option 4) indicates that the client is making a serious attempt at coping. The client is feeling overwhelmed and does not have access to the normal support system.
Crisis intervention assists a client in resolving an immediate problem that the client perceives as overwhelming. Issues from early life experiences and the client’s personality (option 1) are not dealt with during crisis intervention. Crisis intervention focuses on the immediate situation and presenting problem. Other issues, such as personality and early life experiences are dealt with in other therapy modalities and would not be addressed until the presenting crisis is resolved. In early crisis intervention, rather than teaching the client to develop new coping techniques (option 3), the client is encouraged to use previously successful coping skills. The emphasis of crisis intervention is on strengths and coping skills of the individual, not on personal limitations (option 4).
It is natural for clients in crisis to feel isolated and withdrawn. Clients frequently need help communicating with others directly, especially if they place a high value on independence. Role modeling by the nurse helps the client to learn this skill. Option 2 (being resistant to verbal suggestions) is in opposition to a common characteristic of the client in crisis, which is openness to suggestions. Option 3 (being hesitant) is also in opposition to a common characteristic of the client in crisis: readiness to depend on others for assistance with decision making. Most clients in crisis are not guarded (option 4); instead, they give free and direct expression to their feelings of anxiety. Severe and panic levels of anxiety are common to crisis states.
The focus of crisis intervention is on the present, not the past. Particular attention is given to allowing ventilation of current feelings, helping the client with coping mechanisms, and identifying social supports. The focus of the nurse should be on the client, not the family (option 1). The nurse should keep the client focused and provide direction to avoid fragmentation of the client’s efforts. Sending the client to a chapel (option 2) is not appropriate. The client’s behavior and the circumstances require that the nurse respond directly to the client. The client needs to ventilate feelings in order to begin to feel less anxious. Nonpharmacological strategies should be attempted prior to pharmacological strategies (option 4).
The nurse should recognize that ideas of self-harm are very common in situations of this type. While some clients will not introduce thoughts of self-harm, they will usually talk about suicidal thoughts when asked. The nurse should ask if the client has a plan and the means for suicide. Safety is the priority, and suicidal clients should not be left alone. Altered thought process (option 2), availability of social support (option 3), and ability to afford medication (option 4) are important monitoring areas after the client’s safety has been ensured.
It is not normal to have one testicle that does not remain descended into the scrotal sac. The client needs to see a primary care provider for this health problem. Each of the other statements related to testicular self-exam (TSE) are true.
The nurse should recognize that all of the behaviors cited in the stem of the question could result in loss of life. They are therefore considered indicators of indirect self-destructive behavior. There is no indication of a loss that would have precipitated grieving (option 1). While it is true that the client is young and is making unwise choices, there is no indication that the client’s development has been arrested (option 3). Disregard for the life and needs of others is seen in persons with antisocial personality disorders, but there is no indication in the stem that the client is disregarding or abusing the life of others (option 4).
Providing safety and preventing violence on an inpatient unit involves one-to-one supervision for the client as warranted, based on monitoring of current lethality level. This client did not make a commitment to the no-harm contract, so the nurse should consider that the risk for self-harm is still present. (The nurse should be aware of the suicide protocol in the agency of employment. In some situations, this client might be placed on a different level of suicidal precautions.) Checks every 15 minutes (option 1), whether during both day and night or only during waking hours may not be adequate to ensure client safety. The situation does not suggest an urgent, high-lethality situation that would call for the nurse to remain at arm’s length from the client at all times (option 3). Constant visual observation only during waking hours (option 4) may not be adequate to ensure client safety.
When a client has been suicidal, it is essential that discharge preparations include a plan for safety including social support contacts that can be used after discharge. This is particularly so if the client has acted on suicidal urges, rather than just having had suicidal impulses. Option 1 does not clarify what the client’s sleep pattern has been. Additionally, the nurse should remember that disturbed sleep could indicate continuing depressed mood. Options 2 and 4 suggest that the client is feeling more energetic and optimistic, which are of course signs of progress. They are, however, not as urgently important as having a postdischarge safety plan.
Nurses help reduce the client’s feelings of being overwhelmed by helping the client to prioritize concerns and problems. Supporting the client to put off problem solving is not advisable (option 2). Working on problem solving within a group setting is one of many ways to solve problems (option 3). Being directive and setting the priorities for the client should be avoided (option 4).
Warning signs of suicide generally exist but they may not be recognized until after a suicidal attempt or suicidal death (option 2). Since almost all suicidal persons are ambivalent about dying, they either consciously or unconsciously communicate their intent to others hoping (consciously or unconsciously) to be rescued from their own impulses. The nurse should recognize that the risk for future attempts always increases once a person has made an unsuccessful attempt (option 4). This means that the nurse should always inquire about past suicidal behaviors and attempts, including those that occurred in the distant past. Suicide is a very individual act that does not necessarily reflect negative relationships in the family (option 1). Option 3 reflects a commonly held myth about suicide. Sometimes the person does not talk about suicide because he or she has made a specific plan and has the means to carry it out. Not talking about suicide can be a warning sign, and the nurse and family members need to know this. Family members are not responsible for preventing future suicidal attempts (option 5). They should be encouraged to create safe interpersonal and physical environments, but in spite of their best efforts, they may not be able to prevent their family member from ultimate self-destruction. Telling the family members this will lead to an increased sense of guilt if their family member successfully attempts suicide at a later time.
Psychomotor retardation is a pervasive phenomenon involving slowing of all bodily and psychologic processes. Clients with psychomotor retardation not only move, think, and act slowly; they also experience slowing of involuntary internal processes and are therefore at risk for a wide variety of physical and emotional complications. Option 1 is correct as visceral functioning is highly impacted by the state of depression. This leads to hypomobility and hyposecretion of the gastrointestinal tract. Constipation, fecal impactions, and even bowel obstruction are possible. Other factors contributing to constipation are decreased physical activity, medication side effects, and food and/or fluid deficiency. Additionally, the client may not be responsive to normal sensations to evacuate the bowel. Option 2 is correct because the client with severe psychomotor retardation will have insufficient energy to initiate drinking and ask for fluids. Additionally, the client will tire easily and may not be able to drink even one full container of liquid. Option 3 is correct as the client’s psychomotor retardation will be accompanied by fatigue and anergy, which will contribute to activity intolerance. Option 4 is correct because this client is remaining immobile and maintaining the same position for prolonged periods of time. This increases the risk of pressure-related skin problems, which can be intensified by fluid and/or nutritional deficits accompanying extreme psychomotor retardation. Additionally, the client’s responsiveness to painful stimuli can be diminished. Option 5 is incorrect as the client is not at risk for impaired individual coping. Instead, this is an actual problem of the client.
Suicidal clients who are depressed are at highest risk for suicide when they begin to demonstrate improvement and have sufficient energy to carry out a suicidal act. Thus for a time, treatment and improvement, instead of decreasing the suicidal risk, actually increases it. Option 1 is incorrect because in the severely depressed client, mutism is considered to be a manifestation of psychomotor retardation. In addition to slowing visceral and motor responses, psychomotor retardation also affects cognitive processes that would be needed for formulating and acting on a suicidal plan. Option 2 is incorrect as interestingly, nonresponsiveness to medication may not increase the client’s risk for suicide while in the hospital. If the client is showing severe psychomotor retardation, medication nonresponsiveness would lead to continuance of severe depressive symptoms that would make the client unable to form or act on a plan for suicide. Option 3 is incorrect because before the medication is begun, or before it becomes effective, the client’s risk for suicide remains stable. As stated in options 1 and 2, the severely depressed client typically does not have the cognitive nor the physical capacity to formulate or carry out a suicidal plan.
The nurse should ensure that the interview be conducted in a nonpublic, quiet area in order to reduce stimuli. A potentially aggressive client is hypervigilant, distractible, and overreactive. At the same time, the nurse needs to be aware of own safety as well. Option 1 is incorrect because the potentially violent person is likely to perceive an extended hand, or the touch associated with it, as a threatening gesture and/or act of aggression. Touch of any type should be avoided or used very cautiously with aggression-prone clients. Option 2 is incorrect as large public areas of a unit are designed for use by groups of clients and staff. In such a setting, people come and go freely, and these kinds of interruptions and distractions are likely to further agitate the client. Option 4 is incorrect because this client, who is hyperresponsive and suspicious of the motives of others, is likely to interpret this as a statement of threat.
Having clients verbalize feelings of anger and hopelessness that have led to their being suicidal is an initial step in helping clients learn how to cope more effectively. One cannot cope if one does not know exactly what the adaptive challenges are. Option 1 is incorrect as denying feelings of hopelessness and anger is not therapeutic. Indeed, the nursing diagnosis indicates that this client’s impaired coping was attributable to underlying feelings of anger and hopelessness. These feelings must be acknowledged and dealt with directly if this client is to experience improved coping and reduced potential for suicide. Option 2 is incorrect because it is stated in an immeasurable way. How does one measure happy behavior? How can it be recognized? Also, the nurse should keep in mind that absence of anger does require that one be happy. Option 3 is incorrect as voicing no complaints does not necessarily mean that anger and hopelessness are absent. Various meanings for this behavior are possible. For instance, the individual could be suppressing verbal expression of strong negative feelings. The client could be displaying anger passive-aggressively, or be knowledgeable about the hospitalization process and be aware that voicing complaints will delay the date of discharge.
When the client is at risk for suicide, the highest priority of the nurse is to provide security and safety measures for the client. This will involve different levels of special interventions and precautions, beginning with constant visual observation of the client and confinement in a safe physical environment. As the client improves, less intense and/or less frequent observations of the client are necessary. Option 1 is incorrect because while medications may be expected to be effective in reducing the client’s level of suicidality, the most important priority of the nurse is to provide a safe physical and psychological environment. Option 3 is incorrect as the nurse should encourage direct and open discussion of the client’s suicidal thoughts and feelings. Contrary to popular opinion, talking about suicide does not increase the risk of suicide. Instead, if discussed in a caring and nonjudgmental manner, talking about the suicidal urges may diminish the likelihood of the person’s acting on them. Additionally, in order for the nurse to know the level of potential lethality in the client’s situation, direct and frank discussion between the nurse and the client must occur. Option 4 is incorrect because social isolation is a risk factor for suicide. The more socially isolated a person is, the more likely it is that he or she will act on suicidal urges.
Testicular cancer is most likely to affect late adolescent and young adult males. An undescended testicle is one risk for testicular cancer. The client who wears protective gear is not at increased risk, nor is the client who swims. A familial history of colon cancer does not increase specific risk of testicular cancer because colon cancer occurs at a different site.
Alcohol use is highly correlated with suicide attempts, both in dependent and nondependent drinkers. The alcohol does not cause the suicidal act, but since alcohol is a CNS depressant, use of it impairs thinking and judgment. Option 1 is incorrect as the nurse should anticipate that the client will function best if able to reconnect to a former social support system. This is one of the principles of crisis intervention. Option 3 is incorrect because eating a nutritious diet is important for all persons, not just for those who have been suicidal. Option 4 is incorrect as unless the client has agoraphobia or for some other reason is uncomfortable around crowds, this is not a relevant intervention for the postsuicidal client.
It assumes that the client was abused. However, not all clients who are violent or aggressive have been sexually or physically abused. Asking the question as if the client were sexually or physically abused may cause him or her to become aggressive. If the nurse wants to know whether the client was a childhood victim of abuse, a better way of asking the question would be, “Have you ever been sexually or physically abused?” Options 1, 2, and 4 are incorrect as all of these options are appropriate questions to ask a potentially violent or aggressive client. They should be asked calmly and matter-of-factly.
While each of the statements carry some weight as a risk factor for suicide, two are particularly significant: overdose of tricyclic antidepressant and plan to drive car into a tree. Tricyclic antidepressants, more than many other antidepressants and antipsychotics, are very dangerous when taken in overdose, as they can cause significant cardiac dysrhythmias. Planning to drive a car into a tree (assuming that trees exist in the immediate environment) constitutes having a potentially lethal plan with available and proximate means for suicide, a potentially lethal combination of factors.
The client is still verbalizing hopelessness and worthlessness. The client is still at risk for suicide. Option 1 is incorrect as the client is showing no signs of remorse. The client is at risk to attempt again because of feelings of worthlessness and personal failure. Option 2 is incorrect because the client is not verbalizing guilt or thankfulness to be alive. The client is verbalizing feelings of worthlessness and personal failure and remains at risk for suicide. Option 4 is incorrect as the client is not verbalizing ambivalence. The client’s statement should be interpreted as an indication that the client is likely to attempt suicide again.
Violent and aggressive behavior is a learned response that can be changed. Option 1 is incorrect because many times, strict, rigid rules cause clients to “act out” in anger and aggression. Option 2 is incorrect as it is appropriate and expected for nursing staff to share their fears, anxieties, and concerns with their peers. Option 3 is incorrect because when demands for performance and/or participation are made, the likelihood of violence increases.
A situational crisis is one that is often unexpected and unavoidable and causes an acute state of emotional disequilibrium. The stressful event threatens a person’s physical, emotional, and/or social integrity. The person feels anxious, overwhelmed, and confused. This experience is accompanied by a sense of disorganization and an inability to make effective decisions. An adventitious crisis (option 1) occurs following a major catastrophic event, such as an earthquake, hurricane, or war. This type of crisis represents one in which others experiencing the same or comparable event would react similarly. This question describes a unique, personal situation and a response that cannot be generalized to a larger population of individuals. A maturational crisis (option 2) occurs as part of the person’s normal development and maturation. Such crises are predictable and can be expected to occur as individuals age and progress through life events, changes, and stages, such as adolescence and older adulthood. A cultural crisis (option 4) is a response that occurs while a person is adapting to a new culture or returning to a previous culture after having assimilated into another. There is no indication that this client is in a culturally challenging situation.
It is helpful for the client to identify and ventilate personal feelings being experienced. This relieves anxiety, allows the client to feel validated, and prepares the nurse and client to progress to other steps in crisis resolution. The client’s perception of the situation should occur very early in crisis intervention. The nurse must have a clear idea of what the problem represents to the client and also be able to identify the current reality the crisis presents for the client. Then action plans can be developed. The focus of crisis intervention is on the individual who is experiencing the crisis response, not on others (option 3). The goal is to assist the person in crisis to reestablish equilibrium by using previously effective coping techniques. It is premature to develop an action plan at this time (option 4). Complete data collection and analysis of the problem must occur before proceeding to develop an action plan. Past emotional traumas (option 5) are not explored in crisis intervention. Intervention should focus on the current problem and facilitating the client’s coping in order that a return to precrisis baseline may be accomplished. If past emotional traumas become apparent during a crisis, referral for counseling at a later time would be appropriate.
The client’s statement directly indicates feelings of hopelessness, as well as more indirect expressions of risk for suicide. The spouse’s death has left the client without adequate interpersonal support to cope with and adjust to a significant loss. The client is experiencing a situational crisis. In order to cope effectively in a crisis situation, individuals must identify and be able to rely on others in their world to support them emotionally both during and after the crisis. While the client is lonely, there is no indication that the client is helpless (option 1). Additionally, the question does not indicate there was an actual suicide attempt. Note also that as the concern is written, it says that the suicidal attempt caused helplessness, which is illogical. The client’s statement in option 2 does not suggest difficulty with decision making, although this can be one of the manifestations of a crisis state. The nursing concern in option 5 does not follow the “problem related to etiologic factor” format.
The client is feeling overwhelmed by feelings associated with the crisis precipitant. Before advancing to other interventions, including exploring habitual coping styles and assisting the client with problem solving, the nurse needs to allow the client to freely express emotions being experienced. There is no evidence to suggest that the client would benefit from a visit from clergy (option 1). This may be an effective intervention later, but at this point it is not appropriate. The nurse should not make assumptions about this client’s religious or spiritual needs. More complete data is needed. Option 2 is incorrect because the nurse’s first intervention should be to help the client cope with the precipitant and actual event. Emphasis is on perception of presenting event, past experience in coping, available coping mechanisms, and availability of social supports. The client is in a state of emotional crisis that is considered a normal response to the event. Unless the crisis response intensifies and the client develops severe psychologic or physiologic symptoms, the crisis situation should be treatable in a nonhospital setting (option 3).
The nurse must remain focused on the immediate problem. Crisis intervention is viewed as a “here-and-now” type of therapy. The only history that is relevant at this juncture is the recent history of events that led up to the crisis (option 1). Obtaining a complete past history at this time would impede the nurse’s efforts toward assisting in the effective resolution of the client’s crisis state and would not be appropriate. Early life experiences are not examined in crisis intervention (option 3). The goal is to reestablish equilibrium and return the individual to the precrisis level of functioning. Examination of early life experiences occurs in more traditional insight-oriented psychotherapy. In crisis intervention, the nurse and the client enter into a relationship where action plans are developed jointly (option 4). However, it is appropriate for the nurse to be more directive than in other types of interventions.
Each client should exercise at least 3 days per week for a minimum of 30 minutes in order for exercise to be effective. Fast walking is a good form of aerobic exercise. If one cannot speak when exercising, it is too strenuous and should be decreased in speed or amount.
The risk of suicide is not reduced because a person makes frequent attempts or threats of suicide. Instead, the risk for successful suicide is greater once a single attempt has been carried out. Persons who make verbal threats or attempts are conveying their desperateness and need for assistance in controlling their own impulses for self-harm. Clients with certain personality disorders, including borderline personality disorder, are actually at higher risk for suicide (option 1). These individuals are easily overwhelmed and tend to react dramatically to events that others would find more tolerable. The nurse is obligated to provide protection to the client in a suicidal crisis (option 3). In every suicidal situation, the nurse must objectively explore the nature, frequency, and specificity of the suicidal thoughts. Talking about this, and determining whether a plan and a means for suicide are present, is a standard part of nursing intervention with the suicidal client. Talking about suicide does not increase the risk for suicide, which is a commonly held myth among nonprofessionals. There is not enough information to know whether the client will be admitted to an inpatient unit (option 4). If a sufficient action plan is developed that will provide for the client’s safety outside the hospital, it is possible that the client can be discharged from the Emergency Department.
A priority goal for the client, once safety has been assured, is to explore life events leading to the decision to die (option 1). This can be followed by reviewing current feelings and determining whether the client still has active suicidal urges. If so, the client must be adequately protected while in the inpatient psychiatric setting. When determining potential lethality in a situation with a suicidal client, it is useful to know whether the person has made previous attempts (option 3). If so, this increases the potential lethality of the situation. One of the most effective ways of providing for safety of the suicidal client is to have the client agree (or contract) with the nurse to notify a staff member if the urge to act on suicidal ideas occurs (option 4). If the client cannot agree to this, or if the client is very ambivalent or hesitant about agreeing, the nurse should recognize that the risk for self-injury remains very high. It is the nurse’s responsibility to initiate contact with the client and to determine whether the risk for suicide is still present (option 2). Do not assume that the client will be able to initiate interaction with the nurse. In fact, the client may resist such contact, and this behavior could suggest continuing suicidal potential. The priority should be on continually monitoring client’s suicidality and keeping the client safe in the present environment (option 5). While discharge planning is important, it is premature at this time.
The nurse should look beyond the words that the client uses and determine what the underlying meaning is (option 3). Improvement in mood and energy often occurs just before the suicidal person carries out a suicidal act. Once a suicidal plan has been made, it is as if the individual feels relieved of a great burden. While the client’s words may suggest that the risk of suicide is lessened, the hidden or indirectly expressed message is different (option 1). The nurse should recognize that this client may be describing a feeling of relief often experienced by a suicidal client after making a plan to end his or her life. The client may need to be put on heightened suicide precautions (option 2). The nurse should realize the client’s verbalizations indicate an actual plan to end life may have been made and could be carried out after discharge. Improvement in affect and energy is often observed in suicidal clients right after a suicide plan is made and right before the suicidal client carries it out (option 4).
The first priority in caring for the client with suicidal ideation and intent is maintaining safety. Options 2 (ineffective individual coping), 3 (hopelessness), and 4 (defensive coping) are incorrect. All other issues, including major psychological ones, are secondary to safety. Ineffective individual coping, hopelessness, and defensive coping would be appropriate nursing diagnoses only after safety has been assured.
Acknowledging the client’s feelings of frustration and reaffirming the need for safety is the priority. The nurse should remain calm and matter-of-fact in this situation while tolerating the client’s verbal outburst and allowing for expression of feelings. The nurse’s response should include validation of client’s feelings and information about the intent of the one-to-one observation, which is to keep the client safe (option 2). During one-to-one observation, the nurse must remain at arm’s length from the client at all times, including during toileting activities (option 3). The response in option 4 lacks compassion and is demeaning. While it suggests some awareness of safety considerations and procedure, it fails to express concern for this client’s safety.
The purpose of having a health care proxy is to allow that person the right to make health care decisions on the client’s behalf when needed. To uphold the rights of the client at this time, when the client can no longer convey his or her own wishes, the health care providers need to respect the authorized surrogate’s right to make the decision to refuse or stop treatment.
The goal of palliative care is to monitor and treat the symptoms the dying client is experiencing. If treating the cause can alleviate the symptom, it is appropriate. Treating the disease is not appropriate.
It is “ethically justified” to offer pain medication without fear of causing further respiratory depression to a terminally ill client.
Relaxation techniques and minimizing stimulation will decrease the level of delirium and the agitation associated with it.
Minimizing environmental stimulation will help to reduce the sensory input that can aggravate delirium. Delirium without drowsiness is an acute state of disorientation, and frequently is associated with agitation. It has an underlying metabolic cause, and should not be confused with the chronic condition of dementia (option 4). Option 2 has faulty logic. Giving fluids could help to reduce the dehydration that can aggravate delirium, and aspiration might be not as critical a concern for the client who is in the process of dying (option 2). Talking to the client should not be done for the purpose of raising the level of awareness, but rather to comfort the client and to say goodbye (option 1).
Crackers are a soft consistency when chewed and swallowed. Toddlers can easily choke on small foods such as peanuts, popcorn, and grapes, and on firm consistency foods such as cereal bars.
The client needs to perform BSE once per month, on the same day each month. The client is encouraged to associate performing BSE with another monthly activity, such as paying bills, or to do it on the same calendar date each month (such as the first). The other statements represent incorrect timeframes.
General muscle wasting and lack of nutrition are seen with most terminal illnesses. They are caused by a combination of multiple factors, including metabolic changes, depression, treatments for disease or symptoms, or even the symptoms associated with the disease, such as pain.
Fecal impaction causes a diarrhea that has rapid onset. Diarrhea caused by anal incontinence (option 2) often occurs twice a day, and the stool caused by malabsorption (option 1) would be foul-smelling, fatty and pale. Diarrhea caused by food poisoning (option 4) would occur hours after ingestion of food, typically accompanied by severe nausea and vomiting.
An emollient lotion will lubricate and moisturize the skin in order to maintain tissue integrity. Alcohol is a drying agent, while hydrogen peroxide and warm towels could cause harm.
Dehydration causes a variety of physiological changes, inducing somnolence in the dying client. The other options are not stated correctly, and do not help the client's family understand the role of fluid therapy in the terminally ill.
Families need to be taught that lack of fluids can promote comfort in the dying client with decreased secretions, minimize fluid accumulation in the peripheral tissues, and stimulate endorphin production. Lack of fluids, however, would contribute to the client's sense of dry mouth.
Knowledge that energy surges are indicative of the nearness of death can allow the nurse to communicate with family members who wish to be with the client when they die. The explanations in the other options are incorrect.
Role changes can cause altered family dynamics and social change. They do not necessarily relate to lack of discipline, sibling rivalry, or resolution of disputes with friends.
Being able to determine behaviors that indicate the terminally ill child no is longer interested in talking is important when developing trust between client and nurse.
Siblings often feel left out as the parents focus on the dying child. The correct statement is one that illustrates emotional distance between the siblings and either the dying child or the parents.
Life review assists the living to understand and remember the meaningful events of the dying family member. Option 1 only includes remembering, while option 3 (the correct option) incorporates the importance of the memory to the dying individual, and is therefore of greater overall benefit. Option 2 might be interesting, but is not important in this setting. Option 4 is inappropriate.
BSE should be performed once per month, 1 week after beginning menstruation. At this time, the breasts are least likely to be tender and/or swollen from the effects of hormones. At ovulation and menstruation, hormonal changes are likely to interfere with accurate palpation of breast tissue. Performing the exam on the first of the month is recommended for postmenopausal women who do not need to be concerned with changes in hormone levels associated with the timing of the menstrual cycle.
Expression of grief in "safe" and supportive situations helps the nurse acknowledge and express the sadness and mourning experienced while caring for multiple and continuing client deaths.
Bereavement overload and dysfunctional grieving can cause a nurse to experience death anxiety.
Recognizing the five stages of adaptation is important for nurses working with dying clients and their families.
Only option 3 includes a religion or culture that is restricted in the donation of an individual's organs. Individuals with the religious backgrounds in Options 1, 2, and 4 are able to donate if they desire. Nurses need to be aware of the diverse cultural religious practices and beliefs.
Nurses need to be aware of the diverse religious practices and beliefs and the implications for the end of life.
The PSDA became federal law in 1990. This law states that clients have a right to participate in their own care. In addition, healthcare facilities are required to inform clients of the right to accept or refuse medical care. The other options are not provisions within the law.
For nurses to be able to talk openly about death and dying, they must have some level of comfort with death, dying, and the experience of loss. It is important that they have addressed their own personal losses and done the necessary grieving. If this is not satisfactorily done, losses at work will trigger reactions of grief. This may render the nurse less able to be available to assist the client, it may emotionally. Not being able to develop a healthy attitude about death and dying may also prevent the nurse from being able to communicate effectively with clients. Clients should be encouraged to talk about their feelings, both positive and negative. Although the process of life is important, clients should be given permission to talk about their own deaths and deaths of their loved ones. Options 1 and 2 are incorrect as they would actively prevent the client from talking about death. Option 4 would place an unreasonable responsibility on the nurse. Not only is the nurse not responsible for preventing or facilitating the clients from these feelings, the nurse will recognize that experiencing feelings of helplessness and depression are normal during the process of normal grieving.
Cultures have rules for grieving which delineate the appropriate expression of feelings and determines patterns of appropriate behavior. Option 2 is incorrect as it may be a consequence of cultural influence on the individual. Option 3 is incorrect because it will not assist a client in dealing with feelings of anger. Option 4 is incorrect as it may or may not be a tenet dictated by cultural beliefs.
Normal grief is the total response to the emotional experience related to loss or death. Clients experience grief at different levels of intensity and for different periods of time. Option 1 is incorrect as inhibited grief is a suppressed response to loss, which may be expressed by somatic complaints, such as physical symptoms around the anniversary of a loss or during holidays. Option 2 is incorrect because disenfranchised grief is a response to a loss in which the bereaved is not regarded as having the right to grieve or is unable to acknowledge the loss to other persons. The loss is one which is not publicly sanctioned or acknowledged. As a result, the griever does not receive the needed support and validation for their pain. Examples might be abortion, miscarriage, or death of loved one from AIDS. Option 4 is incorrect as delayed grief is a postponed response in which the bereaved person may have a reaction at the time of the loss, but it is not sufficient in proportion to the loss. However, a loss at a later time may trigger a reaction that is out of proportion to the significance of the current loss.
Grief is a pervasive, individualized, and dynamic process that may result in physical, emotional, or spiritual distress because of loss or death of a loved one or cherished object. Options 1, 2, and 3 are incorrect. Although each of these options are partially correct, option 4 provides the most comprehensive information about the conceptual framework the nurse utilizes with a bereaved family doing grief work.
Although all of the exercises listed are aerobic and therefore beneficial, the older adult client with osteoporosis needs to select an exercise that has a weight-bearing component and yet does not stress the joints. Such an activity will help to retain calcium in bone and reduce the rate of bone loss to osteoporosis. Walking is an aerobic exercise that does not stress the joints of the legs. Swimming and stationary cycling are not weight-bearing exercises. Jogging could harm the knee and ankle joints and is not a preferred method of exercise for this client.
In adults between ages 45–65, the aging process can create an emotional reaction known as a grieving response. The loss of peak physical functioning, a change in health status, attempts to change to "healthier" habits, and adjustment to a new body image are all loses and may engender a grief reaction. Options 2, 3, and 4 are incorrect as they are not part of this developmental stage.
Anticipatory grief is anxiety and sorrow experienced prior to an expected loss or death. The family members of a chronically or terminally ill client might anticipate the loss of a loved one before her or his death because of the prognosis or severity of the illness. The family is beginning to "pull away" or distance themselves from the grief and sorrow of the expected death of the client. Option 1 is incorrect as dysfunctional grief is unresolved that does not lead to a successful conclusion. Option 2 is incorrect because disenfranchised grief is a response to a loss or death in which the individual is not regarded as having the right to grieve or is unable to acknowledge the loss to other persons. Option 3 is incorrect as inhibited grief is a suppressed response, which may be expressed in other ways, such as somatic complaints (e.g., having physically symptoms on the anniversary of a loss or during holidays).
Reflecting the communication of the client will enable them to have a feeling of being heard. The goal in assisting a client in grieving can be achieved by the nurse who actively listens and encourages the client to discuss personal feelings. Options 1 and 2 are incorrect as these options provide false reassurance and do not allow the client to discuss feelings of loss. Option 3 is incorrect because while it may be appropriate at some time, at this juncture the client needs someone to listen and provide support.
Adolescents fantasize that death can be defied and may act out defiance through reckless behaviors. Option 1 is incorrect as toddlers do not have an understanding of death. Option 2 is incorrect because preschool children believe death is reversible. Option 3 is incorrect as school-aged children express a fear of death.
Voluntary passive euthanasia occurs when treatment is intentionally withheld by voluntary consent of the individual who is dying. Option 1 is incorrect as voluntary active euthanasia occurs when the person being euthanized has agreed and volunteered for death. Option 2 is incorrect because involuntary active euthanasia occurs when the person being euthanized has not agreed or volunteered for death. Option 4 is incorrect as involuntary passive euthanasia occurs when treatment is intentionally withheld <i>without</i> voluntary consent from the person who is dying.
The child and family will be overwhelmed with such a life-threatening illness; anticipating the loss of a child would be a priority for the family. Options 1, 2, and 4 suggest pertinent interventions, but during the initial period following learning of the diagnosis, the first need of the family is to react emotionally and begin to adjust to the losses implied by the diagnosis.
Self-awareness is a key component of any nurse/client experience. The nurse must be able to examine personal feelings, actions, and reactions in order to better assist the client in fully expressing his or her own feelings and thoughts. A firm understanding and acceptance of self allows the nurse to acknowledge a client's differences and uniqueness. In order to be empathetic to the client, the nurse must be aware of his or her own feelings. Options 1, 2, and 3 do not focus on self-awareness.
Schizophrenia most often occurs in young adults who are in the prime of life and attempting to achieve a normal adulthood. The individual experiences many losses, and the nurse should assist the client through the grieving process. The situation does not indicate that the client is experiencing significant anxiety (option 2). This situation does not indicate that that the client is experiencing impaired coping or that hopelessness is present (option 3). Sadness and hopelessness are different emotions. The client's grieving is not dysfunctional (option 4), as the client is actively grieving a recent loss.
Even though great emotional pain is felt after a loss, it is necessary for the grieving person to talk about memories of the lost person. This process begins early in the grief experience. Options 1 and 3 would actively prevent the reminiscing that is necessary in early. Additionally, option 3 would also change the focus from the grieving person’s feelings to a more impersonal and clinical topic. In option 4, while it is true that people with a high level of ambivalence about the lost person may have difficulty resolving grief, this sort of exploration is inappropriate at this time. The client needs to express initial feelings of loss before moving on to other grieving tasks, which include reviewing the relationship.
Somatic complaints may be experienced around the date of a loss. This is called an anniversary grief response and is not a dysfunctional grief experience if the physical symptoms occur only around the specific date of the loss and the individual has otherwise returned to a full life. Individuals who have been together for many years often have these experiences for many years. Delayed grief (option 1) is a postponed response in which the bereaved person may not grieve sufficiently at the time of the loss but instead has a disproportionate reaction to a later loss, which can be much more minor than the original loss. Disenfranchised grief (option 3) is a response to a loss, which the individual is not regarded as having the right to grieve, or is unable to acknowledge the loss to other persons. Unresolved grief (option 4) is a response that is prolonged or extended in length and severity of response.
Sickle-cell disease has an onset in childhood. This makes it the priority for genetic counseling. The other disorders listed (coronary heart disease, type II diabetes, and hypertension) are adult-onset problems and therefore have lower priority.
Disenfranchised grief is a response to a loss or death in which the individual is not regarded as having the right to grieve or is unable to acknowledge the loss to other persons. Delayed grief (option 1) is a postponed response in which the bereaved person may have a reaction at the time of the loss, but it is not sufficient to the loss. However, a later loss may trigger a reaction that is out of proportion to the meaning of the current loss. Inhibited grief (option 2) is a suppressed response to loss that may be expressed by somatic complaints, such as physical symptoms around the anniversary of a loss or during holidays. Unresolved grief (option 4) is a response that is prolonged or extended in length and severity of response.
Although the stages of grief should be used with caution in labeling expected behaviors and feelings, many clients will experience the five stages of grief as denial or shock, anger, bargaining, depression, and acceptance. Although the stages of grief should be used with caution in labeling expected behaviors and feelings, many clients will experience the five stages of grief as denial or shock, anger, bargaining, depression, and acceptance.
<i>Advance directive</i> is a general term that refers to a client's written instructions about future medical care in the event that the client becomes unable to speak or is incapacitated. Specific instructions about what medical treatment the client chooses to omit or refuse (e.g., ventilator support) in the event that the client is unable to make those decisions is also included. Advance directives do not specify particular practitioners or family members preferred for providing end of life care (options 2 and 3). When an advance directive document is created, the individual makes the decisions about future treatment to be administered or withheld (option 4). Advance directives are not the same as designating another person to make medical decisions for the individual; this is a specific legal process known as healthcare proxy or medical power of attorney.
Preschool children believe death is reversible. They do not have a developed sense of death, and they are unable to understand the permanent impact of death and dying, Children between 5–9 years of age believe wishes or unrelated actions can be responsible for death (option 1). Preschool children do not have a developed sense of death, and are unable to understand the permanent impact of death and dying. The responses in options 2 and 4 indicate the child is aware the death is permanent.
This client needs to be assisted to move through the final developmental landmarks and tasks at the end of life, which include closure and completion in relations with family and friends. This will also assist the family to engage in anticipatory grieving. Option 1 would actively prevent the client from moving through the final developmental landmarks and end-of-life tasks. Relief of pain is of highest priority when the client is terminal (option 3). The nurse should be aware of the fact that there are means of using narcotic analgesics without causing clouding of consciousness. At end of life, the dying person should be allowed to be as independent as possible in order to preserve self-esteem (option 4).
A perceived loss is experienced by one person but cannot be verified by others (e.g., loss of self-esteem or body image). An actual loss can be identified by others and can arise in response to a significant change in a person's appearance, body, or life circumstances, such as weight loss after surgery. An anticipatory loss (option 3) is experienced before the loss actually occurs (e.g., terminal illness). A permanent loss (option 4) is an irreversible deprivation (e.g., paralysis). A painful loss (option 5) is a generalized term that does not have universal meaning.
The capacity for self-awareness allows the nurse to reflect and make choices. Nurses who understand their own feelings and beliefs will be able to be therapeutic when clients need to address issues which are disturbing and difficult. The death of a child will personally affect the nurse, and it is critical for the nurse to share these feelings with others, including the parents (option 2). The nurse must be available both physically and emotionally for the parents in discussing unpleasant and difficult feelings (options 3 and 4).
Although the loss of a child can be devastating, the ability of a parent to reintegrate involvement in usual activities is important to successfully resolving grief and loss. The client's behavior indicates that she has not moved past the initial stage of grief in which preoccupation with feelings of loss and intense emotional pain are prevalent. Options 1, 3, and 4 are more average responses to the death of a child.
The client is showing denial, which is the earliest reaction to loss. This first stage of grieving is normally short-lived, and the grieving person moves on to other grief responses, like anger. The total time for acute grieving is very individualized, but feelings of numbness, emptiness, and active denial of the death 4 months later indicates that this client's mourning is not progressing normally. Disenfranchised grief (option 2) is not present because there is nothing in the situation (such as a clandestine relationship) that would prevent the client from expressing grief. The client is grieving the actual loss of the spouse, not another situation, as would occur in distorted grief (option 3). This client’s reaction is not consistent with the normal pattern of grieving (option 4).
Spiritual and cultural beliefs and practices greatly influence both a person's and family's reaction to death and subsequent behavior. Options 1, 2, and 3 may also be correct, but the common organizing underpinnings to each of these options are cultural and spiritual beliefs.
A body mass index (BMI) measurement is done at age 20 and at each health visit. Serum cholesterol levels are started at age 20 and are recommended every 5 years. Blood glucose screening is recommended to begin at age 45 unless there is evidence of higher risk for diabetes. Colorectal screening begins at age 50 and is done every 1 to 10 years depending on method used. Clinical breast exam is done starting at age 20 and may be done every 3 years or more frequently depending on risk. Mammography is done yearly starting at age 40.
Male or masculine expression of loss or death is commonly limited and less overt. Intense feelings are usually experienced privately with a general reluctance to discuss these with others. Option 2 would not be indicated at this time because the father is probably not experiencing dysfunctional grief. There is not enough data in options 3 or 4 to support these options.
Preschool children (ages 3–5) do not understand the finality of death, but instead may see it as separation. They engage in magical thinking and truly believe in the power of wishes. Magical thinking is most common in preschool aged children (option 1). The child is not experiencing delusions or making up a story to avoid feelings (options 3 and 4).
With mutual pretense, the client, family, and/or healthcare providers know that the prognosis is terminal but agree not to talk about it and make an effort not to raise the subject. In closed awareness (option 1), the client and family are unaware of impending loss or death. There is no mutual concern (option 3). In open awareness (option 4), the client and involved individuals know about the impending loss or death and feel comfortable discussing it, even though it may be difficult.
As the care receiver becomes more chronically ill and the caregiving burden becomes more demanding, a great strain can be placed on the caregiver's emotional and physical health. There is not enough data to suggest ineffective coping, dysfunctional grief, or social isolation (options 1, 2, and 3).
A major outcome of grief counseling is to assist the client in sharing his or her loss and to accept support from others. It is critical for the spouse to share the feelings of loss and grief with others. A vital part of normal grieving is expressing feelings of loss and grief in a supportive interpersonal environment, particularly with those who are most significant in the grieving person’s life (options 1 and 4). It is too early to memorialize the spouse; the client must grieve the loss of client first (option 2).
A client is considered to be obese when his or her weight is greater than or equal to 20% over ideal body weight and the calculated BMI is greater than or equal to 30. The above statement by the client implies that there is understanding of this classification. Option 1 is incorrect because a BMI between 25–30 is categorized as "overweight." Option 3 is incorrect as the findings relate to clinical obesity and not merely overnutrition. Option 4 is incorrect because the client is not underweight as defined by the information presented.
Visualization of serving sizes is an easy tool that can be used to teach clients how to determine accurate serving sizes without the use of formal measurement tools. It allows for a common reference between known objects and serving size and offers visual reinforcement. Option 1 is incorrect as it would not be appropriate to ask the client to take measuring cups with her to school. Option 2 is incorrect because it has nothing to do with determining serving size. Option 3 is incorrect because reading the food label will provide information relative to a serving size for the item, but might not help to identify the concept of what a serving size is to the adolescent client.
Lycopene is a phytochemical with powerful antioxidant activity found in tomato products and has been associated with a decrease in risk of prostate cancer. Options 2, 3, and 4 are not associated with reduction of prostate cancer.
The total number of lymphocytes will decrease when protein deficiency occurs. Options 1 and 3 are incorrect because they will not directly affect the TLC. A bacterial infection will usually stimulate white blood cell production.
All meat products come from one particular group whose name contains the word "meat." All of the other choices are incorrect because hot dogs (beef, turkey, pork, or soy) belong to the meat group.
Blood pressure and vision screening are started at age 3 and continue with each visit. Hearing screening begins at age 4. Lead screening would only be done on an as-needed basis for a 4-year-old. Hemoglobin and hematocrit are done at 12 months and as needed (which may be annually for females during adolescence). Urinalysis is done at age 5, in adolescence, and otherwise only as indicated.
Pesco-vegetarians eat fish in addition to plants. Fish would be an appropriate protein source for this client. The other options would not be used by type of vegetarian.
Soluble fiber from psyllium seed husk or whole oats is connected to decreasing the risk of coronary heart disease and is one of the Food and Drug Administration (FDA)-allowed health claims on food products. Option 2 is incorrect as low folic acid levels are associated with neural tube defects. Option 3 is incorrect because decreased intake of fats (less than or equal to 30%) and increased consumption of fruits and vegetables correlate with reduced cancer risk. Option 4 is incorrect since calcium intake correlates with a decreased risk of osteoporosis.
Nutrient density refers to the amount of calories (in carbohydrates, proteins, and/or fats), vitamins, and minerals in a given quantity of food. Option 1 is incorrect as it relates to caloric value. Options 2 and 3 are incorrect because the quality or quantity of vitamins and minerals in a food is only one part of the calculated nutrient density.
Reliability is the accuracy or consistency of a study, often measured by the ability to replicate the study and obtain the same results. All of the other options are incorrect because they relate to validity issues, which determine whether the study accurately reflects what it purports.
Ingredients are listed in order by descending weight. The information identified in each of the other options is incorrect.
<i>The Dietary Guidelines for Americans 2005</i> apply the principles of scientific evidence in promoting health and reducing risk of chronic disease through diet and physical activity. Option 2 is correct because it includes the two key components found in more than one guideline topics, Option 1 is incorrect because guidelines to recommend a total fat intake of 20–35% and less than 300 mg of cholesterol per day. Options 3 and 4 are incorrect because under the topic "Food Groups to Encourage" milk is mentioned but only sufficient amounts while staying within energy needs.
Alcohol provides calories but is not an essential nutrient. All of the other choices reflect statements that are consistent with basic nutritional knowledge.
A BMI of less than 18.5 is classified as underweight. The most important nursing concern is Imbalanced nutrition: less than body requirements because the client’s intake is not sufficient to maintain a normal BMI. A low BMI places client as risk for respiratory diseases, TB, digestive diseases, and some cancers, but does not create risk for dehydration (option 4). The client could also be at risk for impaired growth, depending on age and specific nutritional deficits existing, but this information is not provided. The client could also have a knowledge deficit, but this is also not evident from the question, so would not be the most appropriate concern.
Height and weight are physical parameters that are considered to be anthropometric measurements. Options 2 and 3 are incorrect because they represent laboratory/diagnostic test results. Option 4 is incorrect because a 24-hour dietary recall is part of a documented history.
The terms <i>light</i> or <i>lite</i> can only be used if the product has greater than or equal to one-third fewer calories or greater than or equal to 50% less fat than a comparable regular product. Option 2 is incorrect since it refers to sodium levels, and the term <i>light</i> is related to specific caloric levels and/or fat. Option 3 is incorrect because it refers to an increased protein level. Option 4 is incorrect because the caloric decrease stated is much higher than the identified level.
Painless swelling of scrotum, dull pain in scrotum, nodules between testes and cord, and dragging sensation in scrotum are signs of testicular cancer. A reddened rash or feeling of wetness in the scrotum are not applicable to this diagnosis but should be followed up for general health reasons.
A low BMR occurs when calories are being burned at a slower than normal rate; therefore, weight gain may occur. Option 1 is incorrect because a low BMR would correlate with increased weight gain due to possible endocrine disturbances. Options 3 and 4 are incorrect because they reflect poor nutritional status, fatigue, and decreased oxygen-carrying capacity, which can occur because a variety of other metabolic factors, not only nutrition.
A food diary involves recording intake of foods and beverages over a specific period of time and also includes emotions and rationales for eating. It can be used to help clients identify unhealthy patterns, and it can also be used for weight loss and bulimia/anorexia. Option 1 describes a dietary intake record, which does not include emotions and reasons. Option 2 describes a 24-hour recall. Option 4 might or might not be part of a food diary.
Soy, beans, and nuts are part of the protein group and would be appropriate for a vegetarian. Vegetarians do not eat animals that must be killed prior to consumption; most vegetarians (other than vegans) will consume eggs, legumes, and dairy products.
Transferrin levels provide information relative to iron stores and visceral protein. Option 1 is incorrect since transferrin does not specifically relate to a low dietary intake level. Option 2 is incorrect because transferrin levels do not relate to blood loss through hemorrhage, they relate to body stores. Option 4 is incorrect because transferrin levels are not affected by bacterial infections.
Promoting healthy nutritional practices incorporates both the categories of undernutrition and overnutrition. The correct option provides a goal that is global and relevant to nutrition. Options 1 and 4 are incorrect because they reflect an intervention, not a goal. Option 3 is incorrect because weight maintenance would only be an appropriate goal if the client is underweight and there is insufficient information to determine this.
A Daily Recommended Intake (DRI) is a nutritional guideline that goes beyond the RDAs. It includes Tolerable Upper Limits and Adequate Intake amounts and is established by the government to provide a more comprehensive approach to nutrition. Option 2 is incorrect because DRIs do not merely relate to caloric intake. Option 3 is incorrect because DRIs are not based solely on weight variables but reflect a recommended intake of nutrient factors. Option 4 is incorrect. Even though the physician is knowledgeable, any one healthcare provider does not have complete knowledge of nutritional therapies. A collaborative approach is necessary to provide information to the client.
MyPyramid recommends three servings a day from milk, cheese, and dairy products. One serving is equal to 8 ounces of milk or 2 ounces of cheese. Option 1 does is equal to one serving, but not a day's supply. Option 3 is an insufficient amount. Option 4 is also insufficient, and eggs are not part of the protein category.
The use of an exchange list is recommended by the American Dietetic Association for use by diabetic clients for meal planning. Option 1 is incorrect: Even though the MyPyramid is developed by the USDA to illustrate healthy diet choices, the use of an exchange system is geared specifically to equivalent carbohydrate contents that are critical for a diabetic client. Options 3 and 4 are incorrect because they are not diet planning guides but rather examples of tools that can be used to evaluate nutritional status.
Sugars are a carbohydrate (CHO), and each gram of CHO or sugar contains 4 kcal. Multiply 3 grams by 4 = 12 calories.
A hot dog bun is found in the bread, cereal, rice, and pasta group. Option 1 is incorrect—peanuts are found in the meat, poultry, and fish group because they are considered to be legumes. Options 2 and 3 are incorrect—coconut is found in the vegetable group; navy beans are in the meat, poultry, and dried beans group.
Options 1, 2, and 3 are true statements. Each physiologic system of a person ages at a different rate.
Health claims on food products are regulated by the FDA, are trustworthy, and are based on scientific evidence. The food products making the claims must meet specific rigid criteria. Options 1 and 3 are incorrect because FDA regulations are strictly enforced, and companies must comply with federal guidelines or risk penalty. Option 4 is incorrect—food product labels are regulated by the FDA and not by individual states.
Calories or kilocalories are the most commonly used measurement of a food product’s energy. Grams and pounds reflect weight measurements. Joules represent electrical energy.
Height, weight, and skin fold thickness are common anthropometric data (measurement of body parts) obtained by the nurse, as well as the body mass index. Options 1 and 2 are incorrect: CBC (and hemoglobin, which is a test included in the CBC) reflect laboratory parameters. Option 5 is incorrect because albumin is a type of serum protein and is another laboratory measurement.
The Body Mass Index (BMI) is calculated by taking the weight in kilograms and dividing by the height in meters squared. It evaluates weight compared to height, or fatness. Option 1 is incorrect—these are merely descriptive terms that relate to body frame variables and overall distribution of weight. Option 2 is incorrect because the metabolic rate of an individual relates to basal metabolic rate (BMR). Option 3 is incorrect, because BMI does not detect hypercholesterolemia. Elevated cholesterol levels can be found in individuals with differing BMI values because both genetic and metabolic factors influence its development.
A positive nitrogen balance implies that a client is in a growth state whereby extra high biologic value protein sources are needed for growth of tissue. Option 1 is incorrect because additional protein, not CHO, is needed to restore nitrogen balance. While CHO sources are the primary source of energy, periods of positive nitrogen balance require additional protein as the necessary nutrient. Even though a decrease in the amount of saturated fat in the diet is advisable, the issue of nitrogen balance addresses protein. Option 4 is incorrect because although milk is a good source of protein, three servings is the usual recommendation in the diet and this will not meet the needs of a client who is in positive nitrogen balance.
A client who is in the hospital due to a gastrointestinal infection is at risk to develop protein deficiencies if GI symptoms such as diarrhea and intestinal inflammation exist. Option 1 is incorrect because the combination of milk and cereal represents a complementary protein and will support needed protein requirements. Option 2 is incorrect because soy burgers are an example of a complete protein source. Option 3 is incorrect as a client who is in renal failure is more likely to have problems related to excess protein due to an inability of the kidneys to handle an increased solute load.
The highest concentration of omega 3 fatty acids is found in cooking oils, margarine, fatty fish (e.g., cod, tuna, salmon, shrimp, and mackerel), and flaxseed oil. The other options are not good sources of omega 3 fatty acids.
Increased amounts of fiber in the diet (in excess of dietary recommendations or increased too rapidly) can lead to GI presentations that include diarrhea, flatulence, and generalized discomfort. Option 1 is incorrect as increased use of insoluble fiber can decrease the absorption of certain minerals. Option 3 is incorrect because excess fiber will increase GI motility leading to diarrhea. Option 4 is incorrect because fiber helps to bind cholesterol in the body for elimination.
The client needs to increase water intake while increasing fiber intake to prevent constipation. It is recommended to have 3–5 servings of vegetables and 2–4 servings of fruit daily, making option 1 incorrect. Option 3 is incorrect as many foods are high in fiber. Option 4 is incorrect because vegetables provide a good source of insoluble fiber while grains and broccoli tend to provide soluble fiber.
A high-CHO meal will lead to an increase in circulating insulin levels as part of the glycemic response. Option 1 is incorrect because insulin production will increase in response to a high CHO meal. Option 2 is incorrect as a decrease in insulin sensitivity and an increase in insulin resistance would be expected in a client who has been consuming a high CHO diet for a prolonged period of time. Option 4 is incorrect because some form of dyslipidemia would be expected in a client who has been consuming a high CHO diet for a prolonged period of time.
Lentigines (brown age or liver spots) represent normal aging of the skin. Presbycusis also occurs in normal aging. These changes do not require medical attention or interventions for vision or temperature.
Option 2 represents the best source of complex CHOs because it includes whole grains and fruit. Option 1 is incorrect as instant rice and canned green peas are examples of food items that have been processed or refined. Option 3 is incorrect because scrambled eggs with ham and sausage represent a meal that is high in protein and saturated fats. Option 4 is incorrect because fried potatoes are high in fat content and fruit juice is high in simple sugars.
The incorporation of tuna in the diet reflects a food that is high in omega-3 fatty acids, which is beneficial in reducing cardiovascular risks. Option 1 is incorrect because the amount of fiber specified is far below the recommended daily dietary intake. Option 3 is incorrect because the use of butter and partially hydrogenated cooking oils increases both the amounts of saturated fat and trans-fatty acids in the diet. Option 4 is incorrect because the use of fried food products contributes to an increase in fat intake.
Food and Drug Administration (FDA) regulations require that foods containing olestra have a warning label stating that abdominal cramping and loose stools can occur from the use of this artificial fat product. Option 1 is incorrect because artificial fat products cannot be substituted for low fat products. Low fat describes the content of a food item as having 3 grams or less of fat per serving. Option 2 is incorrect because there are different types of artificial fats derived from different chemical sources (e.g., carbohydrates and proteins). Option 4 is incorrect because the use of artificial fats in the diet can lead to decreased absorption of nutrients because most artificial fats are not absorbed well from the GI tract.
Natural grain products usually contain little fat, and a half a bagel has a very low fat content. The other choices reflect foods that have a high fat content and represent saturated (cheese and coconut) and monounsaturated (almonds) types of fat.
Omega-3 fatty acids have been shown to reduce risk factors associated with heart disease. They are found in fatty fish, fish and flaxseed oils, and cooking oils.
Clinical evidence has supported that elevated homocysteine levels correlate with increased risk for the development of atherosclerotic heart disease and deficiencies of certain B complex vitamins. Option 1 is incorrect—homocysteine is an amino acid that is produced by the breakdown of the amino acid methionine. Option 2 is incorrect because elevated homocysteine levels are associated with vitamin B deficiencies. Option 4 is incorrect because homocysteine metabolism is not related to lipid absorption.
Clients with deficient protein intake are at risk for immune dysfunction and fatigue. A high intake of protein may put clients at risk of coronary heart disease, not low protein. Steatorrhea is usually associated with altered fat metabolism. Pyelonephritis is an infection and is not caused by low-protein diets.
Clients with heart disease benefit from foods that are low in fat and, if hypertensive, low in salt. Baked fish without added sources of fat represent the best choice on the sample menu. The turkey would be a good choice if it did not have a cream sauce, which is high in fat. Beef is high in fat because it is an animal product and contains more fat than poultry. The baked chicken would be a better choice if the skin were removed, because skin is also high in fat.
Trans-fatty acids are found in processed hydrogenated foods. The other options address reduction of cholesterol and saturated fats in the diet, but do not address trans-fatty acids specifically. Some foods high in cholesterol and fat, although they should be reduced, may not be high in trans-fatty acids.
A state of prolonged CHO deficiency can lead to protein breakdown that results in formation of ketone bodies and altered acid-base balance (metabolic acidosis). Options 2 and 3 are incorrect because they are associated with protein deficiency and lipid deficiency, respectively. Option 4 is incorrect—these are associated with an increased amount of CHOs in the diet.
A normal body temperature of an older adult person may range from 96.5° to 99°F (35.9°–37.3°C). Therefore, a temperature of 98.6°F (37°C) may signify a fever in an older person. Incontinence is not a normal age-related change. Not all older adults have altered mobility needs, and those who do are more likely to use a cane or walker than crutches (which are used for injury). Use of blood glucose devices is generic or related to a diagnosis of diabetes and is not specifically related to normal aging changes.
Pinto beans and rice are examples of the use of complementary protein because this combines two different food items to yield a complete protein source. All of the other options do not combine to make a complete protein source. A complete protein source provides all of the essential amino acids and is of high biologic quality and value.
High intake of sugars (CHOs) is associated with dental caries and progression of dental disease. By limiting the intake of soft drinks in the diet, one is reducing the daily CHO content. Hard candies are mainly composed of sugar and will contribute to dental disease, because they increase the sugar medium in the oral cavity (option 1). Even air-popped popcorn can easily become lodged between the teeth, leading to food's remaining in the oral cavity and bacterial progression (option 2). Option 4 is incorrect because rinsing of the mouth after eating candy will not effectively remove the extra sugar that the candy provided. Brushing and flossing the teeth would prove to be a better option because this would remove food remnants.
Olestra blocks absorption of fat in the diet, sometimes causing abdominal cramping and loose stools. It is not associated with the symptoms in options 1, 2, and 4.
The degree of unsaturation is in the firmness of fats at room temperature. The polyunsaturated vegetable oils are liquid; therefore the more saturated animal fats are solid. Options 1 and 2 are solid and should be avoided. Option 3 should also be avoided because even though coconut oil is oil, not all oils of vegetable origin are polyunsaturated.
CHOs are the primary energy source used to maintain the body and a minimum level of CHOs (50–100 grams/day) is needed in order to avoid protein breakdown. Option 2 is incorrect because there are other methods (besides lowering CHO intake) to establish sustained weight loss. Option 3 is incorrect—a balanced intake of all three macronutrients is needed in order to maximize function, prevent breakdown of constituent products, and maintain energy. Option 4 is incorrect because an increase in dietary fiber will not compensate for a decrease in total CHOs. Although dietary fiber provides health benefits related to elimination and cholesterol levels, an increase in fiber above current recommendations (20–35 grams/day) may cause an increase in GI symptoms and lead to constipation.
The use of complementary proteins in a diet pattern refers to the combining of different plant proteins in a day to form a complete protein that is of high biologic value. Vegetarians should receive instruction on this method in order to maintain required essential amino acid requirements in the body and prevent clinical deficiencies that could arise due to their choice of vegetarianism. Option 1 is incorrect: Gelatin is an animal protein of low biologic value and would not be included in a vegetarian diet. Option 2 is incorrect because the idea of complementary proteins is to combine food choices and not merely to increase the amount of complete protein sources. Option 3 is incorrect because an increase in fruits will not provide complete protein.
It is recommended that cholesterol intake be limited to 300 mg/day. No more than 10% of fats should be saturated. Checking labels is advisable but does not provide the client with specific guidelines. Eggs can be eaten but should be limited to 2–3/week.
Nitrogen balance refers to the concept of a balanced protein state in the body to support metabolism. A client who is in positive nitrogen balance is taking more nitrogen in and excreting less nitrogen in order to meet metabolic needs (growth state with increased demands). Options 1 and 2 are incorrect because they represent normal range findings for sodium and potassium levels in the body. It is important to note that protein function does depend on the interaction of acid/base and serum electrolytes in order to function effectively, and the nurse must be alert to look at pertinent laboratory findings. A slight state of fluid overload (option 3) is less significant than a state of positive protein balance, which correlates directly with the question.
Vegetables, fruits, and grains in the diet are low in fat and are rich in nutrients and phytochemicals. Option 1 is incorrect because trans-fatty acids are associated with increased cardiovascular risks. Option 2 is incorrect because the use of fish oil supplements can interfere with bleeding times, diabetic state, immune status, and wound healing. A balanced level of omega-3 and omega-6 fatty acids is recommended in the diet using natural sources. Option 3 is incorrect because the process of hydrogenation increases the amount of trans-fatty acid and would not be a prudent choice.
Increased intake of animal protein may be associated with cardiac disease because animal food protein sources are also high in saturated fat content. Options 2 and 3 reflect clinical conditions in which there are protein losses due to either intake or cell breakdown. Diabetes (option 4) is associated with excessive caloric intake or an autoimmune origin.
Parent role models of behavior are the best method to develop good habits in children. The other options, although possibly valid (except option 3), are not the <i>best</i> answer.
With normal aging, there is loss of cartilage and joint fluid. Overall wear and tear does occur. Sebaceous glands are less active, and older adults sweat less. There is a decreased need for sleep, with shorter REM and non-REM sleep cycles. Social support may decrease with deaths and fewer resources but does not relate to the question of physiologic needs.
Lipids are not a primary energy source but rather serve as an energy reserve in the body. CHOs are the primary energy source of the body. Options 1, 3, and 4 are incorrect as they all represent functions of lipids in the body (part of cell membranes, support of internal organs, and insulation).
A client with PKU has a genetic condition that prevents the utilization and conversion of the amino acid phenylalanine, leading to increased levels with toxic clinical manifestations. The product Sweet ’n’ Low™ contains saccharin as the sweetening agent, which will not cause problems for the PKU client. All of the other options are incorrect, because both Equal™ and Nutrasweet™ (options 1 and 3) contain aspartame (option 4) as their active ingredient. Aspartame contains aspartic acid, a methyl group, and phenylalanine. Intake of these products can be dangerous for a client who has a clinical diagnosis of PKU; warning labels are found on packages of these food products denoting this fact.
Each gram of fat supplies 9 kcal. Multiply the 9 kcal by 35 (the number of daily grams of fat in the diet) to obtain a result of 315 kcal. (9 x 35 = 315)
Essential nutrients are needed by the body in their original form, as the body cannot synthesize them from other materials in the body. Option 1 is incorrect—an essential nutrient does not provide all the necessary energy requirements for the body. Option 3 is incorrect because essential nutrients differ in their amounts of fat, protein, and carbohydrates. Option 4 is incorrect because this statement describes a nonessential nutrient.
Most healthy clients are able to meet their vitamin requirements through dietary intake. Option 1 is incorrect as vegetables are usually very good sources of vitamins. Option 2 is incorrect because even though a banana has vitamin activity (e.g., A, C, K, and folate), the client is taking this to replace potassium losses incurred with the use of a diuretic. Option 4 is incorrect since vitamin needs are usually able to be met from food substances along with proper diet.
B complex vitamin deficiencies can often present with clinical presentations affecting the mouth and tongue resulting in cheilosis (inflammation of mucous membranes in the mouth and lip) and glossitis (inflammation of the tongue). The other options are not associated with this presentation.
Night blindness is often the first indicator that a clinical deficiency of vitamin A exists in the body. Correction with vitamin A at the time of early clinical diagnosis will correct the clinical condition. Option 2 is incorrect because this condition is not permanent if nutrient deficiency is detected and treatment is started. Option 3 is incorrect as this does not require long-term hospitalization. Option 4 is incorrect because this condition is not caused by an allergic reaction and therapeutic treatment is needed to correct this problem.
A homebound client may be more at risk to develop a vitamin D deficiency because sunlight plays a part in the activation of vitamin D in the body. The other options are not related to being indoors on a consistent basis.
A client who does not respond appropriately to potassium therapy often has coexisting calcium and magnesium deficiencies as well. It is important to monitor for each of these three electrolytes in order to correct the disturbance. Option 2 is incorrect because the client may be experiencing a higher level of phosphorus due to the inverse relationship that exists between it and calcium. Options 3 and 4 are incorrect as neither is related to potassium deficiency.
Absorption of calcium in the diet can be promoted by acidic foods. All of the other options would lead to a state of decreased absorption of calcium. The fiber in beans, oxalates in spinach, and protein in beef would reduce the absorption of the calcium.
With normal aging changes, there is a decrease in vision, hearing, touch, smell, and taste. These changes can lead to falls, inability to leave a situation when called to do so, inability to distinguish temperature with resulting burns, inability to smell smoke in a fire, and inability to taste contaminated food. These changes can have a major impact on the safety needs of an older adult.
Several dietary factors can reduce the absorption of iron in the body, including tannins found in coffee or tea. All of the other options will lead to increased absorption of iron in the diet.
A pre-menopausal client should take 1,500 milligrams of calcium per day as a standard recommendation. Dietary sources are recommended rather than calcium supplements because they differ in their absorption due to bioavailability. Option 1 is incorrect because an increase in protein levels can lead to a decrease in absorption of calcium. Option 2 is incorrect as additional fluids will not help to increase calcium levels. Option 3 is incorrect because supplementation is not advised as a primary dietary treatment and can lead to the development of other potential imbalances.
High zinc levels in the body can cause development of a copper deficiency. The other choices are not affected by high levels of zinc.
Occupational exposure to the manganese can result from dust inhalation and can have profound neurological effects. The other options would not be applicable to this client.
Increased intake of vitamin C can increase risk for stone formation. The daily recommended dose is 90 mg/day. The increased vitamin C intake would not impact the other options.
Good food sources of thiamine include wheat germ, lean pork, beef, liver, and whole and enriched grains, seeds, nuts, and a few vegetables.
Clients who abuse alcohol are prone to develop thiamin deficiency because ethanol affects the intestinal absorption of thiamin. Wernicke-Korsakoff syndrome is associated with a state of encephalopathy that is seen in clients with alcoholism and presents with mental status changes, psychosis, and coma. Option 1 is incorrect—vitamin C deficiency is associated with scurvy. Option 3 is incorrect—riboflavin deficiency is associated with ariboflavinosis. Option 4 is incorrect because niacin deficiency is associated with pellagra.
Processed foods have the highest sodium content. Chocolate pudding is the only option that reflects a processed food item. Meat and milk are animal products and as such have physiological saline. Fresh fruit is lowest in sodium.
Chromium is helpful in maintaining glucose homeostasis by enhancing the activity of the hormone insulin. The other options are sources of vitamins, not minerals.
Iodine is predominately found in the thyroid gland, which secretes thyroid hormones that affect the body's metabolic rate. The other options are not associated with thyroid problems. Other minerals that might be affected include sodium, potassium, iron, and calcium, depending on the underlying presentation.
Osteoporosis, a decrease in bone density, makes the older adult more prone to pathological fractures. Decreased mobility, osteoarthritis, and scoliosis do not cause pathological fractures. Scoliosis is a curvature of the spine, usually diagnosed in adolescents.
Clients who exhibit behaviors of eating nonfood items such as ice, clay, and dirt are likely to have iron deficiency. This odd symptom presentation is often the first indicator that there may be a potential problem. Option 1 is incorrect—a client who is dehydrated would be more apt to drink fluids than ice chips. Option 3 is incorrect because there is nothing to indicate that the client is suffering from a protein deficiency. Option 4 is incorrect because the client is not ingesting sufficient fluid to dilute the serum sodium level.
Folic acid deficiencies have been proven to cause neural tube defects in the developing fetus. Option 1 is incorrect because high levels of folic acid can prevent identification of vitamin B<sub>12</sub> deficiency. Option 2 is incorrect because high homocysteine levels are associated with folic acid and other B vitamin deficiencies. Option 3 is incorrect because folic acid deficiency results in a macrocytic anemia.
Pernicious anemia is due to a clinical deficiency of intrinsic factor that prevents the absorption of vitamin B<sub>12</sub> in the body. This commonly occurs following gastrectomy. Thus, for treatment to be effective, vitamin B<sub>12</sub> must be administered via injection for the rest of the client’s life. Options 1 and 3 are incorrect because niacin is unrelated to pernicious anemia, and iron will not correct pernicious anemia. Option 4 is incorrect because riboflavin is not related to the issue of pernicious anemia and riboflavin is administered orally.
This is a normal finding with folate. Increasing water intake might dilute the urine and make it less yellow, but this response does not provide reassurance this is a normal reaction. Reducing amount of folate may not reduce the color. It does not need to be reported.
Vitamin B<sub>12</sub> deficiency can result in the development of a macrocytic nutritional anemia because it is necessary for red blood cell production in the body. Option 1 is incorrect because: A deficiency of calcium leads to bone demineralization. Option 3 is incorrect because iron deficiency results in a nutritional anemia that is microcytic. Option 4 is incorrect—vitamin B<sub>1</sub> (thiamin) clinical deficiency results in beriberi.
Infants receive an injection of vitamin K to protect them against the development of hemorrhagic disease of the newborn. Infants are born with a sterile gut and are therefore unable to synthesize vitamin K in the small intestines. A single injection of vitamin K helps to introduce enough of the vitamin so that the infant is afforded protection. All of the other options are incorrect—this drug has no clinical impact on these clinical conditions.
Clients who take more than 1 gram of vitamin C daily may have a false negative result on stool guaiac testing. It is important for the nurse to understand that the test results will be inconclusive and should be repeated in a few days once the client has stopped taking the additional vitamin C. Option 1 is incorrect because there is a relationship between the testing chemical reaction. Option 4 is incorrect—the results are not valid and not open to interpretation due to drug interactions.
A clinical deficiency of vitamin D during childhood can result in structural deformities that result in a clinical diagnosis of rickets. The other options will not cause this type of structural deformity.
Baked potato and broccoli are high in potassium. All of the other options reflect food sources that are lower in potassium.
Whole grain products can contain large amounts of phytic acid (phytates), which can limit the absorption of several nutrients: calcium, zinc, iron, and magnesium. Options 2 and 3 are incorrect because phytic acid is composed of inorganic phosphate compounds. Option 4 is incorrect because phytic acid does not affect either sodium or chloride levels.
Because of loss of skin receptors, the older adult has an increased threshold to pain, touch, and temperature. When feeding or bathing, remember that the older adult may be unable to distinguish hot or cold or to determine the intensity of heat. The older adult may feel less pain than younger adults and complain of only pressure or a minor sensation. The older adult, however, is the only one who can identify if they have pain or not. An older client’s sensory perception is less acute than that of younger adults, so when giving a massage, less pressure is needed. Everyone, and especially the older adult, needs touch.
Anemic clients who do not respond to iron replacement therapy and present with symptoms associated with neuropathy are likely to be suffering from an underlying vitamin B<sub>12</sub> deficiency. Option 1 is incorrect because, even if the client were not being compliant, these types of symptoms would be due to an associated clinical deficiency. Option 2 is unrelated to any information presented in the question. Option 4 is incorrect because the use of vitamin C supplements would cause symptoms of iron overload since it enhances the absorption of iron.
Peptic ulcer disease can be aggravated by niacin, and the clients’ complaints of heartburn are indicative of GI irritation. Flushing is a side effect and although uncomfortable, it would not be as serious as gastric irritation. Dryness of the mouth is not life threatening. Diarrhea would be a symptom of niacin deficiency.
Avidin is a protein found in raw eggs that binds with biotin and decreases absorption of this vitamin. Options 2 and 3 represent foods that are high in biotin; option 4 is high in vitamin C.
Heme iron is considered to be the most absorbable form of iron in the body. In order to maximize absorption of iron, meat, fish, poultry, and ascorbic acid (vitamin C) can be used. Milk would interfere with absorption of the iron. Some green leafy vegetables contain oxalate, which also interferes with absorption. Water would not increase absorption.
The catabolism of fats provides the most energy (460 molecules of Adenosine triphosphate) because they are the most concentrated energy source (9 kilocalories per gram). Option 1 is incorrect because vitamins do not yield energy although they function as coenzymes in metabolic processes. Options 2 and 4 are incorrect as both proteins and carbohydrates provide 4 kilocalories per gram.
Vitamin B deficiency can be manifested as peripheral neuropathy, usually experienced as numbness, tingling, and pain in the extremities. Options 1 and 4 can be related to several factors. Option 2 is frequently seen in clients with gastritis or gastroesophageal reflux disease, secondary to excessive alcohol intake.
Alcohol contains 7 kilocalories per gram and provides energy from these calories, but is considered a non-nutrient because it is not needed by the body. Option 1 is incorrect because alcohol provides calories but is not high in protein. Option 3 is incorrect as it is not a concentrated fat source. And option 4 is incorrect because alcohol provides energy but not protein.
Foods known to decrease the lower esophageal sphincter (LES) allowing reflux of gastric acid include chocolate, alcohol, coffee, tea, spearmint, and peppermint. Options 1 and 4 are incorrect because fruit juices and high-fiber foods do not decrease the LES. Option 3 is incorrect as dairy products would not need to be increased.
Pre-biotics are supplements that stimulate bacterial growth, often in the colon, which has been destroyed by antibiotic therapy. Probiotics are given to boost the immune system. Because they help to restore normal bacterial flora, they may prevent diarrhea, but this is not how they work. They do not destroy bacteria.
Due to the increased rate of metabolism associated with hyperthyroidism, additional calories are needed to meet increased energy needs. Protein might be increased, but overall calories are needed for energy. Vitamin supplements and iron are not necessary provided dietary intake is adequate.
Promoting independence is a basic nursing principle. Older adults thrive on independence, even with limitations. Older adults make their own decisions and do not appreciate others making decisions for them. Although some older adults cherish a family role, this is not necessarily the wish of every older adult. Remaining active is important for older adults; unnecessary protection from injury is inappropriate.
Fever increases basal metabolic rate (BMR) approximately 7% for each one degree rise in temperature. Option 1 is incorrect as metabolism is reduced in hypothyroidism. Option 3 is incorrect because although the energy needs of the post-op client are needed for wound repair, activity is reduced and client is NPO the first day. Option 4 is incorrect since metabolism decreases with age and fat cells require less energy than lean tissue.
Hyperthyroidism causes an increase in the production of thyroxine, which in turn increases metabolism and utilization of energy, often leading to weight loss. Osteoporosis does not produce a change in hormone levels and cause weight changes. Weight loss might be associated with options 3 and 4 secondary to anorexia and vomiting, but not due to hormone imbalances. The gall bladder stores and secretes bile for digestion and the pancreas secretes digestive hormones. In severe cases of pancreatitis, the production of the hormone insulin might be affected as well.
Foods known to produce gas, such as carbonated beverages, vegetables, milk products, caffeine, and high-fat and fat substitutes, can cause symptoms of IBS. A high-protein diet is not known to contribute to IBS. Fiber in the diet would not be contraindicated. Cholesterol is avoided with coronary heart disease.
Ketone production in the body can be seen in response to dehydration, starvation, low carbohydrate states, and metabolic conditions such as diabetes. Option 1 is incorrect because the presence of ketones reflects an acidic medium because ketones are composed of keto acids. Option 2 is incorrect as adequate carbohydrates prevent the formation of ketone bodies. Option 4 is incorrect because increased fluid intake decreases the likelihood of ketone production in the body.
Meals that are high in carbohydrates (option 4) promote rapid gastric emptying. The other options are associated with increased transit time because they contain sources of protein or fat, and meals of these types remain in the stomach for a longer time.
The increased surface area of the microvilli on the brush border of the small intestine favors the process of absorption by increasing the surface contact area. Option 1 is incorrect—there is specialization in the GI tract that allows for specific nutrient release in order to maximize absorption. Option 2 is incorrect because the small intestine has an alkaline environment. Option 4 is incorrect because dietary fiber consists of undigested material that usually enters the large intestine for bacterial degradation and elimination as feces.
Gastric surgical resection can cause an alteration in the absorption of nutrients due to altered surface area, thereby delaying entry of food from the stomach to the intestines (i.e., decreasing absorption and digestion). Option 1 is incorrect because hypoactive bowel sounds might or might not affect absorption. Option 2 would affect fluid reabsorption in the large intestine, but most nutrients would have been absorbed before entering the large intestine. Option 3 may affect elimination patterns but does not affect the absorption of nutrients.
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.
Antibiotic therapy can lead to destruction of normal intestinal flora that is used to synthesize vitamin K. Yogurt contains bacteria that help to promote intestinal synthesis. The other options do not contain necessary bacteria.
Celiac disease is a malabsorption disorder affecting the small intestine in which there is a problem with the ingestion of gluten, a protein normally found in grain products such as wheat, rye, oats, or barley. The other options reflect substances that do not contain gluten and should not pose problems for a client with this disorder.
Driving at night requires caution because accommodation of the eye to light is impaired and peripheral vision is diminished. Keeping the inside of the car warm at all times is not a significant issue when driving during the day or in warm climates. Reflexes are slowed for older adults; thus, caution in driving should be emphasized for this group.
Because of deficient nutritional intake, the client with alcoholism frequently has deficiencies of many nutrients. Electrolytes that are particularly affected are magnesium and phosphorus, since they are utilized in maintaining energy production and numerous enzyme reactions.
Clients who are in shock are likely to form lactic acid as the body reverts to anaerobic metabolism in order to maintain homeostasis. Options 1 and 2 are incorrect—these represent metabolic processes that require oxygen (aerobic metabolism). Option 4 is incorrect because transamination involves the exchange of amine groups in amino acids and reflects an anabolic process.
Vitamins function as coenzymes in many of the metabolic processes in the body to facilitate energy release. Options 1 and 3 are incorrect—by themselves vitamins do not provide energy or supply additional calories. Option 4 is incorrect—vitamins should not be consumed in large quantities because they can reach toxic levels (fat-soluble vitamins).
Clients with alcoholism are usually deficient in thiamine, which is needed for carbohydrate metabolism. Administration of glucose solutions can precipitate symptoms of Wernicke’s encephalopathy, characterized by disorientation, memory difficulties, diplopia, ataxia, and nystagmus. The other symptoms may be experienced for other reasons in the alcoholic client, but option 1 is most indicative of the thiamine deficiency.
Crohn’s disease can occur at any location in the GI tract, and the most common clinical manifestations are diarrhea, abdominal pain, weight loss, and fatigue. The disease is not characterized by constipation or uremia. The amount of bulk or fiber in the diet is reduced during acute episodes to control the diarrhea.
The inclusion of dietary fibers helps to add fecal weight (soluble) and bulking (insoluble), which assists with elimination patterns. Option 1 is incorrect because fiber does not provide a coating effect to the gastric lining. Option 3 is incorrect because dietary fiber can affect digestion of nutrients, especially when consumed in large amounts. Option 4 is incorrect because there is no evidence to support the practice of taking mineral oil with dietary fiber to facilitate digestion, transport, and absorption.
A client with TMJ disorder is at risk for developing swallowing problems due to pain experienced from incorrect jaw alignment. Option 1 is incorrect because this client would have problems related to the esophagus. Option 2 is incorrect because “fast food” ingestion does not cause digestive problems. Option 3 is incorrect because a client with wisdom teeth removal may have initial discomfort and swallowing problems, but they usually resolve as healing occurs. Clients with TMJ disorder are likely to have acute exacerbations that can become problematic, affecting dietary intake and leading to a significant complication—weight loss.
Steatorrhea (i.e., bulky, foul-smelling stool) is a common finding related to malabsorption of fats. Option 2 is incorrect—gastric emptying time would be decreased as nutrients pass more quickly because they can’t be absorbed. Option 3 is incorrect because diarrhea and steatorrhea are more common findings. Option 4 is a nonspecific finding that is independent of fat malabsorption and may be related to other factors such as anemia and decreased oxygenation states.
Eating late at night can lead to development of GI symptoms as increased presence of food in the stomach leads to an increase in acid secretion. If the client lies down with a full stomach, it further causes gastric distention and aggravation of clinical symptoms. Option 1 is incorrect because use of a daily antacid can cause alterations in digestion, transport, and absorption of nutrients that can further increase GI discomfort. Option 3 is incorrect because there is nothing to indicate that this client has a problem with swallowing or dentition. Option 4 is incorrect because water and fiber are necessary in the diet to facilitate adequate elimination patterns.
Catabolism refers to processes involving the release of energy in order to restore body dynamics and is seen in clients undergoing acute periods of starvation and/or traumatic injury. The client in option 4 has the most severe triggering condition for catabolism. The client in option 1 would undergo catabolism, but this is a short-term event compared to option 4. The clients in options 2 and 3 are in an anabolic pattern of metabolism representing growth states and new tissue development.
Taking medications on time and, if a dose is missed, taking the next one on time indicates proper self-administration. Misuse of medications by older adults includes combining prescribed and over-the-counter medications, having prescriptions from different physicians and failing to tell each doctor what has previously been prescribed, and taking someone else’s medications.
Lactic acidosis is associated with anaerobic metabolism. All of the other options represent metabolic processes during which oxygen is required.
Lactose intolerant individuals usually lack the enzyme lactase, which is necessary to break down milk sugars. Lack of the enzyme causes abdominal cramps, diarrhea, and gas formation. The other symptoms would not be caused by lack of lactase.
Ketone bodies are formed in response to the incomplete breakdown of fatty acids, when lipids are used as an alternate energy source in response to low ingestion of CHOs, high protein or high fat intake, or fasting states. The presence of ketone bodies is associated with acidotic states.
Celiac disease is due to inability to digest gluten sources, such as found in wheat, rye, oats, and barley products. All other options have an unrelated source of gluten.
Dizziness is a sign of overexertion and as such should alert the client to alter her present exercise regimen. Option 1 is incorrect because decreased, not increased, fetal movement is sign of overexertion due to decreased oxygen supply. Option 2 is incorrect as headache may occur for many other reasons and is not necessarily correlated with overexertion. Option 4 is incorrect because diaphoresis (i.e., profuse sweating) is a normal response to exercise.
Protein needs increase by 20 grams during lactation, and therefore protein-rich foods should be consumed. Option 1 is incorrect because caloric needs only increase by 500 calories during lactation, and a 750 calorie increase would result in weight gain. Option 3 is incorrect as it is unwise to decrease calories during the pregnancy period because the mother's nutritional stores will be depleted. Option 4 is incorrect because if a diet is adequate in calcium, then supplementation is not needed; the requirement is the same for similar-aged lactating and non-lactating women.
Formula must be prepared according to manufacturer's directions to ensure that adequate nutrients are received. All of the other options reflect adequate client teaching.
Most infants feed 6–8 times per day and consume two to four ounces per feeding. This infant does not seem to be feeding often enough. A likely explanation is a sleepy infant who is not being roused frequently enough for eating. Options 2 and 3 are incorrect because the intake pattern is not acceptable. Option 4 is incorrect as it presumes that there is a more serious problem than is reflected by the information provided.
A young pregnant adolescent is at highest risk because this age is associated with rapid growth and increased nutritional demands that are further exacerbated by pregnancy. The clients in the other options have concerns but they are not as immediate. The 27-year-old will have to be monitored for signs of continued altered eating habits, but the choice reflects a past history. The 37-year-old is at risk because of age versus nutrition and the fact that this is her first pregnancy. The 23-year-old will have to be monitored because she is already overweight prior to the demands of pregnancy.
Values that meet or exceed two or more of the designated glucose parameters are considered diagnostic for GDM. This client exceeds parameters in all four levels (i.e., greater than or equal to 95, greater than or equal to 80, greater than or equal to 155, greater than or equal to 140). The other options are incorrect because they do not indicate the client has GDM and there is nothing to indicate that the test results are not valid.
Interrupting the flow of urine assists the external urethra to contract and strengthens pelvic floor muscles. Other actions involve assessment activities.
Protein increases are recommended due to losses in urine, and sodium intake is reduced slightly due to potential edema formation. Options 2 and 4 are incorrect because fluids should not be restricted in pregnancy due to a risk of dehydration. Option 1 is incorrect as proteins should never be restricted because of losses in urine, and a proportional increase in carbohydrates may result in increased weight.
Some anticonvulsants interfere with vitamin D production, increasing the risk of deficiency. Therefore, supplementation may be indicated. Option 1 is incorrect as changing drugs is not usually wise if the disorder is well-controlled. Option 2 is incorrect because even though folate has been known to alter anticonvulsant uptake, the risk of neural tube defects outweighs this difficulty so supplementation is still indicated. Option 3 is incorrect since women may experience increases in seizure activity during the pregnancy; decreasing anticonvulsant doses would not be appropriate.
Weight below the 5th percentile for height is diagnostic for failure to thrive.
Young children should not be given hard, round foods that do not dissolve easily, (e.g., hot dogs) because the risk of choking is too high. All of the other options contain foods that are appropriate or prepared in such a way to make them appropriate and do not pose safety risks.
Weight reduction is never indicated during pregnancy. Moderate weight gains of 15–25 pounds are recommended for overweight clients. Option 1 is incorrect—an in increase in calories in the first trimester is not indicated, whereas in the second trimester and third, caloric needs are increased by 300. Option 2 is incorrect because weight reduction is not indicated during pregnancy. Option 3 is incorrect—all pregnant women receive supplements (e.g., prenatal vitamins) to ensure adequate folic acid is obtained, regardless of dietary intake.
Colostrum is produced before milk until about 4 days postpartum. It is yellow, rich in nutrients, and should be consumed by the baby. Option 1 is incorrect: There is nothing to suggest that the client has a breast infection (e.g., temperature or breast soreness). Option 2 is incorrect: Dehydration may be associated with letdown of milk, not color. Option 4 is incorrect because foods do not affect color (but might alter taste).
Single-grain infant cereals are recommended first because they are easily digestible and have added iron content. Option 3 is incorrect because yogurt is a milk product, and introduction should be delayed until 12 months because of the risk of milk allergy. Options 1 and 2 are incorrect because fruits and vegetables are usually given following the introduction of cereals.
Caffeine may increase a heart rate that is already stressed due to pregnancy. Sodium may cause fluid retention. Both may need to be restricted. The other answers are incorrect because calories, fat, and protein are not usually decreased due to the risk of nutrient deficiencies.
A sign of anemia is pale conjunctiva. If resolved, the conjunctiva should be pinker. The other symptoms are not specific to iron deficiency and are usually associated with other vitamin or mineral deficiencies.
At the beginning of therapy, it is essential that parents understand its importance. Other information is less of a priority. The other options contain information about administration, monitoring effectiveness, and side effects, which can be explained later.
Transparent film dressings on a clean, noninfected wound can be left in place for days, until the seal is broken, exudate leaks out, or the edges roll up. Older adults are at risk for skin breakdown. A nurse needs knowledge of what dressings are chosen and when they are changed.
Vitamin E is a fat-soluble vitamin, and the infant is at greatest risk of deficiencies due to impaired fat absorption. The other nutrients are also at risk for deficiency but usually because of inadequate stores. All of the other options represent water-soluble vitamins.
A client receiving anticoagulant therapy should not take additional supplementation of vitamin K, either through dietary intake or supplemental therapies. Vitamin K antagonizes sodium warfarin (Coumadin). Option 2 is not advised because increased dietary intake can also influence this drug, resulting in altered clotting times. Option 3 is incorrect for the reasons stated above. While it is important to discuss any supplemental therapy with the healthcare provider (option 4), the time delay would place the client at risk for complications related to anticoagulant therapy.
Nutrient stores exhausted during major trauma include protein, B complex vitamins, zinc, and vitamins A and C. Option 2 is rich in all these nutrients. All of the other options reflect a lack of specific nutrients needed to replenish stores.
The most likely explanation is the death of the spouse. All of the other choices reflect factors that would have been present previously; the client had no health problems until the spouse died. Depression and loneliness have been documented as major causes of nutrient alterations in the elderly.
Due to strong correlation between NTD and folic acid deficiency, a 0.4 mg/day supplement is recommended for client considering pregnancy. Note that a dose of 0.6 mg/day is recommended for pregnant women; 4 mg/day is recommended for short-term dosing for women with past history of pregnancy with NTD.
A poorly positioned infant can cause trauma to the nipple. Although nipples can become infected, it is not most common cause. Breasts should be cleansed after feeding; letting breast milk dry on nipples has been an effective treatment for sore nipples due to high fat content and anti-infective substances in breast milk.
According to BMI criteria, the client would be considered overweight and advised to maintain weight gain between 15–25 lbs. A less than 15-pound gain is the restriction for obese clients; weight gains of 25 pounds or greater are for clients of normal weight or who are underweight.
Dark, leafy vegetables such as spinach are an alternative source of vitamin C. Corn is a good source of fiber but not vitamin C; sweet potatoes are rich in vitamin A; celery provides water and fiber.
PKU is a genetic disorder that reflects a problem with the metabolism of phenyalanine. A special diet should be followed that limits the intake of this amino acid in order to avoid potential metabolic complications. The other options do not acknowledge that this inborn error of metabolism has lifelong consequences.
Foods should be introduced singly to identify allergies if they occur. Combination foods, such as those that would be served to the family, are not advised due to difficulty identifying allergies. Some table foods may have high-sodium substances not tolerated well by an infant. Cereal should not be placed in bottle because it deprives the infant of an opportunity to develop chewing muscles. Formula should not be stopped all at once, but rather gradually weaned as the amount of solids increases to prevent weight and nutrient loss.
Ecchymoses are not the result of aging.
Vitamin C promotes collagen formation and hence wound healing. Vitamins B<sub>1</sub> and B<sub>12</sub> are involved primarily with the neurological system; vitamin K is involved with the blood coagulation cascade.
Glycosylated hemoglobin (HbA<sub>1c</sub>) levels are indicators of longer term glucose control (e.g., for past 4–8 weeks); 12% indicates poor control, not good control. To determine cause and best treatment, a comprehensive evaluation of diet and so on would be indicated. One value of 12% would not necessitate insulin administration.
Decreased saliva makes it difficult to moisten the food bolus so that it can be swallowed. Periodontal disease and jaw deterioration affect chewing. Decreased peristalsis affects passage of bolus once in esophagus.
Kidney beans are legumes and contain 5.6 g of insoluble fiber per one-half cup. The other foods are not fiber rich.
The American Diabetes Association Exchange Lists divide food into similar content (e.g., milk, vegetables, fruit, starch/bread, meat, and fat). Each food within a list is similar in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, and orange is fruit.
Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to the client.
Clients should remain NPO upon admission to the clinical setting with a major burn. Initial fluid replacement is started via the parenteral route. NPO status is maintained because burn injuries may cause internal damage to body structures and aspiration can occur. Options 1, 2, and 4 are incorrect because fluids and food via the mouth would be restricted at this time.
Abuse of laxatives and diuretics is a frequent “purging” behavior for bulimic clients. Options 2 and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a reward.
In a 2-gram sodium diet, foods high in sodium content should be eliminated. It is not enough to stop adding salt or to go only by taste; clients should also be taught to read food labels for hidden sodium content. Added salt while cooking is allowed in a 4-gram sodium diet, not a 2-gram sodium diet.
The American Heart Association recommends a diet with reduced saturated fats and cholesterol for clients with coronary artery disease. Canned peaches are high in concentrated sugars, which increase triglyceride levels. Egg yolks are high in cholesterol and whole milk is high in saturated fats. The other options reflect appropriate food selections that are low in saturated fat and cholesterol content.
Driving a car and having the independence to ride with friends is an important milestone for high school–aged adolescents. Some adolescents experiment with alcohol and drugs, putting them at increased risk for motor vehicle accidents. Option 1 is a risk for working adults, and options 3 and 4 are risk factors for the elderly.
Prealbumin is a sensitive indicator of changes in nutritional protein status. Serum albumin can provide data about visceral protein stores but has a relatively long half-life and may not accurately reflect recent protein losses. Prealbumin can also alert the nurse to clients at risk for pressure ulcer development.
A client with GERD should limit (or possibly eliminate) the intake of coffee because this can relax lower esophageal sphincter (LES) pressure and lead to symptoms. The other options would not be warranted because all would contribute to the development of symptoms: large meals, spicy foods (e.g., extra garlic), and peppermint (which would relax LES pressure).
The eggs provide 24 grams of protein and the whole milk adds calories. The other options are lower in protein and calories. A client recovering from burns requires a high-protein, high-calorie diet. Option 1 does not reflect an adequate protein source. Option 3 reflects an increased carbohydrate source and bacon is considered a fat, not protein. Option 4 does not reflect a high-protein, high-calorie meal but rather a low-calorie meal selection with greater carbohydrate content.
Consistency and gentle firmness allow the client to learn that the nurse will follow through and do what is promised. Option 1 is not therapeutic; it may actually push the client away by making too many demands at too rapid a pace. Trust must be established slowly and respectfully. Option 2 allows the client to use manipulative behavior, and option 3 does not develop trust; it is directing/ordering behavior.
Regular exercise can help to normalize bowel function. Cigarette smoking and gum chewing increase swallowed air, while fresh vegetables produce gas.
It is important in the early stages of treatment that a staff member sits with the client during mealtimes to offer encouragement and help calm fears of eating. The other options are not appropriate at this time. Having the client’s mother come during meals may affect the client’s coping status, while leaving the client alone may cause the client to refuse to eat. Obtaining an order for a feeding tube is not warranted at this time, since there is no clinical information to support an alternate feeding approach.
Total kilocalories are based on the hypermetabolism response, which is proportional to the size of the wound or total body surface area burned. Weight does figure into the formula, but not height. Cause and location do not affect total kilocalorie needs.
Increased intake of salad and fresh fruits and vegetables can lead to increased flatus formation in a client with a colostomy. Eating pasta, cereal, and milk and increasing fluids are not associated with increased gas formation. It is important for both the nurse and client to recognize foods that can be gas-forming and limit their inclusion in the diet.
Sodium and potassium are lost via an ileostomy, and these foods are high in potassium (e.g., oranges and potatoes) and high in sodium (e.g., tomato juice). Asparagus is not high in either and may cause an odor. Chicken breast is a healthy choice, but not to offset the electrolyte losses.
Type 1 diabetics should monitor blood glucose levels before, during, and after routine exercise. If levels before exercise are above 100 mg/dL, no additional food is needed. Exercise will lower blood glucose, so additional insulin is not needed. Adjustment of CHO intake prior to practice is not indicated as client’s blood glucose level is above 100 mg/dL.
The American Diabetes Association Exchange Lists group foods according to composition (i.e., similar calories, fat, protein, carbohydrate). One serving can be exchanged for another within the same list. Milk and yogurt are on the milk list. Peanut butter is on the fat list, while ground beef is on the meat list. Carrots and eggplant are on the vegetable list, while grapefruit is on the fruit list. Bagels are on the starch/bread list.
The gastrointestinal system is the system that most older adult clients have complaints about, yet it remains the healthiest system over time with proper diet and care. Prolonged use of laxatives can lead to dependence on them for stimulation of defecation and can actually lead to uncontrollable defecation.
Emotional stress, psychological factors, and food intolerances have been identified as factors that can precipitate irritable bowel syndrome. Carbonated beverages (including seltzer) increase intestinal gas; laxatives can perpetuate constipation and should be avoided; fiber and bulk help to regulate bowel movements and should be increased.
To minimize the risk of a client’s developing dumping syndrome, the client should take several small meals throughout the day rather than large meals, which would cause increased stomach distention. Fluids should be taken either before or after meals to minimize the possibility of developing nausea. The diet should be low in simple sugars, moderate in fat, and higher in complex CHOs and protein. The addition of milk with every meal can cause possible abdominal bloating.
Liver is an organ meat and is therefore high in cholesterol. Egg yolks are also high in cholesterol. Chicken and yogurt are low in cholesterol, while carrots are a plant product and do not contain cholesterol.
The most important objective is to normalize food intake with close supervision to control purging (vomiting, laxatives, diuretics). The other options are secondary to stabilizing nutritional status.
A client who is HIV-positive (regardless of sex) is likely to lose weight due to repeated cycles of wasting and malnutrition. The client, who may be unable to merely increase caloric intake, should be instructed in dietary techniques that maximize quality of intake. Option 1 is incorrect because even though a food diary would provide pertinent information, the response allows for a delay in treatment that could result in further weight loss for the client. The priority is to intervene early on to prevent the onset of wasting. Option 2 is incorrect as it provides the client with a false belief that fluid retention changes associated with the menstrual cycle may have an impact on nutritional status. Option 3 is incorrect because even though increased salt in the diet can lead to fluid retention and weight, it does not address the underlying issue of nutritional balance.
Sjögren's syndrome is an autoimmune disease that destroys exocrine glands in the body, and leads to a generalized “dryness” of body systems. The restriction of fluids is a concern because the use of fluids helps to keep the oral cavity moist. There is no information to suggest that the client has a need for fluid restriction due to other disease processes so this order should be clarified. All of the other options are reasonable for this client.
Due to the anorexia and fatigue frequently experienced by clients with SLE and the need to maintain adequate nutrient intake, small frequent meals are usually tolerated better than large meals. Option 2 is incorrect because the diet should include all nutrients, not just fats and protein. Options 3 and 4 are incorrect as citrus and spicy foods do not necessarily need to be avoided, unless they induce nausea in the client.
A client who is recovering from Guillain-Barré syndrome will need a diet that promotes positive nitrogen balance in order to counteract the effects of long periods of immobility on the body. Option 1 is incorrect as there is no evidence to support that the client is experiencing malabsorption at this time. Option 3 is incorrect because there is no clinical reason to limit fresh fruit. Even though the client may experience difficulty in chewing and swallowing, this is usually in the acute phase of the disease process. Option 4 is incorrect as there is nothing to suggest that the client is experiencing problems in this area or is at risk for aspiration.
Although some raw foods could be a source of contamination to the client with HIV who is immunocompromised, it would not be necessary to avoid all uncooked foods, such as fruits and vegetables. The nurse should clarify this statement by the client in order to provide accurate information. All of the other client statements reflect information that is appropriate for the management of client with HIV/AIDS.
Malnutrition is seen as a consequence of the HIV/AIDS virus because the disease process has a progressive effect on client's nutritional status. Option 1 is incorrect because even clients who are asymptomatic may already have nutrient deficiencies and could be experiencing “subclinical” signs of malnutrition. Option 2 is incorrect as wasting syndrome occurs early in the disease process; current clinical research states that the maintenance and preservation of nutritional status is a priority in the clinical management of this condition. Option 4 is incorrect because clients can experience vitamin and mineral deficiencies early on during the disease process.
Severe osteoporosis causes bone density loss, which can result in pathologic fractures when the client is moved. A lift sheet can reduce the risk. The other choices do not address this safety issue.
Dry mouth can be a common complaint of clients undergoing radiation therapy. Using sugar-free candies or gum will help to stimulate the flow of saliva and ease the discomfort that the client is experiencing. Eating meals prior to radiation therapy may lead to increased nausea because the client would be lying down following eating the meal. It has no effect on complaints of a dry mouth. Eating larger portions of food will not help to ease complaints of a dry mouth. Furthermore, the client may not be able to increase the size of meals due to side effects experienced as a result of radiation therapy. The use of mouthwash can further cause the mouth to be dry and intensify the client's symptoms.
Nutritional goals for a client with hepatitis are aimed at providing a diet that is high in calories (e.g., 3,000–4,000 kilocalories) and high in quality protein (e.g., 1.5–2.0 grams per kilogram). The diet should also be adequate in carbohydrates to spare protein and fat, provide concentrated calories, and improve the taste of food. Option 1 is incorrect because the nutritional management of hepatitis is the same for all types. Option 2 is incorrect as there is no clinical indication to place the client on tube feedings given the information provided. If the gut works, then the usual clinical model is to use it. Option 3 is incorrect because dietary fat should not be limited unless the client is experiencing problems with malabsorption (e.g., steatorrhea) and there is no evidence to support this.
An albumin level of 2.5 miligrama per deciliter indicates decreased protein stores and decreased albumin synthesis by the diseased liver. In cases of hepatic encephalopathy protein will be limited, but there is not evidence of this. Although dairy products do provide some protein, beef and chicken would provide the best source of protein. Fruits and grains would not provide protein.
COPD places a client at risk to develop malnutrition due to reduction in muscle mass and fat reserves. Option 1 is incorrect because COPD clients are more likely to suffer from respiratory infections due to altered immune response (e.g., decreased cell-mediated immunity, altered immunoglobulin production, and impaired cellular resistance). Options 3 and 4 are incorrect because COPD clients usually present with weight loss and are hypermetabolic (i.e., require additional calories due to increased energy requirements as a result of increased work of breathing).
A client with MS is prone to developing both bowel and bladder dysfunction as a result of this progressive degenerative neurological disease. Increasing fluids and roughage in the diet will help to facilitate evacuation by improving stool consistency. Option 1 is incorrect—the client needs increased fluids. Option 3 is incorrect because increasing ROM exercises provides for joint motion but does not necessarily exercise the abdominal muscles, which could influence peristalsis. Option 4 is incorrect because there is not enough clinical information provided to make this determination. The nurse would have to question further for elimination pattern and the date of the client’s last BM.
Even though a client has had an SCI, the use of a diet high in protein, carbohydrates, and fiber is necessary to prevent both the catabolic process that occurs following SCI and potential problems with bowel function. Option 2 is incorrect because it reflects the belief that weight loss is an easy goal to achieve. Option 3 is incorrect because it assumes that merely getting foods that the client likes will correct the problem. Option 4 is incorrect—excess nutrient stores will not merely help to preserve skin integrity but are needed for overall support of the client’s metabolism and immune response.
Scrambled eggs, white toast, and coffee are all foods that are low in purine content. A client who is being treated for gout should restrict dietary purine sources because they can lead to an exacerbation of the disease process. All of the other choices reflect dietary selections that range from moderate to high purine content. If dietary education is successful, then the client would avoid/limit these food selections.
A client undergoing a BMT will probably be fed by TPN in the post-transplant period due to potential complications affecting the mouth, esophagus, and intestines, leading to diarrhea and malabsorption. Option 1 is incorrect—supplemental enteral feedings would not help because the client’s GI tract has been affected by chemotherapy and other medical treatments. In addition, merely supplementing the client will not provide sufficient calories and nutrients. Option 2 is incorrect because oral intake is usually not available due to side effects from high dose chemotherapy regimens that lead to anorexia, taste perception, nausea, vomiting, and inflammation of mucous membranes. Initiation of oral feedings will not prevent gastroparesis. Option 4 is incorrect—there is nothing to suggest that a PEG tube would be indicated. The goal with BMT clients is to return to a “normal” route-feeding regimen as soon as possible once clinical effects of immunosuppression have been resolved.
A client complaining that he has “difficulty eating and swallowing just about anything” may have a fungal infection of the mouth and/or esophagus. A clinical diagnosis of AIDS suggests that the client is at high risk for developing an opportunistic infection. Option 1 is incorrect—even if the client may not be able to shop because of fatigue or other factors, it does not directly explain the client’s statement. Option 2 is incorrect because the client’s complaint addresses the issue of swallowing, not anorexia. Option 4 is incorrect—there is nothing to suggest that the client has not been compliant with the medication regimen. The presence of opportunistic disease can occur even in the presence of medication therapy due to underlying immunosuppression.
A client with COPD is often hypermetabolic from the disease process and requires increased calories, proteins, vitamins, and minerals in order to maintain desired weight and meet additional energy demands. Option 1 is incorrect: Caloric intake is not adequate, and increasing fat percentage above 30% is not prudent. Option 2 is incorrect: Increasing carbohydrates in the diet can lead to increased respiratory workload due to excess acid production. Option 3 is incorrect because increasing activity level will not help to prevent weight loss. In addition, the client may not be able to increase activity level due to effects of COPD.
Posture changes shift the center of gravity in an older adult client and put the client at risk for falls. The other conditions increase the risk of injury if a fall occurs but not the risk of falling.
A client with scleroderma often suffers from increased acid secretion and esophageal reflux. This could pose a significant nutritional problem. Option 1 is incorrect—anorexia is not commonly associated with this disease process. Option 2 is incorrect because alternating periods of constipation and diarrhea are usually seen in a client who is experiencing irritable bowel syndrome (IBS). Option 4 is incorrect—skin becomes hardened during this disease process and skin turgor is not increased.
Cancer cachexia is a syndrome that occurs in clients with cancer (malignancy) that leads to a loss of muscle, fat, and body weight. It is thought to occur due to tumor-induced changes that cause profound effects on metabolism, nutrient losses, and anorexia. A cycle of wasting is established because alterations in nutrient requirements and intake lead to high cell turnover in body organs, affecting the GI tract and bone marrow. Alterations in digestion occur along with decreased immune response. Option 1 is incorrect—in simple starvation the body adapts to a lower metabolic rate. A client with cancer cachexia does not have an adaptive metabolic rate. The metabolic rate can be normal, decreased, or increased. Option 2 is incorrect because cancer cachexia occurs in the presence of both chemotherapy and radiation. Option 4 is incorrect—cancer cachexia can be seen in clients who have adequate caloric intake because it is not calorie dependent.
A client who is receiving isoniazid (INH) as a prophylaxis for tuberculosis is at highest risk for deficiencies of vitamins, specifically vitamin B<sub>6</sub> (because the drug acts as a vitamin antagonist) and vitamin B<sub>12</sub> (interferes with absorption). All of the other choices do not occur as a result of the action of this medication.
Megesterol acetate (Megace) is oral progesterone that is used for both male and female clients to boost appetite and promote weight gain. It is important that all clients receive accurate information about prescribed medications and are aware of the indication for the drug, potential side effects, and expected response to treatment. The nurse should respond to the client’s concern initially with factual information because the client does not seem to understand the effect of the medication. Options 1 and 4 are incorrect because they do not address the client’s concern and may further increase his anxiety about body image changes. Option 3 is incorrect: Even though the client has the right to refuse any treatment, the response does not attempt to communicate pertinent factual information and may even reinforce the client’s concern of body image changes.
Food should be cooked to reduce bacteria, which the immunosuppressed client cannot fight effectively. Option 3 is incorrect, while options 2 and 4 are not relevant to the question as stated.
Even though protein restriction is the mainstay of therapy for clients with impaired renal function, high biologic value proteins are favored due to their high content of essential amino acids. Option 1 is incorrect because high biologic value proteins help to minimize urea production by allowing synthesis of nonessential amino acids from essential amino acids. Option 2 is incorrect: Protein restriction is needed because the kidneys’ ability to excrete nitrogenous end products is impaired in clients with renal disease. Option 4 is incorrect: Even though it is true the high biologic value proteins are necessary, they are not reserved only for clients on dialysis.
Vitamin C in megadoses can increase the risk for oxalate stone formation. It would be important to determine the amount of vitamin C that the client is taking in relation to the potential effects of stone formation. Option 1 is incorrect: Even though vitamin C has antioxidant effects, the potential for stone formation outweighs the benefit of taking large doses of vitamin C. While it is important to increase fluids to prevent urinary stasis, option 2 is incorrect because the statement does not specifically address the issue of vitamin C supplements. Option 4 is incorrect: Animal protein should be decreased in order to minimize potential stone formation.
Elemental zinc taken with food or milk will help correct alterations in taste (dysgeusia). Option 1 is incorrect because this intervention is used to treat anticipatory nausea. While it is important to monitor a client for signs of dehydration (option 2), it is more important to correct altered taste sensation to enable the client to increase intake. Option 3 is incorrect because highly seasoned foods can cause nausea and irritation.
Small and frequent meals provide for adequate intake with reduced fatigue and SOB. Simple carbohydrates do provide quick energy, but a mixture of nutrients reduces carbon dioxide production and maintains respiratory function. Fat consumption can lead to hyperlipidemia and should only provide approximately 30% of total calories. Most individuals have more energy in the morning than evening.
A client experiencing ascites due to liver failure has decreased protein levels (i.e., albumin) that lead to third spacing of fluids. The calculation of dry weight (total weight minus the weight of ascites) is critical to determining fluid status and medical management of the client. Option 1 is incorrect because it does not address the issue of ascites specifically but rather looks at a strict volume measurement. Option 2 is incorrect because one would expect abnormal liver function tests but this information is again not specific to fluid status but rather to the status of liver function. Option 3 is incorrect: Even though serum protein levels would be expected to be low, the caloric intake level would not help to define fluid status.
Motion receptors can be stimulated with instillation of large amounts of fluid. Nausea or vomiting would be stimulated. Relief will occur if the irrigation procedure is stopped.
A client being treated for hepatic encephalopathy has increased ammonia levels and is likely to be experiencing mental status changes and fluid retention (ascites). It is important for the dietitian to note that the client’s mental status precludes normal intake and nutrition support may be indicated. Option 1 is incorrect: Although a weight and caloric baseline would be important for the dietician to review, the current nutritional goal would be to decrease factors that could lead to fluid retention and increased ammonia levels. Option 3 is less important than understanding the mental status as a basis for formulating nutritional goals. Although it is nice to know that the client has been compliant with medical treatment thus far, option 4 is incorrect because it does not specifically address the establishment of nutritional goals.
The neutropenic client is immunocompromised and susceptible to bacterial contamination form food. Cross-contamination is avoided by using separate cutting boards. Vegetables may be eaten raw as long as they are thoroughly washed. It is not necessary to boil liquids and seeds and nuts may be eaten.
A client with Parkinson’s is at risk for aspiration. The statement by the client’s wife indicates that the client is experiencing an increase in clinical symptoms, such as drooling and impaired swallowing. The use of thickened liquids and proper positioning can minimize the risk of aspiration and help the client’s wife to feel comfortable and knowledgeable regarding feeding concerns. The spouse should also notify the physician because an adjustment in medications may be needed. Option 2 is incorrect: There is not enough information to state that the client should be switched to enteral feedings at this time. Option 3 is incorrect because merely increasing fluids in a client experiencing increased drooling and difficulty swallowing could further increase the risk of aspiration. Option 4 is incorrect: Merely using a straw will not help to correct the underlying problems and could possibly increase the risk of aspiration due to inability to manage fluids.
Organ meats, such as liver, kidney, brain, and sweet breads, are high in purines. Moderately high would be meats, seafood, and dried beans. The other choices are not high in purines.
Foods containing gluten (wheat, oats, rye, and barley) are restricted for a client with celiac disease, due to the client's inability to handle gluten protein. All of the other choices reflect items that cannot be used in a gluten-restricted diet.
A client taking MAO inhibitors must avoid foods that are high in tyramine because this can lead to significant complications, resulting in hypertensive crisis. Cottage cheese is unfermented and can be used in the diet. All of the other options reflect foods that are high in tyramine. Aged cheeses are not allowed on the diet.
It is critical to verify tube placement prior to administration of any enteral feeding regimen to prevent the risk of aspiration. All of the other options are important but they are not the highest priority at the present time.
A severely malnourished client with a nonfunctional gut is unable to meet nutritional goals through enteral feeding. This client needs to meet nutritional goals through total parenteral nutrition (TPN) via a central line placement. Option 1 is incorrect because this client will not be able to tolerate cyclic feedings due to existing clinical state. Options 2 and 3 are incorrect because both enteral tube feedings and PPN will not be able to supply enough calories and nutritional support for this type of client.
A client with gestational diabetes encounters increased metabolic needs from the pregnancy that result in an increased hormonal response and insulin sensitivity. Incorporating snacks in the diet plan will help to maintain a constant glucose supply and prevent potential imbalances. Option 1 is incorrect because a decrease in CHO sources is recommended for a client who has gestational diabetes in order to prevent excessive glycemic response. Option 2 is incorrect as an increase in calories is warranted, but this amount is too excessive and may further contribute to health problems and weight gain. Option 4 is incorrect because increasing CHO intake at one meal will lead to an overactive glycemic response.
TPN solutions should be administered via an infusion pump so that fluid rate and volume can be controlled. This will prevent the risk of developing FVE as a result of inadequate rate regulation, leading to increased potential volume. All of the other options reflect acceptable nursing actions in regards to TPN therapy, but these will not affect the nursing diagnosis of FVE.
Older adult clients are at risk for developing fluid overload during fluid therapy. The infusion rate should be slowed to as low as possible to prevent worsening of the problem. Then measure the vital signs.
Serum transferrin levels indicate visceral protein stores in the body. Albumin and prealbumin levels also serve to indicate protein status. Option 1 is incorrect because BUN levels can be affected by a multitude of factors ranging from dehydration to renal status. Option 2 is incorrect as CBC with differential indicates hematology status. While it may reflect anemia, it is not considered a protein status indicator. Option 3 is incorrect because it would give information about to elimination and renal status. While it may reflect protein spilled in the urine, it is not considered a protein status indicator.
Casein and whey are often used as additives and stabilizers in processed foods. The client with lactose intolerance may have difficulty digesting these additives since they are milk products. Sodium phosphate is a preservative. Lecithin is an emulsifier. Maltodextrin is a sugar.
It is important to acknowledge the client's concerns about lifestyle changes. The offer of assisting the client in designing a diet plan with the required restriction but yet focusing on palatability will increase client compliance. Option 1 is incorrect because this statement does not take into account client preferences or stated client concerns. Option 2 is incorrect as this statement does not acknowledge the fact that this is a necessary diet for the client to prevent clinical symptoms. Option 3 is incorrect because this statement is not therapeutic and is viewed as being a punitive choice.
This client presents in a depressed state with mild dehydration and recent weight loss. Enteral feedings via an NG tube would help support the client in meeting nutritional goals. Option 2 is not correct because the client's clinical status does not indicate the need for TPN administration at this time. Option 3 is not correct as surgical placement of a feeding tube is an invasive procedure that is not clinically indicated given the client information. Option 4 is incorrect because merely encouraging fluids, although high in protein, will not provide sufficient calories to maintain nutritional goals. Also, the client is admitted in a depressed state and, as shown by the recent history of weight loss, has not maintained adequate oral intake.
Clients should have a transition period from TPN to oral feedings. The GI tract will need time to adjust, and the client may experience some GI upset, so TPN is not stopped abruptly. Restriction to ice chips would not be necessary; diet can be resumed starting with fluids or as tolerated. The client might not eat sufficient calories during the day, so rate of TPN is usually tapered, rather than only infusing it at nighttime.
TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1 is incorrect because medication therapy can continue during TPN therapy. Option 3 is incorrect since flushing is not required for TPN administration. Option 4 is incorrect because the initiation of TPN does not require a client to remain on bed rest during therapy. Other clinical conditions of the client, however, might affect mobility issues and warrant the client requiring bed rest.
TPN solutions are hypertonic, hyperosmolar solutions that lead to an increased glycemic load. In response to this hyperglycemia, often a sliding scale insulin (with regular insulin) is used to restore, prevent, or control the effects of the hyperglycemia. Options 2 and 3 are incorrect because the TPN rate is individualized to the client and should not be adjusted unless directed by the physician because of changes in the client’s clinical conditions. Option 4 is incorrect: Only regular insulin is used as an additive in TPN solutions.
Elemental formulas represent predigested formulations of macronutrients that are beneficial to clients with severe digestive or absorption problems. Option 1 is incorrect: Modular formulas are not nutritionally complete because they provide only one nutrient source. Options 2 and 4 represent intact protein sources that are not suitable for a client with digestive or absorptive problems.
Avoidance and restriction of food items known to cause allergies is the most effective way to prevent the development of potential food allergies. Option 1 is incorrect: Even small amounts of “allergic” food items can trigger a response (sensitizing—challenging dose). Option 2 is incorrect: Increasing fluids does not affect allergy development. Option 4 is incorrect because the use of antihistamine medication might alleviate symptoms of allergic responses but should not be used as a prophylactic measure in assisting dietary selection.
Milk and milk products are limited in low-residue diets. All of the other diet selections can be used for this type of diet and indicate client understanding.
Determining cyanosis on older adult clients can be difficult, especially if they have darker skin. Fingernails and toenails can have ridges, fungal infections, and yellowing. The oral mucous membranes are the site where cyanosis and pallor are most obvious.
Presence of bowel sounds accompanied by passage of flatus indicates gastric motility and return of “normal” GI functioning. Option 1 is incorrect: Postoperative clients are progressed in diet to assist in the restoration of “normal” bowel activity. A bowel movement is not the initiating factor for diet progression. Option 2 is incorrect: Abdominal distention may indicate a potential problem affecting GI motility. Option 4 is incorrect: Even though client hunger may be present, it is not the deciding factor in diet progression.
A full liquid diet contains all food items found on a clear liquid diet plus dairy products and prepared liquid formulas. Options 1 and 2 represent selections that are only found on a clear liquid diet. Option 3 represents a selection found on a low-residue diet.
Transition (or progressive) diets are used on a short-term basis to help the client move toward resumption of a regular diet pattern. A transition diet can progress rapidly from one meal to the next if the client tolerates the feedings. Option 1 is incorrect because a transition diet is not given on a long-term basis. Even though option 2 includes meal planning and diet selection techniques, this is not the primary focus in establishing a plan of care for this client in this short-term therapy. Option 3 is important, but again, it is not the primary focus for this short-term therapy.
Most clients with lactose intolerance can tolerate H cup milk at one time, and it provides a calcium source. Option 1 is incorrect: Elimination of all dairy products can lead to significant clinical deficiencies of other nutrients and may not be necessary. Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods (especially fat) may decrease transit time and allow for increased lactase activity. Option 4 is incorrect because although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms.
A mechanical soft diet can be used as part of a long-term treatment plan because it includes most foods found on a regular diet, except the texture is modified to assist clients who have chewing problems. All of the other options reflect diets that should not be used on a long-term basis. Clear and full liquid diets are not nutritionally complete and are missing calories, protein, vitamins, and electrolytes. In order to meet nutritional goals, a full liquid diet would require additional source supplementation. Option 3 is incorrect because a long-term high-protein diet can place additional renal demands on the individual client because of imposed solute loads.
It is important to check residuals prior to intermittent feedings (and every 4 hours for continuous feedings) in order to evaluate if the client is able to process the feeding. Option 1 is incorrect: Going to the bathroom prior to a feeding will not affect the feeding status, and the client may also not be able to physically comply with this request. Option 3 is incorrect: Placing the client in this position is not warranted and can cause potential problems relative to impaired feeding or potential aspiration. Although monitoring of the client’s intake and output for the past 24 hours is important, it is not as critical as checking for a residual at this point in time.
The use of thickening agents is recommended for clients who have had CVA and have residual deficits that affect swallowing. The thickening agents are added to maximize texture, facilitate the swallowing process, and minimize potential aspiration risks. Option 1 is incorrect: Bite-sized portions of foods may increase the risk of aspiration if they are swallowed and occlude the airway. The diet should be soft. Option 2 is incorrect since merely placing the client on a full liquid diet gives no indication that the client is being monitored for potential aspiration or neurological deficits. Option 4 is incorrect because clients who are post-CVA often encounter this type of problem; therefore, they should be properly monitored.
TPN is indicated for disease states such as trauma/stress, surgical interventions, and/or related pathology of GI tract or oncological conditions. TPN is more appropriate for long-term nutritional support. All other options are clinical indications for enteral nutrition.
It is important to follow test diet instructions prior to diagnostic testing to ensure reliability and consistency of test results. Conveying the indication for the use of a clear liquid tray will help the client to understand the treatment plan and foster compliance. Although option 1 might represent an accurate statement, it will not help the client with to deal with the present situation. Option 2 does not provide an adequate explanation to the client. Although option 3 is technically true, this response may serve to alienate the client as the nurse is not being sensitive to the client’s needs.
Increased fluid needs are indicated for a client who has burn injuries due to release of plasma fluids through tissue destruction. All of the other options reflect clinical conditions that require a decrease in fluid needs.
It is important for the nurse to listen to the feedback given by the client to ensure the message sent was the message received. Repetition is important in the teaching process but does not evaluate clients’ understanding (option 1). Options 3 and 4 are unnecessary as part of evaluation.
A clinical diagnosis of gout is associated with high uric acid levels in the body. Uric acid represents the end product of purine catabolism in the body; therefore, foods that are high in purines should be avoided. Anchovies are high in purine. All of the other options represent diet selections that are low in purine.
The bag of TPN solution is changed every 24 hours. By reducing the number of times the TPN tubing needs to be connected and disconnected from the central venous catheter, the risk of infection is reduced, especially since high glucose levels in TPN can lead to bacterial growth.
A client being treated for dyslipidemia has an abnormal lipid profile that is high in cholesterol and triglycerides. The client needs a diet low in saturated fats with an increase in monounsaturated fats, small amounts of PUFA, and restricted sodium and hydrogenated food products. Option 1 is incorrect because high intake of PUFAs will cause a further increase in lipid levels. Option 2 is incorrect because protein-controlled diets are usually indicated for clients who have renal disease. Option 4 is incorrect because monounsaturated fats should be increased not decreased.
MAO inhibitor drug therapy can be complicated by excess intake of foods are high in tyramine (an intermediate product of amino acid metabolism), such as chocolate and cheese. These can alter drug action, resulting in hypertensive crisis. Although all of the other options are also important, they are not the priority consideration when monitoring a client on MAO therapy.
Visualization of portion sizes is an extremely important strategy whereby the client is shown graphic representations of what constitutes a serving size. Most often clients do not realize they are eating too large a portion, since traditional and “fast food” restaurants provide large servings. Option 1 is incorrect because following a low fiber diet may contribute to the development of weight gain because there is little satiety value in the diet. Options 3 and 4 are incorrect because an increase in other nutrients can lead to fat conversion during the metabolic process if intake exceeds the body's individual needs.
Malnutrition leads to severe metabolic and physiological consequences, resulting in the inability to maintain adequate temperature regulation. A client with malnutrition is most likely to be found hypothermic upon physical examination. Option 1 is incorrect because hypoglycemia is more likely to occur with malnutrition. Option 3 is incorrect as a decrease in metabolic rate is usually seen with malnutrition. Option 4 is incorrect because immune function is depressed due to loss of protein stores in malnutrition.
A comprehensive effort leads to the most effective long-term management in regard to weight control and will help to prevent the occurrence of weight cycling. Diet alone is not the answer to maintaining weight loss and avoiding the pitfall of weight cycling. If there are no other lifestyle modifications, then it is more likely that the client will regain or even surpass the initial starting weight. Although an increase in fluids is usually a beneficial choice in most diet plans (unless the client has fluid restriction issues related to disease processes), the addition of fluid will not help to prevent the occurrence of weight cycling. An altered meal pattern intake consisting of shakes/supplements for one meal may not translate to a balanced eating pattern. Again, if the client is not utilizing realistic goals and interventions, then resuming a “regular” diet pattern may lead to weight cycling.
The presence of central obesity (i.e., intra-abdominal fat/truncal obesity) is associated with an increased cardiac risk (hypertension and stroke) and diabetes. The accumulation of intra-abdominal fat leads to increased cholesterol levels because the liver converts them directly into low-density lipoproteins (LDL), a known risk factor for several disease processes. Option 2 is not clinically correlated as clients with cancer may present with cachexia or could be underweight. Option 3 is incorrect because an increase in central obesity is associated with an apple profile and it does not affect bone demineralization. Option 4 is incorrect since central obesity is usually seen in clients who smoke or drink alcohol, and it does not relate to vitamin deficiency.
Indoles are found in vegetables such as broccoli, cauliflower, and cabbage and offer protection against carcinogen development. All the other choices are phytochemicals; soy milk and green tea provide isoflavones; carrots are high in carotenoids.
It is essential to address the parent's concern as being important and to include the daughter (client) in the plan of care. A comprehensive nutritional evaluation is needed to support both of the family members. It is important to intervene, not merely react. Options 1 and 2 are incorrect because they are not based on nutritional evidence. Option 3 reflects an alarmist attitude that could worsen the situation.
To evaluate an unresponsive client’s ability to communicate, it is best for the nurse to ask questions that will elicit a single act or response by the client. Option 1 is not appropriate for the client’s condition. Options 3 and 4 may be noted during neurological assessment but do not relate to communication.
Garlic can inhibit platelet function thereby affecting coagulation ability during and after surgery. Nonsteroidal anti-inflammatory drugs and aspirin, but not acetaminophen, can potentiate the action of garlic. The other conditions would not be affected by garlic use.
A client who is 6 feet tall with an average size frame should weigh roughly 178 pounds (106 for the first five feet with 6 pounds for every inch above). Taking into account body frame, there could be a weight range from 168 to 188 pounds (small to large) that would be considered normal. Option 1 is incorrect because clearly the client is overweight with a calculated BMI of 27. Option 2 is incorrect as the client would not be considered to be obese but rather overweight. Option 4 is incorrect because the client clearly does not need additional calories in the diet.
It is important that a client receives accurate information about reported weight loss medication. Although diuretics promote fluid loss and are used in the clinical management of disease states (such as congestive heart failure and pulmonary edema), they do not promote fat loss and are therefore not an effective weight loss measure. Option 2 is incorrect because even though a prescription is required for the medication, it is not an effective weight loss treatment. Option 3 is incorrect as diuretics do have a therapeutic effect on fluid loss in the clinical setting in the management of disease states. Option 4 is incorrect because diuretics are not prescribed as an adjunct therapy for weight loss but might be used as an adjunct in the treatment of hypertension to promote fluid loss.
In order to affect a 2-pound weight gain, a client would need an extra 7,000 kilocalories per week, which would correlate to 1,000 kilocalories per day. Option 1 is incorrect because it does not give a specific amount of foods or calories. Option 3 is incorrect because 3,500 kilocalories per week would also lead to an increase of 1 pound. Option 4 is incorrect since a nutritional supplement may not provide the additional 1,000 calories per day needed.
A recommended weight loss pattern for the obese client is 0.5 to 1 pound per week. Option 3 offers the best possibility of maintaining weight loss. All of the other options are incorrect because too great a loss may predispose the client to weight cycling or loss of lean body mass.
VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates in order to spare protein and prevent ketosis.
Carotenoids are phytochemicals that have been found to decrease risk of CAD and are found in green, orange, red, and yellow fruits and vegetables. Option 1 is high in indoles. Options 3 and 4 are high in isoflavones.
Creatine has been demonstrated to improve the body’s response in an exercise pattern consisting of repetitive short-term activities. Option 1 is incorrect: Creatine is supposed to promote anabolism, not catabolism. Option 2 is incorrect because creatine has not been proven effective for long-term exercise patterns. Option 3 is incorrect because creatine does not decrease lean body mass.
It is important to inform the healthcare provider at the start of herbal therapy, because this can prevent problems from potential drug interactions, verify indication for therapy, and acknowledge the client’s concerns over common complaints. Option 1 is incorrect because it is critical for the client to read all labels in order to be an informed consumer. Even though there are standard products, herbal therapy ingredients can vary in different types of formulations. Option 2 is incorrect: No prescription is required, but herbal therapy can cause a financial burden to the client. Option 4 is incorrect since herbal therapy can cause side effects.
Garlic is a food/herbal product that has long been recognized for its health benefits (lowers cholesterol/triglycerides, improves immune function, and decreases BP). Garlic can inhibit platelet aggregation and therefore prevents blood clot formation. A client who is taking anticoagulation therapy should be advised of potential interactions with excessive amounts of garlic in the diet. Option 1 is incorrect—there is an increased risk of bleeding. Option 2 is incorrect because garlic does indeed affect blood coagulation. Even though garlic does help to support immune function (option 3), this fact does not directly relate to anticoagulation therapy.
A client who is blind does not have the benefit of nonverbal cues to facilitate communication and understanding of the environment. It is important for the nurse to explain physical surroundings and noises because the client cannot determine these without the added benefit of sight. Options 1 and 4 are approaches that a nurse should use with a client who is hearing impaired. Placing a sign on the client’s door encroaches on confidentiality.
Isoflavones and phytoestrogens are deemed beneficial in protecting female clients from developing osteoporosis due to their estrogen-like enhanced effects. Option 1 is incorrect because phenolic acids are effective against cancers because they act as pro-oxidants. Option 3 is incorrect as indoles make estrogen less effective. Option 4 is incorrect: Carotenoids are considered to be in the classification of phenolic acids and helps to decrease cancer risks.
It is important the client demonstrate an understanding of the basics of the treatment program, focusing on a multifaceted approach of intake, physical activity, and weight control. Each one of these is an interrelated variable that affects the client’s ability to achieve and maintain weight control. Option 1 is incorrect because this may not be prudent (physical activity is usually increased). Option 2 is incorrect as it is not wise to utilize this feeding pattern because it may contribute to weight gain. Option 4 is incorrect: The total calories may be somewhat low, but the percentage of calories from fat is too high to effect substantial weight loss.
Anesthesiologists recommend that all herbal and botanical preparations be stopped 2–3 weeks prior to scheduled surgery in order to minimize possible interactions between anesthesia induction and blood pressure response. Options 1 and 3 are incorrect for the reason just stated. Even though it may be good to discuss herbal therapies with a dietitian (option 4), it is more important to acknowledge that herbal therapies should be stopped prior to scheduled surgeries to minimize anesthesia risks.
An extra 3,500 kilocalories per week is needed for a 1 pound weight gain (500 kilocalories per day). Weight gain strategies revolve around consuming foods that provide many kilocalories in small volume along with building muscle.
Obesity is defined by BMI of 30 or above with no co-morbid conditions. It is calculated by utilizing a chart-nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. The other responses represent inaccurate interpretations of the client’s BMI.
Objective anthropometric measurements such as triceps skin fold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all of the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.
Ketchup contains lycopene, which is a phytochemical that has health benefits. Option 1 is incorrect as ketchup does provide flavor to food products, but does not address the concern about health benefits. Option 3 is incorrect because even though ketchup contains a large amount of sodium, this is not a health benefit and even can be viewed as a “hidden” source of sodium in the diet if used in excess. Option 4 is incorrect because ketchup is not a source of fiber in the diet.
A waist-to-hip ratio of greater than 1.0 in a male client indicates an increased risk to develop obesity. This indicates a larger amount of abdominal fat and correlates with an apple body shape. Option 1 is incorrect because a decrease in visceral fat stores in the abdomen would improve a client’s health status. Option 3 is incorrect: A BMI of 19 is associated with being underweight. Option 4 is incorrect because a male client who is 6 feet tall and 162 pounds has a BMI of 22, which is considered within normal range.
Using vegetables as a main dish ingredient will help to increase the amount of functional foods that have phytochemical activity. Option 1 is incorrect—even though milk is a good source of vitamin D and calcium, it will not by itself increase the amount of functional foods in the diet. While limiting the amount of refined food products is beneficial (option 2), this does not increase the amount of functional foods in the diet. Option 3 is incorrect since seasoning to taste may be important with regard to sodium level; however, it does not specifically relate to functional foods.
Leptin is a protein hormone that is secreted by adipose tissue; it is called the obesity gene. Leptin increases the total fat mass in obese clients. Option 1 is incorrect because the presence of leptin usually decreases food intake in normal weight individuals. Option 2 is incorrect because it does not affect the regulation of steroid hormones but does have some effect on insulin release.
Laundry baskets that are set on the floor will pose a risk for falling for the elderly client. All hallways, floors, stairways, and furniture should be free of clutter. Neighbors bringing lunch and family controlling climate for the elderly client are good safety interventions. Keeping diabetic supplies on a kitchen table with easy access will facilitate diabetic testing.
A return demonstration specifically identifies the client’s ability to perform a skill. The client’s skill level may provide incidental information related to options 1, 2, and 4, but they are not the primary reasons for asking the client to demonstrate a skill.
A side effect of orlistat, a lipase inhibitor that aids in weight loss, is rectal incontinence, and/or oily stools that are associated with urgency. The fact that the client is presenting with complaints of this symptom suggests he or she is not following the treatment regimen and is eating high-fat meals. Options 3 and 4 reflect compliance with the treatment regimen. Increasing fluid intake does not affect compliance. Systematically eliminate options 1, 3, and 4 since behaviors are correct.
A BMI of less than 18.5 is considered to represent a client who is underweight and possibly at risk for malnutrition. Option 1 is incorrect because a BMI of 22 is considered within normal range. Option 2 is incorrect: Being above IBW is not consistent with being underweight. Option 3 is incorrect because a waist/hip ratio of less than 0.8 in a female client represents a normal finding. It is important for the nurse to be aware of objective anthropometric measurements (both normal and abnormal values) so that the data can be interpreted adequately.
Pharmacotherapy for obesity is indicated when a client has been unable to achieve weight loss of 1 pound per week after 6 months of therapy while following lifestyle changes. Option 1 is incorrect because this is not a quick-process decision. Option 2 is incorrect because the client has already demonstrated a reasonable weight loss pattern. Option 4 is incorrect because pharmacotherapy is not indicated for an adolescent client.
A client with renal insufficiency should not start a low CHO diet. This implies that protein and fat levels will be increased, resulting in an increased renal solute load. Option 1 is incorrect: 30 grams of CHO is not enough to spare protein, thereby making fat the primary energy source and leading to the development of ketosis, which will further compromise the client’s clinical status. Option 3 is incorrect. Osteoporosis is not associated with being on a low CHO diet but rather is due to multifactorial losses involved with calcium. Option 4 is incorrect because a client with renal insufficiency is unable to handle protein. While high biological value sources are warranted, the protein intake must be monitored cautiously to prevent further metabolic imbalances.
A client diagnosed with Pickwickian syndrome is typically clinically obese and has hypoventilation symptoms. A realistic goal is to establish a weight loss plan because it will help to improve breathing, relieve respiratory symptoms, and decrease the workload placed on both the heart and lungs. Option 1 is incorrect because maintaining the client's current weight will not help to improve clinical symptoms. Option 2 is incorrect as increasing caloric intake will further contribute to weight gain and affect respiratory status. Although the use of increased fluids may be helpful to thin secretions, the client with Pickwickian syndrome does not present with thick secretions, but rather has disturbances with sleep apnea.
Azathioprine (Imuran) can cause a client to develop esophageal lesions; therefore, a soft diet would be an appropriate choice if the client had noted side effects from the medication. Option 1 is incorrect because vomiting and diarrhea are also commonly seen side effects from this medication and would only serve to increase symptoms. Option 3 is incorrect as fresh fruit would not be an appropriate choice due to high bacteria content. Option 4 is incorrect because orange juice might be irritating to a client who had esophageal erosions and/or not be tolerated if a client was experiencing vomiting.
A client who has experienced major trauma is under severe stress and as such experiences a decreased release of insulin, leading to a hyperglycemic response. All of the other options are incorrect because caloric needs, aldosterone, and ADH would all be increased during periods of severe stress.
A client at risk for refeeding syndrome is likely to experience decreases in serum potassium, magnesium, and phosphorus. All of the other choices reflect options that are not seen with refeeding syndrome, such as hyperkalemia, hypernatremia, and hypercalcemia.
The elderly client who has been given a prescription for antibiotics and plans to take them following meals is more likely to be at risk for diet-medication interactions because absorption of the antibiotic may be reduced due to food intake. All of the other options do not pose significant risk for diet-medication interactions.
A client who has undergone severe stress will have increased energy needs. Using the Harris-Benedict equation for estimation of basal energy expenditure (BEE) requires that the client's actual weight and height be used. Depending on the nature of the stress, additional calories will be estimated ranging from 20–100%. Option 1 is incorrect because the client's IBW is not sufficient to base calculations on and will lead to a false starting point. Option 3 is incorrect as a 20% increase is not appropriate for a client who has undergone severe trauma; a much higher percentage would be required to meet the client's energy needs. Option 4 is incorrect because even though albumin levels are needed, they are not part of the client's energy calculation.
Confrontation should not be used as a therapeutic communication technique unless trust has been established in the nurse–client relationship. Because confrontation can be uncomfortable for the client, it is important for the nurse and client to have a trusting relationship as a foundation. The other options represent situations in which the nurse might like to use confrontation but that are not appropriate for this communication technique.
A client on mechanical ventilation as a result of acute respiratory failure is already experiencing fatigue and exhaustion from the work of breathing. The use of nutrient-dense pulmonary formulas to support the client is advised at this time because they provide fewer carbohydrates and a greater fat content to minimize the production of carbon dioxide (CO<sub>2</sub>). Option 1 is incorrect because high carbohydrates lead to an increase in CO<sub>2</sub> production correlating with acidosis. Option 2 is incorrect as parenteral fluids are not being given to loosen secretions; parenteral fluids are used to correct fluid and acid-base imbalances. Option 3 is incorrect because increased kilocalories above client needs could lead to overfeeding that could further increase CO<sub>2</sub> levels.
The dosage of Coumadin is regulated by the client's prothrombin time (PT). Excessive intake of vitamin K rich foods could prolong the PT. A consistent daily intake of food rich in vitamin K, such as spinach, should not affect the PT, whereas a fluctuating amount eaten each day would impact the clotting time. It is not necessary to totally omit vitamin-K foods and the other factors would not affect the clotting.
The sickled shape of the red blood cell (RBC) can lead to occluded circulation and impaired RBC production. Adequate hydration is essential to improve blood flow, reduce pain, and prevent renal damage. There are no specific restrictions or recommendations in regards to protein, sodium, or frequency of meals.
A client who is taking an anticoagulant should not be drinking excessive amounts of alcohol. The fact that the client has been consistently drinking two glasses of wine is a concern since alcohol can enhance the effects of the medication. This information bears further review by the nurse with communication to the healthcare provider. All of the other options do not indicate any concern regarding compliance with medication therapy.
Mayonnaise and salad oils are high in vitamin K, which will prolong the anticoagulation effects of warfarin. CHOs and fruit juice are not high in vitamin K. Option 2 does not directly affect coagulation.
A client who has frequent hospitalizations due to chronic disease is likely to exhibit signs of sadness, depression, and loss of control regarding the disease process. The nurse should allow the client to vent his feelings in the hopes of sharing concerns and offering emotional support. Option 1 is incorrect. Although it is important to ascertain a client’s food preference, the information provided states that the client is repeatedly pushing away the food tray at several meals. Option 2 is incorrect: This client behavior presents as a continued pattern and not an isolated incident. Therefore, the nurse should do more than try again with the next meal to get the client to eat. Option 3 is incorrect because although it might be important to consult with the dietitian regarding food selections, this option does not address the immediate problem of the client pushing away the foods trays.
The first priority with any trauma client is to establish baseline information by examining skin turgor, vital signs, and review of pertinent diagnostic tests in order to stabilize the client and determine the extent of injuries. Looking at the client’s physical and diagnostic presentations will help to determine the client’s fluid balance and pertinent stressors. Option 1 is incorrect: Even if the client is hungry, the existing trauma condition may preclude any feeding attempts at this time. Although it is important to establish IV access for a trauma client, the nurse cannot increase the rate without a physician’s order, therefore option 2 is incorrect. More importantly, increasing the IV rate will not help to maintain nutritional status but rather will help to restore fluid balance. Option 3 is incorrect because the client’s underlying trauma may require surgical intervention and therefore the client should be kept NPO until the exact extent of injuries is known.
A client who is diagnosed with MODS in an ICU setting is critically ill. Determination of overall health status is usually reviewed using the APACHE scoring, which provides relative information regarding risk of mortality. APACHE scoring looks at acute physiological indicators, age, and presence of chronic health conditions to evaluate a client’s response and prognosis. Option 1 is incorrect: Plasma osmolality does not serve as an indicator for acute physiology scoring. Option 3 is incorrect: These choices only reveal information about the client’s age and possibly chronic respiratory health problems. Option 4 is incorrect because a CBC with differential does not provide comprehensive information about the client’s overall health status.
It is important to provide a client with the most comprehensive information available to answer questions and clarify concerns. The consumption pattern (i.e., type and amount) of alcohol has been shown to be a risk factor in many disease processes, and this should be clearly stated to the client. Option 1 is incorrect because even though moderate alcohol consumption has been documented to provide some cardiovascular benefits, the last portion of the statement indicates bias relative to the client’s alcoholism. Option 3 is incorrect because it does not address the client’s concern at this time. Option 4 is incorrect because it implies that the nurse does not believe the client’s statement that he is an alcoholic. It is important for the nurse to respond to the question asked before delving further into confirming a diagnosis of alcoholism.
A 48-year-old female client with the contributory diseases of hypertension (HTN) and diabetes is at a greater risk for nutritional problems than any of the other clients. HTN and diabetes both have dramatic effects on vascular status and lipid physiology. Option 1 is incorrect because there is no information to suggest that the client has any underlying health problems. Even though the client is obese in option 2, this represents only a single risk factor for nutritional status. Similarly, the client in option 3 has only a single risk factor, that of asthma.
Client contracting provides adolescents with the ability to be involved in their care. Adolescents should be involved in planning and decision making regarding their need for information about their own health issues. Lecture, viewing a video, and role-play would not provide opportunity for feedback.
A client taking warfarin should be aware of pertinent medication facts prior to initiation of therapy to avoid possible interactions and to maintain an adequate anticoagulation response. The client should eat a well-balanced diet and consume a constant amount of vitamin K that can interfere with the action of the medication. Green, leafy vegetables are high in vitamin K. Option 1 is incorrect—the client should not double the dose because this can lead to severe consequences and altered coagulation. Option 2 is incorrect because a client taking warfarin should not take other medications unless the physician prescribes them. Option 3 is incorrect: Even though it is important for the client to take the medication at the same time every day, it is also critical that the client be aware of the dosage. This information should be related as part of the client’s pertinent medical history and can influence medical treatment by other healthcare providers.
Early tube feeding leads to fewer complications than parenteral feedings in the acute post-transplant period and is the preferred method if the client has a functioning GI tract. Options 1 and 2 are incorrect because there is increased protein catabolism in the acute post-transplant period as well as an increase in the amount of urinary nitrogen. Option 4 is incorrect because the presence of end-stage liver disease is associated with a decrease in the amounts of branched chain amino acids, leading to an alteration in aromatic amino acids, which may further contribute to the presentation of hepatic encephalopathy.
Adequate amounts of micronutrients (e.g., vitamins A and C, calcium, and zinc) will help support immune function and restore healing in the trauma client.
Refeeding syndrome can occur in the critically ill client in response to feeding attempts whereby glucose and electrolytes (e.g., phosphorus, potassium, and magnesium) rapidly enter into body cells. These electrolytes are involved in enzyme reactions and ATP physiology that is part of metabolizing the TPN. Option 1 is incorrect because serum phosphorus levels are decreased dramatically in response to increased glucose needs. Options 2 and 3 are incorrect because hyperglycemia is present along with increased insulin resistance.
The client is usually kept NPO in order to minimize secretion of digestive enzymes that can contribute to the condition, and the client in acute pain is unlikely to want to eat until the pain is adequately controlled. IV therapy may be instituted to maintain hydration levels, and the client may also require administration of total parenteral nutrition (TPN) if the case is severe. The client with a mild case might receive enteral nutrition for support. The client will not have altered taste perception, and gastroparesis is not part of the clinical picture. The client should not lose more than 10% body weight if enteral or parenteral nutritional support is adequate.
To make valid recommendations to meet nutritional goals with regard to ACD, it is vital to evaluate the client’s present dietary pattern for nutritional adequacy. This helps to establish a nutritional baseline and determine food preferences and other related factors that influence the client’s intake pattern. Option 1 is incorrect—even though medication therapy is aimed at increasing RBC production, it does not specifically address nutritional adequacy in terms of maintaining nutritional stores. Option 2 is incorrect—merely increasing caloric intake without regard to adequacy or balance may place the client at an increased risk of nutritional imbalance. Consuming an adequate diet with all essential nutrients is as important as increasing caloric intake in clients with chronic disease processes. Although it is important to instruct the client about good sources of iron, this option is limited, since it will not provide the most comprehensive approach in dietary evaluation.
Critically ill clients on ventilator support must be provided nutritional support in order to maintain nutritional adequacy, prevent depletion of nutrient stores, and respond to increasing hypermetabolic demands of illness and therapies. Clients receiving medications such as dopamine and narcotics (opiates) are at risk to develop delayed gastric emptying, which can lead to further problems. In addition, changes in acid-base and fluid/electrolyte balance can lead to decreased gastric emptying.
The use of hypertonic enteral nutrition can lead to bowel necrosis and therefore should not be used for a critically ill client. All of the other choices would not lead to feeding complications in the critically ill client. Elemental formulas require minimal digestion and are readily absorbed. The use of full-strength formula feedings in small volumes with appropriate monitoring according to individual tolerance is an accepted practice. A client should be hemodynamically stable prior to the initiation of enteral feeding.
A client who is critically ill on a ventilator and receiving parenteral nutrition should have daily weight measured as a reliable indicator of nutritional status. Serum albumin levels are not reliable indicators of effectiveness of nutritional therapy, although prealbumin levels reflect nutritional status over the past few days. Intake and output are excellent measures of fluid volume status, but not overall nutritional status. Skin turgor is a measure of fluid volume, but can be affected by other factors, such as age, and is not a reliable indicator of overall nutritional status.
A client with a multiple disease profile is at great risk both medically and nutritionally because of multiple organ system problems that could alter metabolism and absorption of nutrients. Since the client is likely to have a multiple medication profile, it would be prudent to obtain a listing of all medication (both prescription and OTC) in order to evaluate potential drug–drug and drug–food interactions. Option 1 is incorrect: A 3-day food diary will only provide information relative to intake. Option 3 is incorrect because vital signs will not enable the nurse to calculate a BMI, since height and weight are needed. Even though it is important to ask if the client is satisfied with current management of disease processes, option 4 is stated as a closed-ended question, which will provide no further information, and the client may not be able to provide an accurate evaluation of his or her own treatment.
Praising the client for steps performed correctly provides positive reinforcement. In addition, explaining the client’s mistakes reinforces the correct way to perform the procedure. For the nurse to redo the dressing decreases the client’s confidence. Praising the client without correcting the mistakes gives feedback that the procedure was done correctly. Having the client repeat the procedure and stating it was done correctly without further guidance does not reinforce or assist learning.
A client on Coumadin (sodium warfarin) needs to avoid foods that are high in vitamin K, which acts as an antidote to the drug. Foods high in vitamin K include green, leafy vegetables (options 1 and 2), and tomatoes (option 4), as well as wheat grains and liver. Corn is not high in vitamin K.
Increased weight gain can be attributed to fluid retention due to medical treatment therapies post-transplant and as such does not reflect accurate information about nutritional status. The use of immunosuppressant drugs can lead to increased nutrient needs due to side effects (nausea, vomiting, mouth lesions, and diarrhea). Option 2 is incorrect because the client’s pre-transplant nutritional baseline status has a very profound impact on post-transplant nutritional status. The organ is being replaced, not the vascular system, and clients with liver failure often have longstanding nutritional deficits as a result of altered liver metabolism. Option 4 is incorrect because a post-transplant client still has to follow dietary restrictions due to existing medical treatment regimens and is followed closely by a dietitian.
A client with a longstanding history of congestive heart failure is likely to develop chronic protein energy malnutrition resulting in cardiac cachexia. Option 1 is incorrect because clients with chronic CHF often have weight loss with superimposed edema that goes unnoticed, thereby masking poor nutritional status. Options 3 and 4 are incorrect: Clients with chronic CHF have decreased activity tolerance and airway clearance due to disease pathology.
Discussing dietary meal planning activities with an obese client who has multisystem disorders would be the most helpful in terms of prospective therapeutic management. This option would allow the client to provide information relative to meal planning and demonstrate both application and compliance with medical/nursing treatments. Option 1 is incorrect since there is no indication that the client requires intervention by a psychiatrist. This option reflects a judgment by the nurse with no other defining information to suggest that the client is having a psychological problem. Option 2 is incorrect because there is no information to suggest that the client needs or is ready to accept medical treatment for obesity. Although it is important to ascertain that the client is being compliant with medication therapy, option 3 does not answer the question with regard to the nutritional management of the client.
One issue for clients with anorexia nervosa is an altered view of their body appearance (i.e., visualizing themselves as being fat even when they are emaciated). Option 1 involves a knowledge deficit. Option 2 involves possible resolution of family dynamic issues. Option 4 involves psychological adaptation.
Clients with burns are hypermetabolic and require increased protein levels in order to maintain a positive nitrogen balance. Vegetables (option 2) and fruits (option 3) are low in protein, although the nuts in option 3 are reasonable sources of protein. Dairy products and shellfish contain protein but are not as good sources as the foods in option 1.
Captopril is an ACE inhibitor that leads to an elevation of serum potassium levels. Foods high in potassium such as oranges and bananas should be avoided. Other foods to avoid are potatoes and beans, and vegetables such as broccoll and carrots.
Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates may be needed to balance the usual insulin dose. All of the other options will increase blood glucose levels.
Small meals prevent overdistention and rapid emptying of stomach, thus helping to prevent dumping syndrome. A low-residue diet is not necessary for this client because this diet plan is usually used as a transition diet from liquids to solid foods to allow the colon to rest. A fluid intake below 1000 mL/day is too low and could cause the client to become dehydrated. Instead, the client should drink liquids between meals. A high-carbohydrate diet is not recommended because concentrated sweets pass rapidly out of stomach and will intensify symptoms of dumping syndrome. A high-protein diet is needed for tissue repair.
One form of bulimia is the “nonpurging” type. Clients with this type of bulimia use fasting and excessive exercise to compensate for food binges. Many clients with bulimia will appear in a normal weight range and perform their eating behaviors in secret. Option 1 is incorrect since anorexia presents with documented weight loss. Options 2 and 4 could be possibilities, but there is no evidence to support depression or use of drugs at the present time given the information provided.
When presenting information to a client, it is important that the nurse find out what the client already knows, and then build on existing knowledge. It is not necessary to consult with a physician. It may be helpful to have family members present, but it is not the priority at the time of initial teaching. It is important when teaching to begin with basic concepts and progress to the complex after determining current client knowledge.
The client with burns often develops paralytic ileus within a few hours, thus a nasogastric tube should be used for stomach decompression. When bowel sounds return, feeding can begin, either via feeding tube or orally.
High HDL levels are associated with reduced risk for coronary artery disease (CAD) and are thought to be cardioprotective. Decreased LDL and VLDL levels are associated with reduced risk for CAD. Increased levels of LDL and VLDL are associated with increased risk for CAD as are low HDL levels.
A nutritional goal for a client with burns is to maintain weight within 10% of the pre-burn weight.
Clients with hypoparathyroidism require calcium replacement. These foods are high in calcium. Option 1 reflects foods that are high in potassium; option 2 reflects foods that are high in sodium; option 3 reflects foods that are high in starches.
Option 1 is a factor related to the adult; option 3 is related to school-age children, and option 4 is related to the elderly.
It is important that circulation is checked regularly. Typically the restraints are removed, one at a time, every 2 hours to evaluate skin condition and circulation. Although options 3 and 4 are correct, they are not the best response as they do not have to be checked as regularly as the circulation and skin condition. Option 2 applies to an elbow restraint.
Options 1, 3, and 4 are all age-related changes and do not suggest alterations. Orthopnea or difficulty breathing when not in a sitting or upright position is suggestive of airway obstruction or respiratory or cardiac disease.
Middle-aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected pattern in older adults; option 3 is expected in young adults, and option 4 is expected in neonates.
The laboratory value given is within normal limits (12–16.5 g/dL). All the other statements are inaccurate.
The ileum, which is a part of the small bowel, is used to form a pouch where the ureters are implanted. Option 1 is incorrect because stool does not drain. Option 2 refers to a cutaneous ureterostomy. Option 4 is incorrect because the ileum is not part of the big intestines.
Restating the information in different ways may assist the elderly client in understanding. Increasing speech volume and gesturing (option 1) only further confuses the client. Older adults do better with a slower paced interview with frequent breaks to decrease exhaustion (option 2). Relying on the family (option 3) is not respectful of the older adult’s autonomy.
Anxiety or anger increases peristalsis leading to subsequent diarrhea. All the other options lead to the development of constipation.
In a divided colostomy, the opening from the digestive or proximal end produces fecal wastes while the other stoma, often called the mucous fistula, produces only mucus.
A toddler is mobile and naturally curious and experiments with things in the environment; therefore, the parents need to know that supervision will be necessary. Toddlers' reflexes are not necessarily slow, and reading is not a concern. Social and personality development is a good topic for health teaching but is not the main concern in regards to safety.
One of the purposes of restraints should be to prevent interruption of therapy such as the use of dressings. Restraints should not be used for the convenience of the staff (option 1), nor should they be used because a client is weak or distraught (option 3). The client in option 4 has no need for restraints.
Because the client has been incontinent, the possibility of skin bacteria reacting with the urea in the urine can lead to ammonia dermatitis. Erythema (option 1) is reddening of the skin; contact dermatitis (option 3) is a possibility if a client is allergic to soaps or other substances; and petechiae (option 4) are tiny pinpoints of bleeding in the skin.
The proper sequence for using a spirometer is: exhale completely; place the mouthpiece and inhale; remove the mouthpiece; hold breath and then exhale. A Fowler's or sitting position best allows full chest expansion. Slower breaths are better and deeper than fast ones. Client should remove the mouthpiece, exhale through pursed lips, and not exhale into the spirometer.
The client did not vomit blood (i.e., hematemesis), has no manifestations of being able to breathe only when in a sitting position (i.e., orthopnea), and has no indrawing chest movement between the ribs (i.e., intercostal retraction). The client has the symptoms associated with hemoptysis: bubbling sensation in the chest, tickling in the throat, and coughing up blood with the sputum.
Electrical equipment in good condition (e.g., with no frayed wires) is acceptable for use in the vicinity of oxygen. Petroleum products and most oils have the potential for being flammable when used on the body, which is a contraindication for their use. Cotton clothing limits static.
Pain can often interfere with sleep. Options 2, 3, and 4 do not negatively affect or interfere with sleep. Absence of unfamiliar stimuli (option 2) can assist with sleep; dealing with stress by talking about the day's events (option 3) promotes relaxation and eventually sleep; moderate fatigue (option 4) might lead to a restful sleep.
To promote bowel function, instruct clients to drink plenty of liquids, including fruit juices such as apple and prune. In addition, foods that are high in fiber and roughage should be encouraged to avoid constipation secondary to immobility.
The communication technique of reflection (option 3) occurs when the nurse directs feelings and questions back to the client to encourage elaboration. The nurse uses the technique of focusing (option 1) by asking questions to help the client focus on a specific area of concern. In summarizing (option 2), the nurse highlights important points of the conversation. The nurse uses restating (option 4) by repeating back to clients the main points or content of the conversation.
When a premature urge to void occurs, focused breathing exercises may assist the client to overcome the sense of urgency. The intervals between voiding should eventually lengthen, rather than voiding every hour or more often when an urge is felt. Protector pads should be worn continuously for leakage. Adult diapers are used only as a last resort.
A full liquid diet allows such items as puddings, creamed soups, sherbet, strained cereals, and all items that are liquid at room temperature. Options 1, 3, and 4 would not be appropriate.
The client needs to be supervised and monitored and placed in a room that is more accessible. Evaluation is needed to determine causes of wandering. Stimulation is not necessary for a client who is a wanderer. Anti-anxiety medications may cause more agitation, and locking other clients' rooms will not prevent the client from wandering.
The environment has to be clutter-free. Therefore, unnecessary pieces of equipment or furniture have to be out of the way. Lights on and side rails up are not mandatory at all times. It is unnecessary to keep equipment out of view.
In the side-lying position, fluid is more likely to flow readily out of the mouth or pool in the side of the mouth where it can easily be suctioned. Fowler's position and Trendelenburg positions are not appropriate since the unconscious client does not have the control to stay up in those positions. The supine position is unsafe as the client may aspirate the fluids.
Stress and long-term alcohol use increase the blood pressure. Physical exercise increases respirations and cardiac rate, increasing the supply of oxygen to the body. Nicotine increases blood pressure and vasoconstriction which prevents oxygen from reaching the different parts of the body.
Gentle rotation ensures that all surfaces are reached and prevents trauma to any one area caused by prolonged suctioning. In oropharyngeal suctioning, the catheter should be advanced to 10–15 cm; 20 cm is the distance for tracheal suctioning (option 1). Fifteen minutes of suctioning (option 2) and applying suction while inserting the catheter (options 1 and 4) can cause trauma to the mucous membranes.
Although all of the actions are appropriate, the highest priority on admission is to anticipate any emergency that may occur if problems with the chest tubes occur, such as disconnection or accidental removal.
Soft, flaccid muscles are signs of inadequate nutritional status. Muscles should be firm and well developed. All of the other options are signs of adequate nutritional status.
Options 1 to 3 are all normal levels; option 4 is indicative of potassium depletion that occurs in severe cases of malnutrition.
Empathy is the ability of the nurse to see the client’s perception of the world. Challenging clients (option 1) forces them to defend themselves from what appears to be an attack by the nurse. False reassurance (option 2) is another way of telling clients how to feel and ignoring their distress. Advising (option 3) occurs when the nurse tells clients what to do, preventing them from exploring problems and using the problem-solving process to find solutions.
Symptoms and ways of preventing an infection are crucial for a client to understand. Performance of perineal care independently and disposal of urinary output are not appropriate outcomes. Tub baths are to be avoided, especially in females, as they may increase the possibility of developing lower tract infections.
The foods that thicken stools are in option 2. Option 1 foods increase stool odor. Options 3 and 4 foods loosen stools.
Catheters should be inserted only during one suctioning period to minimize the risk of contamination from allowing the catheter to lie out of the sterile packet, which would allow bacteria to grow between suctioning periods.
Deep breaths will relax the abdominal muscles and allow additional fluids to enter the colon while under less abdominal pressure.
Increasing girth shows a backup or buildup of contents or air in the abdominal area without adequate movement within the gastrointestinal system to remove stool. If the source of the problem is not identified, additional complications will develop as stool stagnates or goes backwards in the GI tract. The most common problem of loss of peristalsis is an ileus.
The air vent opening should remain clear, to allow air to decompress the stomach, and suction is connected to the larger, primary opening of the double-lumen tube. An anti-reflex valve might be covering the air vent, but it does allow air to enter. Decompressing the stomach is achieved when some air enters the stomach through the air vent to prevent the pull of stomach mucosa into the hole of the larger lumen to which the suction is connected.
All of the other responses indicate a temporary decrease in oxygen when suctioning. Bradycardia indicates a vagal stimulation response that could cause cardiac arrest.
Hyperventilation is giving too much volume of air into the lungs, and is not recommended, due to the risk of rupture of lung tissue. Other responses are appropriate actions that are recommended to minimize the loss of oxygen when suctioning the client.
Stress of a life change such as having a permanent suprapubic catheter must be addressed like any other loss with which a client must deal while hospitalized. By exploring feelings and coping strategies that are present, the nurse will be able to work on strategies using familiar coping strategies that have been successful for the client. Also, if the strategies have not worked in the past to reduce stress, then new strategies can be introduced to the client as options to deal with this new stressor once the feelings have been clarified with the client.
The chest tube in the second intercostals space is used to remove free air in the chest cavity. Therefore, the chest wall should move equally bilaterally by the third day, when the air is removed.
Transference is the unconscious process of displaying feelings for significant people in the client’s past onto the nurse in the present relationship. Countertransference (option 2) is the nurse’s emotional reaction to clients based on feelings for significant people in the nurse’s past. Psychosis (option 1) is a state in which a client is unable to comprehend reality and has difficulty relating to others. Projection (option 4) is a defense mechanism in which blame for unacceptable desires, thoughts, shortcomings, and mistakes is attached to others in the environment.
Clamping the tube (option 1) is not recommended unless there is an air leak or break in the closed system. Dressing changes (option 3) are not done daily, since the sealed system needs to be maintained, and risk of tube displacement would increase with manipulation of the dressing. Option 4 is incorrect because drainage chambers are meant to be measured and not emptied.
Edema develops, pushing both internally and externally when it forms. Edema pushes on whatever structures are near it (i.e., airway, gag point, vocal cords). Pressure can occlude any of the areas that are vital to air flow, speech, or gagging. Rechecking the equipment will eliminate the possible cause of the loss of suction from no negative pressure. With no negative pressure to remove secretions, edema will stay in the tissues, create an obstruction, or damage vital tissue.
Coughing would indicate irritation or increased stimulation of the diaphragm. When the fluids are removed, all of the other symptoms are expected as signs of improved ventilation and the removal of the pleural effusion.
A gradual decline in urinary output shows lessening pressures through the kidney and potential cardiovascular collapse. When urinary output is below 30 ml per hour on a consistent basis, either the circulating volume is decreasing or the kidneys are not perfusing. Either of these requires immediate medical attention.
The symptoms in option 1 are those of potassium lost during excessive washing out of gastric secretions, causing hypokalemia. The symptoms in option 2 are those of hyperkalemia. The symptoms in option 3 are those of hypocalcemia. In option 4, the symptoms are those of hypercalcemia. Note that pathological fractures occur as the body pulls calcium from the bones to maintain the high blood levels.
By the second day, the drainage fluid should have slowed down considerably. A volume of 500 ml is almost 2 units of blood, and if the drainage is still sanguineous on the second day, the nurse should suspect that a problem is present. Frank bleeding should have stopped soon after surgery, and secretions gradually should become more serosanguineous in nature within a few hours postop.
Normal capillary refill is less than three seconds; six seconds represents a delay in circulation. The graft should have no negative impact on the circulation to the hand. Additional examination needs to be performed by the nurse.
The wound must be open enough to place the foam dressing into the site before the sealed dressing can be applied to minimize the damage to the site with the VAC suction.
By lifting and stretching out the shaft of the penis, the meatus is opened more directly, and curling up of the urinary catheter is less likely to occur.
The urinary system should remain a closed-seal system to minimize the risk of cross-contamination. The port hole is designed for puncturing for specimens. Using only the area designed to be punctured, which will reseal when the needle is removed, is the only safe way to collect the specimen without cross-contamination to the specimen or the catheter’s drainage system.
Taking into account the age and ethnicity of the client, it is helpful to speak slowly and provide short and simple explanations. Speaking quickly does not help the client understand the information presented. Eye contact is acceptable. There is no need for an interpreter based on the information in the question.
Gastric pH should be between 0–4 pH. The color of the gastric content should be yellow–green or tan, but this is a less reliable indicator of location.
The feeding should not hang for more than four hours, if continuous. However, for intermittent feedings, if a bag is used, the bag should be changed every day to minimize the risk of bacterial growth in the tubing. Most intermittent feedings are hand-poured into a syringe.
Under the law, if a medication order is written incorrectly, the nurse who administers the incorrect order is responsible for the error. This includes both the right medication and the right dose (i.e., 2 of the 6 "rights" of medication administration). The other responses are incorrect.
The thin layer of epithelium and the vast network of capillaries under the tongue enhance sublingual absorption. This medication dissolves rapidly and is absorbed immediately. The other responses are incorrect.
For an adult with well-developed muscle mass, the preferred IM injection site for medications requiring a large muscle mass is the ventrogluteal. The vastus lateralis is the preferred IM injection site for children under 7 months of age. The other responses are incorrect.
For a well-developed adult, a 5/8–1-inch needle is the appropriate size for an IM deltoid injection. Because this is an obese client, the longer needle is appropriate to ensure it reaches the muscle. The other responses are incorrect.
Z-track technique prevents "tracking" and is used for administering medications that are especially irritating to subcutaneous tissue. With Z-track the skin is pulled approximately 1 inch laterally away from the injection site, the medication is injected, the needle withdrawn and the tissue released. The other answers are incorrect.
The device that provides the most accurate infusion rate is the electronic infusion pump. The other devices are less accurate.
In the apothecary system, 1 grain = 60-65 mg. 10 grains would = 600-650 mg, so 2 tablets would be needed at 325 mg each to reach the needed dose.
If blood returns while aspirating during an IM injection, the nurse should discard and prepare a new injection. Blood indicates that the needle has entered a blood vessel, and medication injected directly into the bloodstream may be dangerous.
The nurse should never interrupt the process for administering medications. Errors are typically made when the nurse is interrupted. Military time is frequently used by institutions for documentation. The nurse should always ask for assistance with dosage calculations when in doubt. The nurse should never give a medication that a client questions. Always double check the order, dosage, and medication, and give the client an explanation.
The core issue of the question is the communication by the nurse that is most likely to elicit further data from the client. With this in mind, option 1 provides a broad opening for the client. Option 2 places a judgment on the client’s behavior. Option 3 begins by acknowledging the client’s feelings, but then risks putting the client in a defensive position by asking, “Is something bothering you?” Option 4 also places the client on the defense.
Clients should be instructed to hold inhaler 2 inches away from mouth, hold the breath for 10 seconds, slowly exhale through pursed lips, and wait 2 minutes between puffs. The other options are incorrect.
When medications are administered enterally and cannot be administered with tube feedings, it is best to stop the tube feedings for at least 30 minutes prior to and after the administration of the medication. A time period of thirty minutes allows for the tube feeding to clear the GI tract and therefore not mix with the medication. The other answers are incorrect.
A client has the right to refuse a medication regardless how important it may be to their health. Withholding the medication because of client refusal does not require an incident report, but it should be documented and reported to the physician. The other answers are incorrect.
For an intradermal injection, the needle enters the skin at a 15-degree angle and the mediation forms a bleb under the epidermis. The other answers are incorrect.
Several factors indicate the size and length of the needle to be used: the muscle, the type of solution, the amount of adipose tissue covering the muscle, and the age of the client. A smaller needle such as a #23 to #25 gauge needle 1-inch long is commonly used for the deltoid muscle. More viscous solutions require a larger gauge (e.g., #20 gauge). The other answers are incorrect.
The vastus lateralis and the rectus femoris are located on the thigh. The dorsogluteal is located on the buttocks. The ventrogluteal site is in the gluteus medius muscle with the greater trochanter, the anterior superior iliac spine, and the iliac crest as the landmarks. The other answers are incorrect.
The essential parts of a drug that must be present in order to implement the order are: name of the drug, date and time the order was written, dosage, route, frequency, and signature of the person writing the order. Nurses may not administer a medication without all of the essential parts, or determine a route based upon the client's condition. Administering Tylenol without a medical order is practicing medicine without an order.
A nurse can take a verbal order from a physician. When the nurse transcribes the order, "verbal order" is recorded with the order and the physician must co-sign the order usually within 24 hours. The other answers are incorrect.
Blood levels of two metabolically produced substances, urea and creatinine, are routinely used to evaluate renal function. Both are normally eliminated by the kidneys and are measured as serum BUN and creatinine. The other answers are incorrect.
Eye drops are placed in the lower conjunctival sac to prevent damage to the cornea and to facilitate coating the eye with the medication. The other answers are incorrect.
The nurse is more likely to exhibit therapeutic verbal and nonverbal communication by being aware of the extent of the client’s disfiguring injuries. This will reduce the likelihood of surprise that can be seen in nonverbal behavior. The remaining options are also items that the nurse will do, but they are general to all clients and not particular to the client in the question.
Pulling the ear pinna down and back straightens the ear canal allowing the drops to enter the ear. The other choices are not the most important concepts in the teaching.
0.45% Normal saline is a hypotonic solution that draws fluid from the vascular compartment into the cells. The other answers are incorrect.
The Groshong catheter is designed with a three-way pressure-sensitive valve that restricts air from entering the venous system or a backflow of blood. The other answers are incorrect.
If it takes 15 drops to deliver one milliliter, 15 times the 75 milliliters you want to deliver would yield 1125 drops required per hour. However, the question asks for drips per minute so divide 1125 by 60, which equals 18.75. It is impossible to deliver 0.75 drops, so round to 19.
Infiltration is leakage of fluids into the surrounding tissues resulting in edema around the insertion site, blanching, and coolness of skin around the site. The other options are incorrect.
Continuing the infusion at that site would only increase the phlebitis. The IV is discontinued and restarted at a new site. Applying a warm compress to an area of phlebitis dilates the vessel, improving circulation, and reduces the resistance to blood flow from within the vein reducing the pain. The other options are incorrect.
Tourniquets are made of latex. A blood pressure cuff can be used as an alternative method of vein distention. A new tourniquet does not resolve the latex issue. The other responses are incorrect.
Before making a decision about how to infuse the antibiotic, the nurse should check compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion were compatible, they would be run at the same time. If the drug and infusion were incompatible, the nurse would stop the infusion during the period of antibiotic administration and flush the line carefully before and after the antibiotic. It is always inadvisable to start a second IV site unless absolutely necessary. The other answers are incorrect.
Alarms sound on electronic infusion devices when the infusion is complete, there is an occlusion, air is in the line, low battery, or the cassette is improperly loaded. The other answers are incorrect.
The client is manifesting signs and symptoms of dehydration. Since the serum remains isotonic, this is isotonic dehydration or hypovolemia. Appropriate treatment is with an isotonic fluid to replace fluid volume. Options 1 and 2 are incorrect because they are hypotonic solutions and would cause fluid shifting leading to cellular edema (i.e., client’s cells are normal size and free water is not needed for cells). Option 3 is incorrect because the solution is hypertonic and will cause further fluid shifting leading to cellular dehydration.
The client may have a need for increased personal space, which may account for withdrawing to the other side of the bed. However, cultural considerations cannot be ruled out by the information in this stem. With this in mind, the correct action by the nurse is to validate the reason for the client’s behavior. This is what option 1 represents, an attempt to determine whether increased need for personal space is the reason for the behavior. Option 2 punishes the client for the behavior by leaving the client alone. Option 3 is inappropriate because it does not acknowledge an unspoken need by the client. Option 4 would further invade personal space and is inappropriate until further data is gathered.
25% albumin is a hypertonic colloid solution that will expand the plasma volume. This increase in plasma volume should increase blood pressure, which in turn will decrease the strain on the heart and thereby decrease heart rate. The increase in volume will not lower temperature or decrease peripheral perfusion; rather, it will have the opposite effect.
Normal saline is an isotonic solution that will replace lost vascular volume and promote perfusion. All of the other options are incorrect because they are either hypotonic or act as hypotonic solutions in the bloodstream, providing free water that moves into the interstitial space and cells. Administration of these fluids can cause further fluid shifting, which will not help to replace lost volume or promote perfusion. In addition, when blood is available, it can be hung with the normal saline. Dextrose will cause lysis of red blood cells.
Albumin is given to facilitate remobilization of third space fluids. In the case of ascites it would pull fluid from the abdomen into the intravascular space, resulting in a decrease in abdominal girth. Option 2 is incorrect; the increase in intravascular fluid would lead to an increase in blood pressure. The pulse may increase in compensation to the increased blood volume, but this does not reflect effectiveness of the albumin treatment. A decrease in weight would most likely be seen as the reabsorbed abdominal fluid is excreted by the kidneys.
The client’s plasma is hypertonic (i.e., very concentrated) to begin with and thus serum osmolality, BUN, and hematocrit would be elevated from hemoconcentration. Once isotonic fluids are administered, the plasma concentration should decrease and all three laboratory test results should show a corresponding decrease. Option 1 is incorrect because you would expect to see an improvement upon administration of isotonic fluids and BUN and serum osmolality remain increased. Option 3 is incorrect because these findings would be consistent in a client who has not been treated for hypertonic dehydration. Option 4 is incorrect because you would expect to see a decrease in hematocrit with the administration of isotonic fluid therapy.
Abrupt changes in weight are an important clue to changes in fluid status. Unusual losses, e.g., fever or diarrhea, are significant; they need to be reported and may help the client prevent a fluid volume deficit (FVD) in the future, especially since the client is taking a diuretic. Option 1 is incorrect because increasing salt and fluids may put the client at significant risk for fluid volume excess (FVE) considering the history of CHF. Options 2 and 4 may put the client at risk for FVE or FVD, respectively.
Very common substances to be avoided during pregnancy include aspirin, caffeine, cough and cold products, stimulants (e.g., diet pills), and nicotine, but acetaminophen generally is safe and effective for occasional use.
Almost all forms of drugs in the maternal circulation can be readily transferred to the colostrum and breast milk. For this reason, women should use drugs only if necessary during lactation. The statements contained in the other options are not true.
The neonate has as immature renal system, and cannot metabolize medications effectively. This places the neonate at risk from the viewpoint of pharmacokinetics (absorption, distribution, biotransformation, and excretion). The neonate might not have hyperactive bowel sounds; the musculoskeletal system is not necessarily weak; and thermoregulatory issues can affect temperature regulation, but would not directly affect pharmacokinetics, making option 3 the best answer.
If a breastfeeding mother must take medication, it is suggested that the dose be timed immediately after breastfeeding, to maximize the time span before the next feeding. This will allow for the greatest amount of the drug to be metabolized and excreted. The other time frames listed provide less time for clearance from the maternal bloodstream, and therefore can cross into the breast milk more readily.
Because the client is hospitalized and is receiving an IM dose of thorazine, the primary concern should be to monitor for a decrease in the psychosis. Blood pressure and pulse should be monitored as a general measure for initial treatment with thorazine whether IM or PO. Ability to walk and eat lunch is not significant to the issue of initial concern.
The nurse has two competing priorities: the need to accomplish work on a busy shift and the need to address the psychosocial needs of a client in distress. Option 1 takes into consideration both of these factors. Option 2 creates psychological as well as physical distance between the nurse and the client because the question is asked from the doorway. Option 3 ignores the other workload of the nurse. Option 4 puts the client’s feelings on hold.
The only correct option is slurred speech and drowsiness. Olanzapine is a relatively new drug approved for schizophrenia and other psychotic disorders. This agent is generally well tolerated and appears devoid of serious adverse effects.
The only correct answer is option 1. Trazodone is an atypical antidepressant used more often for insomnia than for depression. It is not used for panic attacks or anxiety.
The most important person to instruct is the client, not the family member, as indicated in option 4. With MAOIs it is important to give the client not only oral but also complete written instructions concerning medication administration, food interactions, etc. It is good to instruct the client how to notify the appropriate health care professional, but it is not a major objective to teach the family how to contact an appropriate health care professional.
Diazepam and chlordiazepoxide are contraindicated for use with elderly clients (options 1 and 2) while trazadone is an atypical antidepressant, not a benzodiazepine. Lorazepam is the only appropriate benzodiazepine listed that is good for use with elderly clients.
The primary reason for re-hospitalization is that a client with bipolar disorder stops taking medication (option 3). There will always be other problems in families and in life (options 1 and 4), but these do not necessarily bring the client back to the hospital. If the client decides to lose weight, this in itself does not indicate that the client will need to be hospitalized.
The nurse should ask if the client is taking disulfiram (option 4) because this medication causes the adverse reactions noted above when alcohol is also ingested. Option 1 is not highest priority because the smell of alcohol indicates that the time of the last intake was relatively recent. Options 2 and 3 are not the first questions that the client should be asked in this situation because they do not relate to the issue of vomiting and drug interactions.
The nurse should refer the client back to the physician for clarification rather than try to second-guess the physician's thoughts or speak for the physician. Option 1 is not appropriate because there is no basis for the statement. Option 2 is only one aspect of the difference between a tricyclic antidepressant and a selective serotonin reuptake inhibitor, but it does not address the client's concern. Option 3 is accusatory and therefore inappropriate.
Option 3 answer is correct. Clients taking fluoxetine usually demonstrate a weight loss. The client needs to weigh himself daily and adjust nutritional intake as necessary. The client will need to increase the caloric intake (option 2), not the fluid intake. The client does not necessarily need a change in medication (option 1). Option 4 is incorrect; it will take 3–4 weeks for the effect of the medication to be seen.
Chlorpromazine (Thorazine) is not only the oldest of the antipsychotic medications, it can also used for relief of intractable hiccups. Risperidone (option 1), molindone (option 2), and thioridazine (option 4) do not have this effect.
Halooeridol is a high-potency antipsychotic. Option 1 is not a classification of antipsychotics. Options 3 and 4 are valid classifications of antipsychotics but they do not describe haloperidol.
Option 1 demonstrates honesty and openness between the client and the nurse. It also addresses the client’s need for information. Options 2, 3, and 4 are incorrect because they put the client’s information needs on hold and do not represent a candid response by the nurse. The correct answer to communication questions is the one that best acknowledges the client and utilizes therapeutic communication techniques.
Dizziness, drowsiness, headache, and insomnia are some of the common CNS adverse effects of bupropion. Decreased appetite (option 1) is not a concern. Option 2 is incorrect because it asks about depression, while bupropion is used to treat anxiety. Option 4 indicates that the client has had hallucinations, which are not associated with bupropion.
The nurse should observe the same safety standards of medication administration as with all clients. Crushing a medication and placing it in applesauce is not necessary for a client on suicide precautions unless there is a problem with swallowing or taking tablets or capsules (option 1). Option 2 is incorrect because it is not the responsibility of the nursing assistant to remain with a client taking medications. As with all clients staying with the client for 5 minutes (option 4) is not necessary for safe medication administration.
The symptoms listed are those of lithium toxicity, and are seen when the serum level is 2–3 mEq/L. The other options indicate lesser serum concentrations that would not produce these manifestations.
In option 2, the client is demonstrating progress in returning to usual living. She is working a reasonable amount of the day, sleeping regularly, and making plans with others. In option 1, the client is sleeping too many hours each day. She is reporting very little activity outside of sleeping. She remains withdrawn and demonstrates no change in mood or activities. Option 3 indicates that the client is overworking, sleeping only 6 hours each night and still reporting feelings of depression. Option 4 alone shows no signs of change.
Clients undergoing withdrawal from heroin exhibit craving, lacrimation, rhinorrhea, yawning, and diaphoresis. Option 1 is incorrect because irritability and insomnia are seen with withdrawal from marijuana. The manifestations listed in options 3 and 4 pertain to withdrawal from alcohol.
Option 1 is true for the symptoms of dry mouth, but is not the priority response because it does not fully address the information provided by the client. Option 2 is incorrect. The client is describing expected side effects of the medication ordered to decrease anxiety, so the dosage should not be changed. Option 3 is the priority because of the need for safety when using a benzodiazepine, given the common side effects the client described. Option 4 will serve no benefit to treat or help with the described side effects.
TCAs account for 70% of all deaths from intentional drug overdose. SSRIs are not usually fatal if overdose is taken. MAOIs can be fatal if the client experiences a hypertensive crisis, but MAOIs are not usually that widely prescribed because of their numerous side effects, especially with tyramine-rich foods and drug–drug interactions. Anxiolytics are not a class of antidepressants.
It is essential to teach both the client and his mother about the medication and why compliance is very important. Option 2 is incorrect because it places responsibility for eating and taking medications on the mother, not on the client, which is inappropriate. Option 3 is incorrect because it is the client's responsibility to take prescribed medications. Family members should know about the medications and be able to support the client and remind the client of the benefits of taking the prescribed medication, but it is ultimately the client's responsibility. Option 4 is inappropriate because there is no guarantee for the client that he will remain symptom-free indefinitely.
Option 1 is subjective data only and should not be the sole data for the nurses' evaluation of the effects of the anxiolytic medication. Option 2 is more objective and uses previous data and present facts to evaluate the client's condition. Option 3 is false. There should be a change observed with an anxiolytic after two weeks, and option 4 does not address the primary effects desired for use of anxiolytics (e.g., decrease of the anxiety).
Option 3 is correct because it acknowledges the client's feelings and addresses his concerns while still allowing him to make decisions for his present and future. Options 1 and 2 disregard and negate the client's feelings. Option 4 acknowledges his concern but takes away his decision-making options by having someone else such as the nurse make a plan for his daily activities, rather than have him participate and make decisions for himself with help.
Because the client does not speak English, the nurse must utilize nonverbal communication. With this in mind, option 3 is the one that takes this need into account. Options 1 and 4 are helpful when the nurse is working with a client who is hearing impaired. Option 2 would be useful for the aphasic client who has use of the dominant hand, such as after a CVA.
Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. Confusion (option 4) is not a side effect of this agent.
The symptoms of hair loss, the student's age, and edema indicate that this is not a stage of puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. By the process of elimination, the correct answer is option 2. In order to answer this correctly you need to have noted the muscular build of the student and know the signs and symptoms of illegal steroid use.
Option 4 is correct because the client is honest, has an understanding of how to take the medication, what the side effects are, and knows that the side effect will subside eventually. Options 1 and 2 indicate that the client is feeling forced to take the medication but has no desire or understanding of the benefits of the daily routine and dosages. Option 3 indicates that the client has memorized the actions but does not understand the benefits or side effects of the medications.
Option 3 is correct because it addresses the client's concern and addresses his issue. Option 1 denies the client's feelings and does not address his concern. Option 2 is disrespectful and again does not acknowledge the client's feelings or concerns. Option 4 is incorrect because it is disrespectful, denies the client's feelings, and does not address the client's issue.
There is a high potential risk for NMS with the use of haloperidol. Monitoring for tardive dyskinesia is not indicated this early in treatment. There is no reason to monitor for intake and output (option 2). Option 4 is unnecessary although the nurse monitors mood, behavior and orientation during therapy.
It is part of standard nursing practice to evaluate the effectiveness of medications that are administered. Option 1 is inaccurate because antipsychotic medications are not addictive. Options 2 and 3 have nothing to do with the effects of an antipsychotic medication.
Measuring blood alcohol level (option 3) is the most accurate test to indicate intoxication level. Testing urine for alcohol level (option 1) is not an accurate measure for alcohol. Testing MCV and GGT (options 2 and 4) will indicate if the individual has been using alcohol chronically.
The medication normally works within 1/2 to 1 hour after administration, making option 2 correct. Option 1 is incorrect because the client should not be watching stimulating shows on TV before trying to fall asleep. Option 3 is incorrect because the medication will not work instantly. Option 4 is incorrect because the client should not take a sedative and then stay active for 1/2 to 1 hour after taking medication.
With an MAO inhibitor such as phenelzine, the client needs to eliminate foods that contain tyramine. Intake of tyramine-containing foods could lead to severe hypertension and other complications. All of the other considerations are not major teaching considerations for MAO inhibitors.
The symptoms of an acute asthma attack are related to constriction of the airway. The medication is a beta-adrenergic agent administered to dilate the airway. Option 2 is a side effect of the medication but is not the intended effect. Options 3 and 4 are incorrect because bradycardia and bronchoconstriction are the opposites of the expected side effect and intended effect, respectively.
The correct answers to communication questions are those that utilize therapeutic communication techniques and avoid communication blocks. Options 1, 2, and 5 utilize these techniques, while options 3 and 4 use the communication blocks of false reassurance (option 3), challenging the client (option 4). Another block would be putting the client’s feelings on hold.
Adrenergic agents are contraindicated for clients with cardiovascular disease because of the potential to increase myocardial oxygen demand. Epinephrine would raise the heart rate and blood pressure but may decrease oxygenation of the myocardium for the client with cardiovascular disease. Asthma (option 1), hypotension (option 3) and bradycardia (option 4) are not contraindications for use of epinephrine (Primatene).
Caffeine in coffee or tea can have an additive effect with theophylline, and therefore coffee should be eliminated from the meal tray. Peas (option 1), beans (option 2), and milk (option 3) are not problematic because they do not contain caffeine.
A potential side effect of an inhaled corticosteroid is oral fungal infection. It would be therapeutic to have a decrease in audible wheezes (option 1). Inhaled corticosteroids can cause dry mouth (option 2) and with less respiratory effort from effective therapy, the nurse should anticipate a decreased respiratory rate (option 4).
Bitolterol is an adrenergic bronchodilator that is effective to provide bronchodilation in an acute asthma attack. Aminophylline (option 1) is a xanthine, triamcinolone (option 3) is an inhaled corticosteroid, and cromolyn (option 4) is an inhaled nonsteroidal. All three of these agents can be used with asthma; however, they are not effective during an acute attack.
Zafirlukast is a leukotriene modifier. This is a newer class of medications for the prophylaxis and chronic treatment of asthma. Because they are not to be used during an acute attack, this response indicates that the client needs more teaching. Fluid intake should increase to liquefy secretions and assist the client with expectoration. This medication should be taken one hour before meals or two hours after meals. It does take a few weeks of medication administration for the client to begin to see positive results.
Claritin should be taken on an empty stomach to increase absorption. It is a second- generation antihistamine and does not cause drowsiness like the first-generation medications (option 1). It has a rapid onset of action (option 2) and is not effective in an acute asthma attack (option 3).
Cardiovascular side effects are possible with the administration of decongestants. If the client develops these symptoms, the medication should be discontinued and the physician notified. Oral agents should be used for long-term therapy (option 1). Rebound congestion (option 4) is more likely with nasal spray decongestants. Often, decongestants cause a dry mouth (option 3), but the client should use hard sugarless candy rather than discontinue the medication.
Guaifenesin is an expectorant. Potential side effects are nausea, vomiting, gastric irritation, rash, dizziness, and headache. It does not cause hypertension (option 2), hypotension (option 3), or urinary retention (option 4).
A non-rebreather mask should have flaps on the sides that are open during expiration and closed on inspiration. The idea is for the client to breathe in oxygen and not the expired carbon dioxide. If the flaps are missing, the client needs a new mask. The nurse should not change the oxygen order (option 2) and it is unnecessary to call the physician (option 4).
Potential side effects of this medication are stimulation of the central nervous system (CNS) and cardiovascular (CV) system. Metaproterenol is a beta 2 stimulant and these effects are not as likely, but with increased doses, they may occur, especially in a 6-year-old child. Lethargy and bradycardia (option 2), decreased blood pressure (option 3), and fatigue (option 4) are not consistent with either CNS or CV stimulation.
The action that demonstrates cultural sensitivity is the one that inquires about the significance of the braided necklace while taking into account issues of client safety (in this case risk of strangulation). Option 1 addresses risk of infection but not safety, while options 3 and 4 fail to demonstrate any cultural sensitivity.
Use of salmeterol is prophylactic, not for an acute attack. Salmeterol is predominately a beta 2 stimulant and therefore does not frequently cause tachycardia (option 3). It takes 20 minutes for onset of action and is used for prophylaxis not treatment of acute attack (option 2). It is dosed every 12 hours because of a 12-hour duration of action (option 1).
Oxtriphylline is a xanthine brochodilator, and the mechanism of action is to increase the amount of cyclic adenosine monophosphate (cAMP), which leads to bronchial dilation because of relaxation of smooth muscle. Xanthines can increase heart rate and force of myocardial contraction, but that is not the rationale for the administration of the medication.
Theophylline is contraindicated in clients with hyperthyroidism as the disease can be exacerbated. It is also contraindicated in clients with tachydysrhythmias. Options 2 and 4 result in low heart rates and are therefore incorrect.
When both an inhaled and systemic corticosteroid is used, a decrease in the dose of one or the other medication may be appropriate due to the additive effect of local and systemic corticosteroids. Options 1 and 2 are incorrect because they indicate increased doses, while option 3 is incorrect because the symptoms should decrease rather than increase.
Administration of corticosteroids such as fluticasone suppresses the immune system and the administration of these drugs is contraindicated in clients with suppressed immune systems (as in AIDS). Fluticasone may be helpful with asthma (option 2) and COPD (option 4). It is not contraindicated with CAD (option 3), although it may be used cautiously because of possible fluid retention.
Necrodomil should be used as ordered even if no symptoms are noted. This medication is used for the prophylaxis of asthma, not during an acute attack (option 1). It is possible that a decreased amount of bronchodilator and/or inhaled corticosteroid may be needed after starting this medication (not increased as in option 2), but this is not certain. It can take 3 weeks of daily dosing prior to seeing therapeutic effects (option 4).
Zileuton is a leukotriene modifier that blocks production of leukotriene and thereby reduces inflammation. The side effects of zileuton include headaches, dyspepsia, nausea, dizziness, and insomnia. They do not include lethargy (option 1), constipation (option 2) or diarrhea (option 4), although zafirlukast, another leukotriene modifier, may cause nausea and diarrhea.
Promethazine is a traditional antihistamine that causes drowsiness because it works centrally as well as peripherally. It can cause central nervous system depression or stimulation. The client should be kept in bed with the side rails up until the effects of the drug wear off to promote client safety. The effects are heightened by the client's age. The actions in options 1, 2, and 3 provide a lower margin of safety for the client.
Afrin is a topical decongestant and an adrenergic agent that promotes nasal decongestion by vasoconstriction. Adrenergic decongestants are contraindicated for the client with hypertension and coronary artery disease. Contraindications do not include hypotension (option 1), hypothyroidism (option 3), or emphysema (option 4).
Epinephrine is a beta-adrenergic agent that that has beta 1 adrenergic action causing increased heart rate and increased force of myocardial contraction. The results of subcutaneous epinephrine should be seen in 5 minutes. The effects may last up to 4 hours. The other options are incorrect.
The nurse should continue to monitor the client’s status because the fever is low grade and considering that treatment consistent with the client’s beliefs will probably be the most successful. The other responses fail to show cultural sensitivity in respecting the client’s culturally based beliefs about health.
Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol stimulates beta 1 and beta 2 receptors and therefore should not be used with clients with tachydysrhythmias.
With increased age, there is an increased sensitivity to xanthines. Also, there could be other disease processes that may lead to this elevated value. The dose of theophylline should be decreased to get the blood level to the 10–20 mg/dL range. Theophylline doses should be based on lean body weight to prevent entering the medication into the adipose tissue.
Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 is incorrect because the client is young and therefore the age is insignificant. The smoking history (option 1) is not an issue. In fact, smokers metabolize theophylline more quickly and may need increased doses. There is no data about the client's weight (option 4) in the stem.
The child receiving inhaled corticosteroids should be monitored for impaired bone growth. Bone growth should be monitored closely especially in children between 4–10 years of age. Improved respiratory function is an expected outcome of treatment (option 1). Decreased urinary output (option 3) and increased immune response (option 4) do not apply.
Inhaled corticosteroids do predispose clients to osteoporosis. The mouth should be rinsed after the medication is administered to decrease the likelihood of oropharyngeal candidiasis (option 1). Clients should avoid allergens (option 2). The medication should be taken prophylactically, not with an acute attack (option 4).
The nurse should teach the client proper administration technique for inhaled medications. The canister should be shaken (option 1) and the cap removed. The client should sit or stand for maximal lung inflation (option 2). The client should coordinate pressing the canister to release the medication and inhalation to get the medication into the lungs. The client should hold his or her breath for 10 seconds. One to three minutes should elapse between inhalations or prior to administration of another medication (option 3).
It is not advised to take two antihistamines concurrently as they can have additive effects. Loratadine is a second-generation antihistamine and not as likely to cause drowsiness (option 1). Loratadine, unlike other antihistamines, should be taken on an empty stomach to increase absorption (option 2). Prolonged exposure to sunlight (option 4) can cause sunburn especially while on antihistamines.
Dimetane-DC is an opioid antitussive that contains codeine, affecting the cough center directly and suppresses the central nervous system. Dextromethorphan is a nonopioid antitussive that suppresses the cough reflex directly by affecting the cough center.
Clients with COPD usually have a lower oxygen tension in the blood than a client who does not have chronic lung disease. In fact, because COPD clients usually have high carbon dioxide levels, their drive to breathe is from the low oxygen tension instead of the high carbon dioxide level. Starting oxygen at higher than 2 liters/min may cause hypoventilation because it may diminish the drive to breathe. SO<sub>2</sub> values of 87–90% are usually satisfactory for clients with COPD.
Vitamin C helps to enhance the absorption of iron in the diet and is an easy step in diet management towards improving iron levels in the body. A strict vegetarian diet focuses on non-heme sources of iron that are not as readily absorbable as heme sources (option 1). Eating ice cubes is an example of pica, which is ingestion of a non-food substance (option 2). Nonfood items will not help to maintain or prevent iron deficiency and in certain cases can actually lead to deficiency states. Tea contains tannic acid and cereals contain phytates and fibers, all of which lead to decreased iron absorption in the diet (option 3).
The response that shows cultural sensitivity is one that respects the personal boundaries for the client and asks permission to engage in care activities. There is no need for family or a female nurse to assist in these noninvasive procedures at this time without evaluating first what the client’s issues may be. The nurse should also not ignore the nonverbal communication being sent by the client; this would not be therapeutic.
Inspection of the client's skin is necessary to verify if there are additional areas of bruising or discoloration of which the client might not be aware. It is important to review current findings and compare them with baseline findings as this might provide data to support a potential response to drug therapy. Asking the client if the bruising is related to a particular incident is important (option 1). It does not, however, rule out the possibility that drug therapy has made the individual more susceptible to bruising or bleeding tendencies. If the client has not taken the medication as ordered, it would be unlikely that the bruise would be a consequence of drug therapy (option 2). It is important for the client to continue to self-monitor during drug therapy, but that choice by itself does not answer the question (option 3).
Ferritin levels reflect the visceral stores of iron in the body. Transferrin levels reflect how iron is transported in the body (option 2). Hemoglobin and hematocrit refer to concentration and proportion measures of red blood cells (RBCs). While they provide information relative to blood count, they are not specific to body iron store values (option 3). A CBC will provide information relative to blood concentration of all three cell lines (red, white, and platelets) but again, it is not specific to body iron store values (option 4).
Activase is used in the emergency setting post stroke and myocardial infarction (MI) in order to dissolve clots and increase perfusion. A client receiving this medication is at risk to develop significant cardiac dysrhythmias and therefore should be placed on a cardiac monitor during treatment. While vital signs (including blood pressure and temperature) are important, they are not the priority intervention (options 1 and 4). The monitoring of urinary output is not a priority unless there are underlying conditions regarding volume management (option 3).
The target range for hematocrit with epoetin alfa therapy is 30–36%. A client who is taking Epogen must be monitored closely so as to prevent adverse side effects that can occur because of either a rapid increase or high-level hematocrit. Rapid or increased hematocrit levels can cause the client to develop seizures and hypertension (option 2). Bone pain and fever are seen in response to administration and are not indicators of effective drug management (options 1 and 4).
Facial flushing is an expected side effect of niacin caused by its vasodilator properties. While dosages are often adjusted, it is usually for the purpose of managing side effects related to gastrointestinal complaints and not based on lab values (option 1). Additional dietary sources of niacin are not required to enhance the effect of niacin supplements (option 3). Clients should not take niacin and lovastatin concurrently as this can lead to the development of myopathy (option 4).
DDAVP and cryoprecipitate are considered effective treatments for clients with von Willebrand's disease because they contain specific clotting factors (vW and VIII). They are considered a form of replacement therapy but do not stimulate production of blood factors (option 4). While DDAVP is an antidiuretic, it also has other pharmacological actions in the body; specifically, it stimulates the body to release vW factor (option 2). These medications do not have to be given concurrently in order to potentiate their effects (option 3). Clients can receive them independently based on physician preference.
Hemostasis is the ability of the body to prevent bleeding and hemorrhage using platelets in the coagulation process. Thrombocytopenia, which is a reduced level of platelets in the body, can profoundly affect the body's ability to react to a vascular insult. Neutropenia, which is a reduced neutrophil count affecting WBCs, can profoundly affect the body's ability to react to an immune response (option 3). Low ferritin levels and elevated triglyceride levels do not directly affect a body's ability to maintain hemostasis (options 1 and 2).
Clients who have valve replacement surgery require lifelong anticoagulation therapy. Therefore, they must be instructed as to the possible risks for bleeding and modify their environment and activities of daily living accordingly. Follow-up lab testing is required but is not usually limited to a weekly basis (option 1). Coumadin therapy is usually taken as an evening dose (option 3). Clients are instructed not to double up doses and to take the medication as specifically ordered to assure safe and therapeutic effects (option 4).
Heparin administration requires the use of an infusion pump in order to maintain an accurate level of medication. While vitamin K is important in the coagulation cascade, it is not required to be readily available when heparin is being infused. Protamine sulfate is a heparin antagonist and should be used when reversal is indicated (option 1). The client does not have to be NPO during this type of therapy (option 2). If using weight-based therapy, it is important to weigh the client once a day at the same time with the same scale to verify accuracy (option 4).
Teach client that the activity in which he or she is engaged may be causing the chest pain. Instruct the client in the exact method of taking NTG to avoid dizziness. The teaching about the frequency of the medication must be accurate and specific to prevent overdose as could happen in option 4. Option 1 is incorrect because NTG becomes unstable when exposed to heat, light, and moisture. Option 3 is incorrect because the client should not drive due to safety concerns.
The nurse is exercising autonomy, the right to make one’s own decision. Nurses who follow this principle recognize that each client is unique. In this situation, perhaps because of the developmental level, the nurse assessed that a video would be a better teaching-learning method than written literature. Paternalism restricts the freedom of the individual because another determines choices. Noncompliance occurs when an individual is fully aware of the consequences yet chooses the action anyway. Informed consent is providing agreement to undergo treatment following a description of a procedure with the risks, benefits, and alternatives explained.
Iodine is used in many radiological procedures. Shellfish allergies may be an indicator of iodine allergy. The other options do not address this concern.
Pain is an experience that is more likely to be culturally influenced for clients. Hispanic or Latino clients are more likely to externalize their pain, while Asian clients and some European American clients tend to show few external signs. The best interpretation is one that does not judge the level of the client’s pain without direct assessment (options 1 and 2) and that does not label the client unfairly (option 4).
Nitroglycerine patches and ointments must be rotated daily to a hairless area to reduce skin irritation. Options 2 and 4 are incorrect statements, while option 1 is only partially correct.
It is important to monitor the apical-radial pulse for a full minute before the administration of digoxin. Record and report significant changes from the client's own baseline data. Without solid data regarding client's baseline, it is prudent to report a heart rate less than 60, since bradycardia could indicate drug toxicity. Depression, respiratory rate, and blood pressure are unrelated to this medication.
The blood pressure and heart rate must be monitored closely to prevent hypotension and tachycardia. Shortness of breath is important but not directly related to NTG. Respirations, urine output, and headache do not determine administration decisions. Headache frequently occurs and is treated commonly with acetaminophen or another mild analgesic.
Metoprolol is a beta-blocking agent which blocks the effects of both β<sub>1</sub> and β<sub>2</sub> receptors, leading to a reduction in systemic vascular resistance. This effect also may lead to bronchospasm (from bronchoconstriction secondary to β<sub>2</sub> blockade), and therefore metoprolol would be contraindicated in clients with bronchospastic illness. The drug has no effect on seizure activity or on myasthenia gravis, a neuromuscular disorder.
Verapamil is a calcium channel blocker used to treat angina. Constipation is a frequent complaint of clients taking the sustained-release form of verapamil. Many elderly clients have difficulty with this, and the nurse must anticipate the need for teaching about increasing fiber and fluid intake. Hypotension is an adverse reaction to verapamil. Skin rash is unrelated to the medication.
Ibuprofen is excreted through the kidneys and should not be administered to anyone with kidney disease. The other options would not be affected by ibuprofen administration and can be ruled out.
Digoxin is classified as a positive inotropic drug. It increases contractility (inotropy) of heart, whereas propranolol (a beta-blocker) and verapamil (a calcium channel blocker) are negative inotropic medications. Atropine has a neutral effect on contractility.
Lidocaine IV is used to treat ventricular dysrhythmias (premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation), particularly in clients with a myocardial infarction. It is a class 1-A antiarrhythmic. The drug causes no anesthetic effect unless the client receives an overdose that is evidenced by a central nervous system deficit (e.g., paresthesias, confusion, and slurred speech). Lidocaine may cause drowsiness but is not used for relaxation (option 2). It is not a diuretic (option 4).
The side effects of amiodarone take several weeks or longer to manifest themselves. Sometimes they persist for up to 4 months, and because photosensitivity is a continuing concern, the client should avoid tanning. The pulse should be monitored and if it remains above 100 the physician should be notified. If a dose is missed, the client should call the physician before taking any more medication.
Mevacor belongs to a group of drugs classified as statins. They work by inhibiting cholesterol synthesis in the liver. Bile-acid resins and fibric acid derivatives also work to decrease cholesterol levels but they work at different sites (options 1 and 3). Bile-acid resins work in the gastrointestinal tract and bind bile salts in the intestine. Fibric-acid derivatives work on lipoproteins and triglycerides to reduce cholesterol. Mevacor is not a hormone (option 2).
Cultural practices near the time of death are important for clients and their families. The nurse should respect the client and family wishes, since medical care is ineffective at this point in time (option 4). Options 1 and 3 do not fully respect the needs of the client and those who are important in his life.
It is important for the nurse to understand that both intrinsic and extrinsic factors are necessary for the absorption of vitamin B<sup>12</sup>. If clients lack intrinsic factor (i.e, has pernicious anemia), the medication must be administered via the IM or deep SC route. The PO route of administration will not solve the problem if intrinsic factor is absent (option 1). Lifelong administration of vitamin B<sup>12</sup> is required for clients with this type of therapy (option 2). Injection therapy starts out on a more frequent dosing schedule. Therefore, it is incorrect to tell the client that injections will be given only once a month (option 4). In addition, this response minimizes the client's concerns, and is therefore not therapeutic.
Muscle aches are a common side effect of this medication that can often be reduced by taking the medication before bed. This is not an allergy, but a side effect so option 4 is incorrect. Option 1 is outside the scope of practice for the nurse and other measures should be attempted before asking the physician to change the prescribed medication.
The reticulocyte count is an indication of the number of immature RBCs found circulating in the body. An increased reticulocyte count will indicate that the bone marrow is functioning and that RBC production has been stimulated. INR, PT, and APTT (options 2, 3, and 4 respectively) all refer to coagulation studies that are useful in managing anticoagulation therapy or clients who have coagulation disorders.
Oral contraceptives taken concurrently with folic acid will diminish the effectiveness of the folic acid. The nurse should be alert to the potential drug interactions, educate the client, and notify the physician of potential interactions. Vitamin E, tetracycline, and allopurinol (options 1, 2, and 3) all affect the administration of iron.
Because heparin is metabolized quickly in the body, it is important to know both the amount of drug that was given and the elapsed time frame. The dose of protamine sulfate will be calculated based on individual need by the physician. While it is true that the maximum dose of protamine is 50 mg over a 10-minute period, that might not be the dosage required since the pertinent information relative to heparin is not stated (option 1). APTT levels would be monitored but are not the priority action at this time (option 2). Vitamin K should not be given with protamine sulfate, as it is the antagonist to Coumadin (option 4).
Hemostatics such as aminocaproic acid are used to control excessive bleeding. They can be applied topically to stop a local hemorrhage, or they can be administered parenterally to stop a systemic hemorrhage. Thrombolytics are used to dissolve existing clots (option 1). Antiplatelet agents are used to prevent platelet aggregation and anticoagulants act on the coagulation cascade to prevent clot formation (options 3 and 4). It is important for the nurse to have a basic understanding of each of the drug groupings so that appropriate therapy can be properly monitored.
If the client still complains of symptoms of anemia, then it is possible that treatment with folic acid may not be the primary problem. Folic acid and vitamin B<sup>12</sup> work together to aid the growth of RBCs. Obtaining and comparing APTT results will not demonstrate whether the drug treatment is effective as this test looks at the intrinsic coagulation pathway. While it is true that alcohol has a major effect on folic acid levels and intake, there are many other medications that can affect folic acid levels. This response, while of concern, does not indicate that the drug therapy is effective. A review of dietary sources might be indicated, but if the client were taking drug therapy, then the amount of folic acid in the diet would not indicate whether the drug therapy is effective.
It is very important for the client to be aware of foods that are high in vitamin K while on Coumadin therapy. Green, leafy vegetables are very high in vitamin K, and if the client is eating a large amount of these during the week, this might affect the action of Coumadin. While milk is a good source of vitamin K, the amount that the client is taking is not enough to cause concern with regard to Coumadin interaction (option 1). The amount of wine and wax beans is not clinically significant to affect Coumadin interaction (options 2 and 4).
The APTT level should be 1½–2½ times the control value to reach a therapeutic range. A control value is always run with the test to make sure that the results are referenced. Higher APTT levels are not considered to be therapeutic and may require that the medication to be stopped until APTT levels fall back into a safe and therapeutic range.
Sotalol is a beta-adrenergic blocking agent. Side effects include bradycardia, difficulty breathing, wheezing, bronchospasm, GI disturbances, anxiety, nervousness, weakness, mood changes, depression, and loss of libido. Options 1, 2, and 3 do not occur.
The nurse should notify the health care provider of the client’s practices and should continue to monitor the client to promote safe management of his health problem. It is unnecessary to ask for a nurse of the same culture to be assigned. The nurse would not indicate that the medication would not work because of health beliefs. It would be punitive to discharge the client from services because of culturally based health practices.
Calcium channel blocker agents, such as diltiazem (Cardizem) are used cautiously in clients with aortic stenosis, bradycardia, CHF, acute myocardial infarction, and hypotension. The nurse would monitor for signs that indicate worsening of these underlying conditions. Bradycardia and peripheral edema signal adverse effects of this class of medication, and require follow-up if they occur.
Hydralazine (Apresoline) is a powerful vasodilator that exerts its action on the smooth muscle walls of arterioles. After receiving this medication, blood pressure is checked every 15 minutes until stable, and then every 1 hour. Although options 1, 2, and 4 are components of client care, they are not directly related to the action of the medication.
Nitroglycerin is an antianginal of the nitrate type that causes vasodilation of coronary and other arteries. It would be expected to cause a headache, and nausea can occur with most medications but neither are considered a significant adverse reaction. The heart rate could also decrease with overall improvement in cardiac output. A decrease in BP from 130/80 to 90/64 is excessive, and warrants further monitoring by the nurse to determine whether perfusion to major organs is adequate.
Amlodipine (Norvasc) is a calcium channel blocker. Adverse or toxic reactions from over dosage might produce excessive peripheral vasodilation and marked hypotension with reflex tachycardia. Frequent side effects include peripheral edema, headache, and flushing. Some sustained-release forms of calcium channel blockers (such as Calan SR) might lead to constipation, a milder side effect than the others.
Atenolol is a beta adrenergic blocker that causes a decreased heart rate, blood pressure, and cardiac output. Fatigue is the most common side effect. If fatigue becomes severe enough, it could interfere with the client's activity level. Activity intolerance is the state in which an individual had insufficient energy to complete activities of daily living. There is no evidence that the client has Ineffective cerebral perfusion, Ineffective health maintenance, or self-care deficit.
The normal reference range for potassium for an adult is 3.5–5.1 mEq/L. Hypokalemia can make the client more susceptible to digitalis toxicity. The nurse monitors the results of electrolytes for the potassium level. If the potassium level is low, the dose is withheld, and the physician is notified. This client's result is in the normal range, so the dose should be administered.
Lasix depletes potassium stores, and a client taking digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia makes the client more susceptible to digitalis toxicity. Option 3 is the best choice because all three foods are high in potassium and low in sodium.
The medication has side effects that could be disturbing to the client. These include hypotension, insomnia, lethargy, bronchospasm, mood changes, and decreased libido. The client should be alert to these so that they can notify the physician or other healthcare provider. It is not the nurse's role to describe alternatives to the currently ordered medication (option 1). It is unnecessary to teach about effects at the cellular level (option 3) unless the client has interest in this. It is also unnecessary to teach the client about various dysrhythmias (option 4) because this is not pertinent.
Option 1, quinidine, is a Class I-A antiarrhythmic that is very effective as a chemical cardioversion agent. Option 2, verapamil, is a calcium channel blocker generally used to control heart rate. Option 3, nifedipine, is a calcium channel blocker used as a vasodilator. Option 4, bretylium, is generally used for control of ventricular arrhythmias.
Clients who are taking cholestyramine, which is a bile resin, should be monitored for fat soluble vitamin deficiencies (vitamins A, D, E, and K), as the gastrointestinal side effects of the medication can lead to reduced absorption. Niacin, folic acid, and vitamin B<sup>12</sup> (options 1, 2, and 4) are all examples of B complex vitamins that are water soluble.
The Jewish religion prohibits the ingestion of meat and dairy products during the same meal. The nurse should ask that the entire meal tray be replaced by the dietary department. It is unnecessary to remove the tea (option 1) or the chicken alone (option 2). Option 4 will not resolve the dietary issue.
Clients who are taking Coumadin should be alerted to the potential for drug interactions when they are on long-term anticoagulation therapy. Aspirin can potentiate the effect of Coumadin and interfere with the ability to maintain a therapeutic level. The use of Darvon, although previously prescribed, is not in the best interest of the client at this time due to Coumadin therapy. Telling the client to keep taking Darvon would lead to drug interactions (option 2). While a further evaluation of the client's back pain may be necessary (option 1), it is not the primary action that the nurse should be addressing at this time. Option 4 is a false statement, because the two drugs together could enhance bleeding.
Low-dose heparin therapy is indicated in many postoperative clients to prevent the development of thromboembolic episodes. It is not used in every postoperative situation (option 1), but it is usually for clients who have orthopedic surgery or are anticipated to be immobilized for a time following surgery. Short-term therapy is not given to maintain adequate blood clotting levels (option 2) but merely to intervene as a preventative measure. The statement that heparin is given subcutaneously in to the abdomen and is not usually painful is factual but is not the reason for the medication being given to the client (option 3).
The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation. Therefore, the medication should be stopped per protocol, resumed at a decreased dose in 1 hour with a repeat APTT ordered in 2–3 hours per protocol. The dose should not be increased, as this would cause serious consequence to the client. Stopping the medication for a total 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another APTT and continuing administer the medication could also cause serious consequences to the client.
With an INR level that high and no incidence of bleeding, administration of vitamin K and withholding of Coumadin doses are usually indicated. Protamine sulfate is the antagonist to heparin administration and is not indicated in this situation. Merely withholding the Coumadin dose is not appropriate, since the INR level is too high. The amount of vitamin K in the diet is not an immediate concern at this point as the INR level is too high.
Folic acid helps to reduce hemocysteine levels and is therefore important for cardiovascular health. Decreased levels of folic acid and other B vitamins (B<sup>12</sup> and B<sup>6</sup>) can lead to increased levels of homocysteine, which are associated with increased risk of cardiovascular disease (option 1). Method of cooking/preparation can affect the bioavailability of vitamins but is not usually the main cause of folic acid anemia (option 3). Folic acid anemia is not related to the development of diabetes (option 4).
Often, clients who have multiple risk factors for developing hyperlipidemia must use a combination therapy of drugs and diet to achieve results. Diet management, weight control, and the use of drug therapy work together in supporting and maintaining lipid levels. There is also a genetic component to hyperlipidemia that needs to be addressed by the client. Clients who are compliant with diet therapy often have to use drug therapy because of this genetic predisposition to produce more cholesterol. Drug therapy will not by itself eliminate the need for watching fat intake. Effective drug therapy is not only seen with documented weight loss. The chemical actions of the drug depend on compliance to the medication schedule. Lovastatin (Mevacor) does not reduce triglyceride levels. Different antilipidemia agents work on various lipoproteins and triglycerides.
When using a lipid-lowering agent, the standard of care is that liver enzymes be routinely evaluated both before and during the course of therapy. These medications can cause abnormal results in liver function tests that can lead to serious consequences if the client is not properly monitored. CBC, clotting studies, and doppler studies are not indicated for the management of this drug therapy.
Heparin is the drug of choice for clients who have presenting symptoms of DVT due to its rapid onset of action. Lovenox is an example of a low molecular weight heparin (LMWH), low-dose therapy that is used as a prophylactic measure to prevent thromboembolism (option 2). Coumadin is an oral anticoagulant that has a slower onset of action and is therefore not appropriate as first line therapy for a client with a DVT (option 1). Persantine is an antiplatelet medication that works on decreasing platelet aggregation. It works to prevent arterial thrombosis (option 4).
With initial therapy, it is recommended that iron preparations be taken with meals to prevent GI upset. As therapy is tolerated, the medication can be given between meals to maximize absorption. Antacids and antibiotics when taken together with iron decrease its absorption (options 1 and 4). Oral iron salts are different in their amount of elemental iron, therefore iron preparations should not be used interchangeably (option 2).
Apresoline is a vasodilator and if the client becomes dehydrated, hypotension will result. In other words, during dehydration both preload and afterload are reduced causing the "tank" to get larger with less volume. The normal dose of hydralazine is 5–25 mg PO. Serum potassium is high but unrelated to Apresoline. The increased heart rate is a reflexive response to the low cardiac output to compensate with decreased preload and afterload.
The client may be trying to demonstrate interpersonal harmony, which reflects a culturally based value. There is insufficient evidence to support any of the other interpretations listed.
Digoxin (Lanoxin) is given to slow and strengthen heart rate as it is a positive inotropic medication. After administration the nurse should monitor pulse rate as it would be anticipated the heart rate should slow. Digoxin (Lanoxin) has no effect on respirations, does not typically cause headache as a side effect, and will not typically affect blood pressure unless an overdosage occurs.
The standard protocol is to administer up to three doses of NTG 5 minutes apart as long as the vital signs remain stable. If pain is unrelieved after three doses, the physician should be called. An electrocardiogram (ECG) can be ordered, but not an EEG to measure brain waves. Using NTG paste, a longer-acting form of the medication, is not appropriate at this time.
Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine suppresses automaticity in the His-Purkinje system (HPS) by elevating electrical stimulation threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without converting the rhythm to an atrial or sinus rhythm is not therapeutic. An increase in level of consciousness (option 4) would only occur once the ventricular rhythm is terminated.
The client's diet should be high in potassium to avoid hypokalemia. The hydrochlorothiazide is a potassium-depleting diuretic. If the client develops hypokalemia, he or she would be at a greater risk for developing digitalis toxicity. The client should measure the pulse before taking the cardiac glycoside (digoxin). For the best therapeutic effect, the medications should be taken at the same time each day, preferably in the morning (so client will not have nocturia from the diuretic). A combined therapeutic effect increases the urinary output via the positive inotropic effect of digoxin and the diuretic effect of hydrochlorothiazide.
Because of the vasodilating effects of nitrates, headache is a common side effect. Medical attention is not necessary unless the headaches increase in frequency or severity. All three medications are nitrates and will increase coronary artery blood flow by dilating the coronary arteries and collateral blood vessels, which results in increasing blood flow to the heart. The medications are used to prevent the frequency, intensity, and duration of anginal attacks. All should be stored in a cool, dry place.
Adenosine (Adenocard) is an antidysrhythmic used in the treatment of paroxysmal supraventricular tachycardia (SVT). Cardiac performance must be monitored before and throughout treatment by cardiac monitoring. An endotracheal tube may be used if an emergency arose necessitating mechanical ventilation, but the tube itself is a rather isolated item. An IV pump may be needed but is not a priority because this medication is administered rapidly by IV push. A pulse oximetry machine may be helpful in monitoring oxygenation but is not a priority item.
Prinzmetal's angina results from spasm of the coronary vessels. Calcium channel blockers are the medication that is prescribed for this condition. The risk factors are unknown, and it is relatively unresponsive to nitrates. Beta-blockers might worsen the spasm. Diet therapy is not indicated.
Amiodarone (Cordarone) is a class III antiarrhythmic medication and will probably not demonstrate therapeutic effects for 1–3 weeks. This medication can cause fatigue, cough, and pleuritic pain. The client must wear dark glasses and avoid exposure to the sunlight. The medication is given with food to avoid gastroenteritis distress.
Blood urea nitrogen (BUN) and creatinine are the best lab values to indicate kidney function. BUN will elevate with increasing dehydration, and a value greater than 80 would indicate a need to consult the physician before administering furosemide. Lipase is a measure of pancreatic function, and neither hemoglobin, hematocrit, nor cholesterol would indicate kidney function.
A client taking a diuretic such as furosemide should self-administer the medication in the morning to allow for diuresis throughout the day. This will help to prevent nocturia, which could cause disruption to the client's sleep pattern. The timeframe in option 2 is not as early as option 1, while options 3 and 4 clearly increase the risk of nocturia.
Yin and yang provide for balance in the body according to this theory. Because yin foods are cold and yang foods are hot, the client needs to eat cold foods for a hot illness and hot foods for a cold illness. Options 3 and 4 are incorrect because the two types of foods are not mixed in treating illness.
The National Institutes of Health (NIH) Committee has defined hypertension as a systolic pressure of 140 or higher and diastolic of 90 or higher when two or more blood pressure measurements are averaged on two or more subsequent visits. Options 1, 3, and 4 are incorrect.
Losartan is an angiotensin II antagonist that inhibits the conversion of angiotensin I to angiotensin II, resulting in vasodilation and normalizing blood pressure. The client should be monitored for dizziness, cough, and diarrhea while taking this medication.
Dry, persistent, tickling, and nonproductive cough is a common side effect of angiotensin converting enzyme (ACE) inhibitors.
Beta blockers inhibit cardiac beta 1 receptors but also may affect beta 2 receptors in bronchial and vascular smooth muscle causing bronchoconstriction. Therefore, the client with COPD should avoid taking beta blockers. Options 1, 2, and 3 are incorrect.
Indipamide (Lozol) is a thiazide diuretic. Its hypertensive effect might be due to direct arteriolar vasodilation and decreased total peripheral resistance. Lozol might cause hypokalemia. Signs and symptoms of hypokalemia include muscle weakness and leg cramps. Electrolytes, particularly potassium, need to be evaluated. The other options are irrelevant.
Thiazide diuretics decrease the effect of antigout medication by increasing hypersensitivity to allopurinol. Hyperuricemia is a side effect of thiazide diuretics. Option 3 is not the best answer: Although clients might experience pain and burning sensation in the lower extremities as well as signs of infection, there is no mention of diabetes history in the above question.
Oxybutynin (Ditropan) is an antispasmodics medication used for urinary tract problems. It produces anticholinergic side effects such as dry mouth, constipation, urinary hesitancy, and decreased gastroenteritis motility. Periodic interruptions in therapy are recommended to determine continued need for this medication.
Urinalysis and urine dipstick should be performed to monitor for the presence of blood cells and bacteria in the urine. Infection should be established before instituting pharmacologic therapy. Clients with urinary problems should be encouraged to increase fluid intake, but it is not the most important intervention at this time.
Proscar is an androgen inhibitor used to treat benign prostatic hyperplasia (BPH). Pregnant or women of childbearing age should not be exposed to semen fluid of a male taking finasteride (Proscar). Proscar is teratogenic and may produce fetal abnormalities. Options 1, 3, and 4 are incorrect.
Verapamil is a calcium channel blocker that decreases blood pressure and heart rate. Option 1 is incomplete. Calcium channel blockers have no effect on urinary output (option 3). Option 4 is an opposite effect to this medication.
Because American women tend to be more autonomous and have fewer relatives who assist in the postpartum period, American women are more at risk for postpartum depression. Many non-Western cultures will have family involvement in the care of the mother and infant for up to 50 days after delivery. This prolonged support helps to prevent the new mother from feeling overwhelmed with new responsibilities or feeling abandoned.
Phenazopyridine is a urinary analgesic with a local anesthetic effect on the urinary tract mucosa. This medication relieves pain during urinary tract infection. It causes the urine to have an orange/red color. It has no effect on volume of urine. Foul odor to the urine might be caused by urinary tract infection.
Dopamine acts on the alpha/beta adrenergic receptors resulting in vasoconstriction, increasing systemic BP, and increasing force and rate of myocardial contraction. Options 1, 3, and 4 are incorrect.
Emphasis should be placed on the client's adherence to the plan of treatment to avoid serious consequences of noncompliance. The complications of high blood pressure include stroke, cardiac failure, and chronic renal failure.
Some clients will experience an increased blood pressure with OTC cold preparations such as pseudoephedrine due to vasoconstriction. Therefore, they should avoid taking these medications with an antihypertensive. Options 1, 2, and 4 are incorrect.
Methylphenidate is a central nervous system stimulant. It increases releases of norepinephrine and dopamine in cerebral cortex to reticular activating system. Ritalin is contraindicated in clients with glaucoma. Congestive heart failure, diabetes mellitus, and hyperthyroidism, do not represent contraindications to the use of methylphenidate.
Medication must be taken to maintain therapeutic blood levels, even if there is no seizure activity. The urine might turn pink or brown, but that is not the most important item to teach. Options 1 and 4 are incorrect. Often, after 6 months with no seizures, a client can drive again.
The client needs to give the medication opportunity to work without aggravating the headache. Ergotamine should be given orally 1–2 mg followed by 1–2 mg every 30 minutes until the headache abates or until the maximum dose of 6 mg/24 hours (option 1). It is unnecessary to drink large amounts of fluids (option 2) and increased warmth and energy are not associated with this medication (option 3).
Dantrolene is a central-acting skeletal muscle relaxant. This medication may be used to control spasticity after spinal cord injury. Dexamethasone is a corticosteroid used to decrease swelling, especially cerebral edema. Dichlorphenamide is a carbonic anhydrase inhibitor used to treat glaucoma by decreasing production of aqueous humor and thereby lowering intraocular pressure. Dobutamine is a medication used to treat hypotension by increasing cardiac output.
Because opioid analgesics relieve pain, the nurse needs to determine the client's pain intensity before and 30 minutes after administering a dose. The respiratory rate and level of consciousness need to be monitored because respiratory depression and sedation are two adverse effects of this drug class. The items in the each of the other options are only partially correct. Urine output, liver function studies, seizure activity, electrolytes and blood glucose are not ongoing data collection directly related to opioid administration.
Clients may take more aspirin, acetaminophen, and NSAIDs than prescribed by their providers if they are not aware that many OTC medications are combined with these medications. The other answers are cautions for a variety of other types of medications.
Following birth, the umbilical cord may be buried near a place or an object that symbolizes the parents’ hope for the child’s future. For this reason, the parents of the newborn are likely to request to take it home. The other options do not represent the cultural beliefs of Native Americans regarding the significance of the umbilical cord after birth.
The client should be monitored for seizure activity, changes in mental status, and respiratory status as highest priority. Monitoring kidney function (BUN and creatinine) and urine output are not the priority nursing considerations when the client is taking anticonvulsants. The data collection in the other options are pertinent for a variety of other types of medications.
Tegretol is contraindicated within 14 days of taking MAOIs because this can lead to a fatal reaction. The other drug classes listed do not have this interactive effect with carbamazepine. NSAIDs are used to treat inflammation and pain, while opioid analgesics and skeletal muscle relaxants are drug classes that exert an effect on the central nervous system.
The seizure threshold is decreased when anorexiants or amphetamines are used concurrently with anticonvulsants because of changes in the brain chemicals caused by the anorexiants and amphetamines. The medications listed in options 1 and 3 listed do not change the seizure threshold. The medications listed in option 4 might be used to treat seizures, which might raise the seizure threshold.
Dantrolene is a skeletal muscle relaxant. Hepatotoxicity is an adverse reaction for dantrolene, which may be manifested by abdominal pain, jaundiced sclera, or clay colored stools. The items in the other options do not address this adverse effect.
The client needs to understand that high-protein foods must be avoided so that the medication can be absorbed properly. Side effects do not include cushingoid symptoms (option 1) or oral ulcerations (option 3). There is no need to avoid vaccinations (option 2).
Medication must be taken to maintain therapeutic blood levels, even with no seizure activity. If the client understands that adherence is important, he or she is more likely to be compliant with the medication regimen. The client does not need to lie down after a dose (option 1) or have cholesterol levels checked (option 2). Anticonvulsant therapy is prescribed for long-term or lifelong use (option 4).
If the client understands the importance of the finding the triggering factors, she or he will be more willing to be involved in decreasing the triggers, including lifestyle changes that might be necessary. The client should continue to exercise for general health and stress management (option 2). Medication might not be needed every 4 hours (option 3) and driving is permitted (option 4).
A history of Tourette's syndrome is a contraindication for Ritalin. There would be other medications that could be used for treatment of ADHD, such as pemoline (Cylert) or dextroamphetamine (Dexedrine). The medications listed in the other options are not contraindications for methylphenidate.
The dose of an antihypertensive medication usually needs to be adjusted when a CNS stimulant is added to a client's medication regimen. The other options are incorrect because NSAIDs, skeletal muscle relaxants, and opioids are less affected than antihypertensives.
Anticholinergic medications cause decreased stimulation in the GI and urinary tract systems that lead to urinary and bowel problems such as urinary retention, hesitancy, and constipation. Other side effects of the anticholinergic medications are dry mouth and constipation. The items in options 1, 3, and 4 do not represent particular concerns when administering an anticholinergic medication.
In the Latino culture, herbal medicines are just as important as Western medicines in treating illness. Mourners would not be hired by a family to demonstrate grief after a death (that practice could occur in Korean culture). Staring at a child could cause the “evil eye” because of their inexperienced and vulnerable spirits. Depending on the specific illness, either hot or cold foods would be used in treatment. Males may be the typical decision makers regarding health care. The client may want a caregiver of the same gender to enhance privacy.
Potentially fatal interactions occur between selegiline and opioids, especially meperidine (Demerol). Therefore, nurses should be aware of all medications that a client routinely takes when selegiline is ordered concurrently. The other classifications may have interactions, but none are potentially fatal.
The medications used to treat disorders of either the neurological or musculoskeletal system are complex and require the client to understand how they work. When the client is informed, he or she is more likely to take the medication correctly. Options 1 and 2 might not apply, and option 3 is of lesser importance than option 4.
Phenytoin binds with the protein in the tube feedings, which decreases the medication absorption into the blood. The tube feedings may need to be shut off for 30–60 minutes before and after the dose. The other answers are incorrect statements.
The effects of muscle relaxants are intensified when taken in combination with other central nervous system (CNS) depressants such as alcohol or cough preparations. The client should consult with the provider before taking other medications. Cholesterol levels do not need to be checked (option 2). Apical pulse measurement is unnecessary (option 3), and it is antibiotics, not cyclobenzaprine, that must be finished even if symptoms improve (option 4).
Tonic-clonic seizures are the most common generalized seizures. Periods of inattention and daydreaming characterize an absence seizure. Sudden loss of muscle tone and falling characterize an atomic seizure. Repetitive small muscle group activity characterizes a partial seizure.
After the seizure, the client will be postictal, which is a deep-sleeping state. The client could aspirate secretions unless side-lying to promote drainage from the upper airway. Positioning the client on the back (option 1) increases risk of aspiration. Positioning the client on the abdomen (option 3) or upright in chair (option 4) is unrealistic given the client's postictal state.
Phenytoin is a first-line anticonvulsant medication that is used to control seizure activity. Selegilene (option 1) is used to treat Parkinson's disease. Diclofenac (option 2) is an NSAID, while sumatriptan (option 4) is used to treat headaches.
The client must understand the medication information as a priority item. Option 2 is a false statement. Effective medication dosing should control seizure activity (option 4). Teaching that urine might turn pink to brown may be included if appropriate, but is not the highest priority and global response.
The ability to avoid the headache triggers is important for the client and therefore must be included in teaching. The urine does not change color (option 1). Effective therapy should not take 1–2 years (option 2). Gingival hyperplasia is a concern with phenytoin (option 4), which is used to control seizure activity.
Dopamine is the neurotransmitter that is lacking in Parkinson's disease. The other neurotransmitters are not as integral in PD.
Use of empathy in option 3 communicates understanding to the client and allows him or her to explore inner feelings of hopelessness. Options 1, 2, and 4 ignore and discount the client’s feelings. These responses would not encourage the client to further explore his or her feelings with the nurse.
Clients with PD have difficulty initiating movement; so arising from a chair is difficult without assistance. The tremors of PD are resting tremors, not intentional. Medication therapy is targeted at controlling tremors. The other options do not reflect manifestations of this disorder.
The client must have pain control with oral medications and have begun an exercise program prior to discharge. Option 1 is completely incorrect, while options 3 and 4 are partially incorrect.
The most important nursing diagnosis for the client at this time is related to inadequate knowledge of medication management. Ineffective sexuality patterns and impaired thought processes might be addressed later as needed, but pain related to headache is not applicable.
The primary issue for migraine headache sufferers is pain relief and is amenable to treatment with medication therapy. Disturbed sleep pattern might be addressed later, while ineffective sexuality patterns and impaired thought processes are not applicable.
Aldactone is a potassium-sparing diuretic that increases sodium excretion and decreases potassium secretion in the distal convoluted tubule. Potassium levels greater than 5.5 mEq/L are contraindicated with spironolactone due to increased risk of hyperkalemia. The other options are describing normal conditions.
Epinephrine and oxygen should be available at the bedside because of the risk of anaphylaxis during administration. An oral airway and suction catheter are not the priority items.
The Joint National Committee VI treatment algorithm recommends diuretics and beta blockers as the preferred agents for uncomplicated hypertension as they lower morbidity and mortality. ACE inhibitors, calcium channel blockers, alpha and beta blockers, and angiotension II antagonists are also acceptable as monotherapy.
Each dose of this medication should be administered with a full glass of water, and the client should be encouraged to maintain a high fluid intake. The medication is more soluble in alkaline urine. Option 4 is incorrect, and the client should not discontinue or decrease the dosage without consulting with physician.
Alpha blockers may cause first-dose syncope within 30–60 minutes after the first dose. The effect is transient and might be diminished by administering the medication at bedtime.
Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. Its effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy.
If there is confusion related to a medication order, refer to and verify the original written order. Be careful to read abbreviations and dosage correctly. Asking another nurse or the pharmacist, or calling the physician are correct interventions, but not the first intervention, because the first step in the medication process is the writing of the order. Once that is verified, the nurse could choose any of the other options, which are correct.
Option 4 is correct because these actions indicate the client is attempting to cope with the situation in some way. Option 1 is incorrect because these actions may not be appropriate. Options 2 and 3 are incorrect in terms of the demonstrated behaviors.
Calcium channel blockers should be administered with a meal high in fat content. Grapefruit should be avoided before and after dosing due to altered effects. The foods listed in the other options will not have a dose-altering effect.
In hypertensive urgencies, clients present with a systolic BP greater than 240 mmHg and diastolic BP greater than 120 mmHg. In hypertensive emergencies, the client's diastolic BP is greater than 130mmHg.
Spironolactone is a potassium-sparing diuretic used to treat hypertension. Gynecomastia is one of its adverse reactions. Adverse reactions usually disappear after the drug is discontinued. However, gynecomastia might persist after discontinuance of spironolactone.
Thiazide diuretics increase urinary excretion of sodium and water by inhibiting sodium reabsorption in the cortical diluting tubule of the nephron thus relieving edema. The loop diuretics inhibit electrolyte reabsorption in the thick ascending loop of Henle thereby promoting the excretion of sodium, water, and potassium. Potassium-sparing diuretics directly increase sodium excretion and decrease potassium secretion in the distal convoluted tubule.
Alpha adrenergic blockers are used for peripheral vascular disorders, hypertension and BPH. Options 1, 2, and 4 are incorrect.
Of all the calcium channel blockers, verapamil and diltiazem have the greatest effect on the AV node to slow the heart rate. Additional drug effects are slowing of the ventricular rate in atrial fibrillation or flutter and conversion of supraventricular tachycardia (SVT) to a normal sinus rhythm (NSR).
Loop diuretics have the disadvantage of requiring more frequent dosing but are advantageous in clients with creatinine clearance less than 30mL/min. The other types of diuretics are not as useful when the client has a decreased creatinine clearance level.
Nonselective beta blockers are associated with adverse events of hyperglycemia and hyperlipidemia. These changes might be temporary but the client should be monitored for occurrence. Decreased liver enzymes and increased BUN are not directly related to non-selective beta blockers.
Sympathomimetics act predominantly by direct stimulation of alpha adrenergic receptors, which constrict blood vessels and increase their resistance. This in turn results in increased total peripheral resistance and increased systolic and diastolic BP.
Norethindrone (Micronor) contains only progestin, with no estrogen. Because estrogen might decrease lactation, progestin only pills are commonly used in lactating women. The other options do not address the issue of contraception during lactation.
Laboratory test results are part of biological examination because they may provide insight into the occurrence of psychological symptoms. Options 2 and 3 do not relate to biological examination, but to emotional and social history. Option 4 is not part of the assessment process, but rather is a prediction about the outcome of an illness.
Breast tenderness, abdominal bloating, and monthly bleeding are common side effects of hormone replacement therapy. Severe leg pain in either the calf or the thigh may indicate deep vein thrombophlebitis, and requires physician assessment.
Methylergonovine (Methergine) is only administered postpartum to control or prevent excessive uterine bleeding. It is not used during pregnancy. The other options represent appropriate orders that the nurse does not need to question.
Premarin (conjugated estrogens, equine) is derived from the urine of female horses, and therefore is animal-based. Premarin may be rejected as a hormone replacement therapy product by women who follow strict vegetarian guidelines. The statements in options 1 and 3 are factually incorrect, while option 2 does not address the client's concern.
Ovarian hyperstimulation might result after fertility drugs are utilized. Women are instructed to rest, avoid heavy lifting or activities that may cause their abdomens to be bumped because of the risk of rupture of the ovary. Intercourse is prohibited to prevent a multifetal pregnancy and ovarian rupture.
Anabolic steroids promote protein buildup. They are similar to testosterone, but with less androgenic activity. The other statements are incorrect.
Different forms of estrogen are administered IM, transdermal, or PO. Ethinyl estradiol is administered orally in many combination oral contraceptive pills, and IM in the product named Lunelle.
Medroxyprogesterone acetate (Provera) taken for 10 days by a client facilitates thickened endometrial growth, and when the medication is ended, a menstrual cycle-like bleeding episode will occur. It does not immediately induce menstrual bleeding (option 2), rule out pregnancy (option 3), or maintain a state of amenorrhea (option 4).
Medroxyprogestrone acetate (Depo-Provera) is given IM every 85–90 days. Amenorrhea usually develops after the second or third injection (option 4), while breakthrough bleeding is common during the first 3–6 months (option 2). Contraindications include inability to receive the injections on time and desire to become pregnant within a year (option 3).
Menotropin (Pergonal) is given IM (not IV, as in option 2) for 9–12 days to mature ovarian follicles. The rate of multifetal pregnancy is about 20% of pregnancies (option 3). Several cycles of fertility medications are often needed to achieve pregnancy (option 4).
Dosing of all medication is started small and increased if needed to minimize the risks of side effects. Viagra should be taken approximately 1 hour prior to sexual activity. Option 3 is incorrect because Viagra is offered at three different doses: 25, 50, and 100 mg. Option 2 is incorrect because the smallest dose is utilized, while option 4 is incorrect because the client does not titrate the dose at will.
Bargaining is the stage in which the client attempts to bargain for more time. Denial (option 1) indicates the stage in which the client denies that he or she is terminally ill. Seeking (option 2) reflects the stage in which a client seeks more answers and cures. Resolution (option 4) is the stage in which the client has come to terms with the illness.
Oxytocin (Pitocin) used for labor induction augments the endogenous oxytocin. It is administered as a dilute solution of 10 or 20 units in 1 liter IV fluid via infusion pump, with a goal of increasing the frequency and intensity of contractions. Options 1, 2, and 4 are correct statements, indicating that the client understands these aspects of medication administration.
When given parenterally, magnesium sulfate acts as a central nervous system (CNS) depressant and also depressant of smooth, skeletal, and cardiac muscle function. The side effects of this medication when taken IV are drowsiness, flushing, heaviness in the limbs, and decreased deep tendon reflexes. Option 2 is incorrect because a decreased respiratory rate is a sign of magnesium toxicity. Option 3 is incorrect because these are signs of CNS excitability. Option 4 is incorrect because this is the side effect of magnesium sulfate when taken orally.
Clomiphene (Clomid) stimulates the production of lotein hormone (LH) and follicle stimulating hormone (FSH), and therefore increases ovulation in women with anovulatory infertility. Clomiphene is not used to treat hypogonadism (option 2), postpartum hemorrhage (option 3), or as hormone replacement therapy (option 4).
When 2 pills are missed, the client should "catch-up" by taking 2 pills per day for 2 days and then 1 pill until finishing the pill pack. This will keep her cycle controlled and will minimize the chance of mid-cycle bleeding. However, the client could ovulate when missing 2 or more pills. Thus a backup method such as condoms should be utilized for the rest of the cycle.
Ritodrine (Yutopar) is a beta-adrenergic medication utilized for tocolysis in the treatment of preterm labor. It stimulates beta 2 receptors in uterine smooth muscle, reducing intensity and frequency of uterine contractions and lengthening gestation period. Options 2 and 4 are incorrect because the clients do not require medication with a tocolytic effect. Option 3 is incorrect because ritodrine is not used for postpartum hemorrhage.
Oxytocin (Pitocin) is used to control postpartum hemorrhage and promotion of postpartum uterine involution. It causes the least increase in blood pressure of all of these oxytocic medications, and therefore, by considering the history of the client, would be used first in this case.
Human chorionic gonadotropin (Chorex) serves to release the matured ovum from the follicle, which has matured by the action of the menotropin or Humegon (option 2). Chorex does not limit the number of ova released (option 3) or prepare the uterine lining for the fertilized egg (option 4).
Testosterone is responsible for development of male sex organs and the secondary sex characteristics, and facilitates growth of bone and muscle. In cases of hypogonadism, too little testosterone is naturally produced, and supplementation may be required. The responses in options 1 and 3 do not identify the purpose of this medication for a 16-year-old. The response in option 2 is incomplete and does not address the client's learning need.
Danocrine (Danazol) is an androgen used in the treatment of endometriosis. It is taken orally b.i.d. for several months. Option 2 is incorrect because the medication is given for 3–6 months; therapy may be extended to 9 months if necessary. It is important to know that regimen cannot be repeated. Danazol is only given orally (options 3 and 4).
Progestins thicken cervical mucus to prevent sperm penetration, while estrogen administration prevents the luteinizing hormone (LH) surge that stimulates ova maturation. Option 1 is incorrect because additional estrogen is not needed. Option 3 is incorrect because taking estrogens alone would not prevent pregnancy. Option 4 is incorrect because the contraceptive is made as a combination product without the option of taking them separately.
Option 1 reflects the client’s statement in that the client’s normal eating pattern has been disturbed in some way. Options 2 and 3 reflect a more severe, true eating disorder diagnosis. Option 4 relates to a different psychiatric illness comprised of other behaviors.
Sildenafil is a medication used for erectile dysfunction among male population. It is contraindicated if the client has had MI, cerebro-vascular accident (CVA), or life-threatening dysrhythmia in the past 6 months, or if the client has hypotension, hypertension, unstable angina, or CHF.
Clomiphene (Clomid) induces ovulation through stimulation of luteinizing hormone (LH) and follicular stimulating hormone (FSH). It is taken orally in 50 mg dosage for 5 days each month, beginning on the fifth day of the menstrual cycle. Options 1, 2, and 4 are factually correct, which means the client understands medication teaching.
Androderm will replace the testosterone that should be produced by the testes. This therapy is utilized when the testes have been removed to maintain libido, sexual functioning, and secondary male characteristics. The clients in options 1, 2, and 3 do not require additional testosterone.
Oxytocin (Pitocin) is administered by diluting 10 or 20 units in 1 L of IV fluid, and administering small amounts (not large, as in option 4) via infusion pump. The synthetic oxytocin supplements the endogenous oxytocin, and uterine contractions result. The medication is not given by mouth (option 1) or IM (option 2).
Ergonovine (Ergotrate) causes uterine contractions, and is indicated for use only in normotensive postpartum women. Option 1 is incorrect because this medication causes an increase in blood pressure. The clients described in options 2 and 3 are not presenting any signs and symptoms of bleeding, thus using this medication would be irrelevant.
The symptoms of possible complications of combination oral contraceptives form the acronym ACHES: <b>A</b>bdominal pain, <b>C</b>hest pain, <b>H</b>eadache, <b>E</b>ye problems, and <b>S</b>evere leg pain (calf or thigh). The complications indicated by these symptoms are: <b>A</b>bdominal pain-liver tumor formation; <b>C</b>hest pain, <b>H</b>eadache, and Eye problems-embolus; <b>S</b>evere leg pain-thrombophlebitis. Sudden onset of blurred vision may indicate blood clot formation and subsequent pressure on the optic nerves.
Terbutaline sulfate (Brethine) is a smooth muscle relaxant, and therefore used to treat both bronchospasm as well as premature labor. A beta-adrenergic, the medication causes side effects of increased heart rate with a sensation of the heart beating harder, palpitations, muscle tremors, and nervousness. The symptoms in options 1, 2, and 3 are the opposite of those caused by terbutaline.
Testosterone preparations are contraindicated with pre-existing liver disease. Acne (option 1), melanoma (option 3), and testicular cancer (option 4) are not contraindications for use of this medication.
Prepidil is a form of prostaglandin E2, and is used for cervical ripening. The gel is inserted around the cervix either through a speculum or sterile vaginal exam. Positioning the client on her back with knees up and apart will facilitate administration of the gel.
Activated charcoal absorbs ipecac syrup, thus decreasing its effect by inhibiting absorption from the GI tract into the general circulation. While calling the poison control center is important, it is not the highest priority action to ensure the safety of the client. Option 3 is incorrect, and option 4 could result in harm to the client.
Option 3 relates to social history and should be considered in terms of how a client might respond to the illness based on cultural background. Options 1, 2, and 4 relate to biological evaluations.
Metoclopramide is a GI stimulant, increasing motility of the GI tract and shortening gastric emptying time. The other options do not represent correct actions of this medication.
Dicyclomine is a cholinergic-blocking agent that decreases hypermotility and spasms of the GI tract. The dose should be taken before a meal to be effective when needed.
Pepto Bismol (bismuth salicylate), is contraindicated in clients who are allergic to aspirin or salicylates. The other medications can be given to the client safely.
Metamucil is a bulk-forming laxative that could aggravate diarrhea. Kaopectate (option 2) is an antidiarrheal agent that is commonly used to manage this health problem, which is usually self-limiting. The client should contact the health care provider again if diarrhea persists (option 3), because diarrhea lasting more than 2 days requires attention. Dairy products are a food source that may aggravate diarrhea (option 1).
Bulk-forming laxatives rely on water to form an emollient gel and increase the bulk of stool in the intestines, stimulating peristalsis. Forcing fluids would be necessary when using this type of laxative. Clients on fluid restrictions are at increased risk of constipation (option 1). Bulk-forming laxatives are commonly used (option 2), and stool softeners are often used initially for those clients who should not use the Valsalva maneuver (option 3).
Laxatives can precipitate electrolyte imbalances and dehydration. The underlying cause of constipation should be determined to rule out pathological conditions. Losing weight, decreased appetite, and abdominal pain are not directly related to prolonged use of laxatives.
Imodium is an antidiarrheal agent. It is prescribed for acute and chronic diarrhea and to reduce the volume of drainage from an ileostomy. This medication would worsen constipation (option 1) and is not effective in treating vomiting (option 2). It would only be useful in abdominal pain (option 3) if the discomfort was caused by the diarrhea, but there is insufficient information in the question to determine this.
Misoprostol (Cytotec) inhibits gastric secretion, and increases bicarbonate and mucus production thereby protecting the gastric mucosa. Ranitidine is used to treat an active duodenal ulcer. Magnesium hydroxide is used to treat constipation. Bethanechol is a direct-acting cholinergic agent that strengthens both peristalsis and micturition.
Misoprostol (Cytotec) is not responsible for urinary incontinence, which represents a pathological condition. It might cause dysmenorrhea (option 1), headache (option 3), and diarrhea (option 4).
Anticholinergic effects include dry mouth, urine retention, constipation, and dilated pupils. Other side effects might include tachycardia, decreased sweating, increased risk of hyperthermia and decreased salivation.
Option 2 is correct: It is typical of clients with a chronic illness to become tired and feel as though they can’t continue on in this way. Option 1 is incorrect because atypical is the opposite of typical. Options 3 and 4 are incorrect labels.
Castor oil is a pregnancy Category X preparation. It may induce premature labor and should not by used by pregnant women. Bisacodyl is pregnancy Category C, while mineral oil and sodium bisphosphonates are listed as unknown.
Bisacodyl is a stimulant cathartic producing results in 15 minutes to 2 hours. Hyperosmotic treatment of constipation may not be effective for 2–4 days. The other options are hyperosmotic laxatives.
Ipecac syrup is contraindicated with corrosive or petrolatum-based substances. Determining stability, identifying the source of poison, and contacting poison control are all first-line interventions.
There is no contraindication to giving this medication to a client with occasional heartburn, since this is likely due to food intolerance. Mineral oil should not be given to anyone with swallowing problems due to increased risk of aspiration leading to lipoid pneumonia (option 1). Mineral oil should also not be given unless disease processes are ruled out (option 2). The client with fecal impaction needs to be disimpacted and may require enemas (option 3).
Ipecac syrup is an emetic that causes vomiting. It may be abused by clients with eating disorders. The other groups listed pose no additional risk of abuse. Nursing data collection must include abuse potentials and possible interventions and referrals.
Infants under 6 months of age should not take ipecac syrup because of increased risk of aspiration. Instead, gastric lavage should be performed. There is no evidence that using emetics is contraindicated in the other age populations.
Urosodiol is a naturally occurring bile acid used to dissolve gallstones. Prilosec is a proton pump inhibitor, cimetidine is a H2 antagonist and ibuprofen is a NSAID. None of these three are indicated for cholelithiasis.
Cimetidine interacts with the metabolism of beta-adrenergic blockers, phenytoin, lidocaine, procainamide, quinidine, benzodiazepines, metronidazole, tricyclic antidepressants, oral contraceptives, and warfarin. Therefore, it should not be giving concurrently with phenytoin. The other histamine 2 receptor antagonists are acceptable for use.
Taking Dulcolax on an empty stomach will enhance a rapid effect. If taking at bedtime, the client will have a bowel movement in the morning. Taking the medication with a meal will delay the absorption. Drinking plenty of fluids is a good general measure to reduce the risk of constipation.
Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of juice.
Option 1 is correct because hospitalized clients often feel that things are out of their control and their frustration rises. Although the behavior may not be appropriate if it is disruptive, the nurse should first recognize that it is a common response. There is not enough data to support options 2, 3, or 4.
Ciprofloxacin is not recommended for <I>Helicobacter pylori</I> infection during pregnancy. The other medications can be used after consulting with the physician.
Bismuth-containing preparations, such as Pepto-Bismol, can cause all the above side effects, but transient darkening of the tongue and stool is a specific side effect to bismuth.
Anticipatory prevention of nausea with antiemetics is effective if medication is taken 30–60 minutes before any activity causing nausea. The other options indicate incorrect timeframes.
A full urinary bladder may obscure the auscultation of bowel sounds. Have the client empty his/her bladder and re-auscultate. If bowel sounds are absent, the health care provider should be notified to rule out obstruction or other pathology. Options 2 and 4 do not provide for safety or don't give active assistance to the client.
NSAIDs inhibit the secretion of prostaglandins, thereby increasing the risk for ulcer formation. The other options do not directly result in peptic ulcer formation.
Antibiotic therapy may cause pseudomembranous colitis by changing the normal flora of the colon, causing an overgrowth of other pathogens. Pseudomembranous colitis presents with mild to moderate watery diarrhea and abdominal pain and cramping. The other options are irrelevant.
Antidiarrheals slow GI motility reducing the volume of stools, in turn increasing viscosity and decreasing electrolyte loss. The other options contain incorrect factual information in the nurse's responses.
Metamucil is a bulk-forming laxative that increases fecal mass, stimulating peristalsis. The products in all of the other options can cause laxative dependence, producing a cathartic colon that resembles ulcerative colitis.
Aspirin and aspirin-containing medications cause irritation to the gastric mucosa. All the others may cause GI symptoms, but aspirin is a main contributor to ulcer formation.
Growth hormone is only approved for use in children to treat a documented lack of growth hormone. It is available as a parenteral medication only, to be given IM or SC (option 2). Only long bones are affected (option 3). Option 4 is incorrect because this response implies that this treatment is appropriate despite the lack of additional diagnostic evidence needed for this therapy.
These symptoms are indicative of possible depression (option 4) and require further examination. The observed behaviors do not indicate hopefulness (option 1), anxiety (option 2), or an eating disorder (option 3).
Abrupt cessation of long-term steroid therapy can cause acute adrenal insufficiency, which could lead to death. Options 1 and 4 are incorrect statements. Central nervous system symptoms such as confusion and psychosis are adverse effects of steroids such as prednisone (option 3).
Desmopressin is not given by the intramuscular route. This medication may be given by the intravenous, subcutaneous, or intranasal routes (options 2, 3, and 4 respectively) in the treatment of diabetes insipidus.
Fludrocortisone is a mineralocorticoid used to treat Addison's disease. High doses of fludrocortisone may result in excess retention of salt and water and depletion of potassium. Options 2 and 3 contain incorrect statements. In the treatment of Addison's disease, fludrocortisone is commonly used in combination with a glucocorticoid (option 4).
After the start of therapy, peak levels of the drug may not be expected for many weeks to months. Thus, increased energy levels cannot be expected within a few days (option 2). The drug works best when taken before breakfast on an empty stomach (option 3). Lack of energy is a common symptom with hypothyroidism (option 1).
Symptoms of adverse effects and thyrotoxicosis of liotrix (Thyrolar) include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat tolerance, and sweating. Options 1, 3, and 4 represent manifestations that are opposite those of thyrotoxicosis, which are also manifestations of hypothyroidism.
Agranulocytosis is the most serious toxic effect of this drug, and it can make the client predisposed to a variety of infections. Although rare, this adverse effect may occur within the first few months of treatment. Options 1 and 2 are incorrect conclusions. Although option 4 is possible, the manifestations reported are general signs of infection that might or might not be consistent with influenza.
Calcitonin rapidly lowers blood calcium levels by reducing mobilization of calcium from bone, decreasing intestinal resorption, and promoting urinary excretion of calcium. Options 2 and 3 are effects that are opposite to the ones caused by calcitonin, while option 4 is incorrect because of the word <i>gradual</i>.
Hunger, nausea, pale, cool skin, and sweating are signs of a hypoglycemic reaction. Fruity breath (option 1) might accompany ketoacidosis. Flushing of the face (option 2) might accompany hyperglycemia. Dry flaky skin (option 4) is unrelated to hypoglycemia.
The initial action by the client is to take some form of oral glucose in order to raise the blood glucose level. Option 1 would delay appropriate self-treatment. Options 2 and 3 would cause further harm to the client.
The expected growth rate with growth hormone therapy is 3–5 inches in the first year. Height and weight should be measured monthly instead of daily (option 2). Growth hormone is discontinued when optimum adult height is attained, fusion of epiphyseal plates has occurred or when there is no response to growth hormone (option 3). Growth hormone is related to growth of long bones, not fat deposition (option 4).
Recent illnesses should be considered when conducting a biological exam to determine impact of these illnesses on current illness. Past medicines are not a primary concern related to biological exams (option 1). Spiritual needs (option 3) and cultural background (option 4) are a part of social history.
Jogging increases insulin requirements and absorption can be increased if the drug is injected into the thigh. This lifestyle factor of the client requires special instruction. Options 1 and 4 are unrelated to teaching about insulin administration. Option 2 guides the nurse to include the spouse in teaching, but it does not indicate the need for special instruction regarding insulin.
Tolbutamide interacting with alcohol can lead to a disulfiram-like reaction causing complaints of headache and flushing of the skin. This is an important teaching point for the client who has a history of alcoholism, even if currently not drinking. The reactions listed in the remaining options do not occur as a result of co-ingestion with alcohol.
Resistance to growth hormone eventually develops, and the rate of growth begins to slow down with increasing age. Efficacy of the drug is usually lost by the age of 20–24 years (options 2 and 3). The medication is quite effective in children (option 1) as long as there is a demonstrated deficiency in growth hormone.
In the presence of adrenal insufficiency, metyrapone may cause an adrenal crisis by stopping the synthesis of cortisol. Options 1 and 4 are the opposite of what is occurring with the client. Option 3 is an unrelated finding.
Hydrocortisone succinate might be given IV or IM and is the preferred drug for replacement therapy in all forms of adrenocortical insufficiency. ACTH is mostly used for diagnostic testing (option 3). Dexamethasone is used for non-endocrine disorders (option 2) and ketoconazole (option 4) is used to suppress the synthesis of adrenal steroids.
Desmopressin is a drug used to treat diabetes insipidus. The manifestations listed are all signs of water intoxication, which could occur as an excessive effect of the medication. Options 1 and 2 are unrelated to this medication, while option 3 is associated with diabetes insipidus, the underlying condition for which this drug would be ordered.
Propranolol is a beta-adrenergic blocker and is used to treat sympathetic nervous system symptoms related to hyperthyroidism such as tachycardia, cardiac dysrhythmias and mental agitation. The manifestations identified in the other options would not be adequately treated with this medication.
Parenteral calcium can cause severe bradycardia in clients taking digoxin. Option 1 is the opposite effect of what could occur. Hypertension is not an expected effect (option 4) and hypotension could occur as a result of severe bradycardia, but this is a secondary effect (option 3).
Vitamin D regulates calcium and phosphorus metabolism and increases blood levels of both elements. The vitamins in the other options do not have this beneficial effect.
Children with growth hormone deficiency are smaller than peers and frequently experience problems with self-esteem and body image. Option 1 would be the opposite problem of what the client is experiencing. The nursing concerns in options 3 and 4 are unrelated to the client in this question.
Acceptance (option 1) indicates that the client is accepting limitations imposed by the illness and is attempting to help self as much as possible. A client would not be helping self if the stage was denial because there would be no awareness of need in the denial stage (option 2). Compensation (option 3) and indulgence (option 4) are not stages related to helping the self in medical illness.
Signs of overdosage of desmopressin, an antidiuretic hormone, include blood pressure and pulse elevation, mental status changes, and water and sodium retention. Because the medication therapy needs to be interrupted, the nurse should notify the physician. Option 2 would place the client at risk because of lack of timely treatment. Options 3 and 4 would not address the current complication.
Graves' disease is caused by elevated levels of thyroid hormone. Clients experience tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder needs a high-calorie diet, not a low-calorie plan (option 3).
Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing intestinal absorption and mobilization from bone, and reducing renal excretion of both elements. The statements in the other options are the opposites of the actions of vitamin D.
Drug therapy for Paget's disease focuses on decreasing calcium release by decreasing activity of osteoclasts and thereby decreasing bone resorption. The other options indicate effects that are opposite those that are intended with drug therapy.
Glipizide is given to type 2 diabetic clients. It is used as an adjunct to diet therapy and exercise, but does not replace insulin for clients who need it (option 1). It increases the release of insulin from pancreatic islet cells (option 4). Its use is contraindicated during pregnancy and lactation (option 2).
Metformin is given to clients with stable, type 2 diabetes mellitus to inhibit glucose production by the liver and increase sensitivity of peripheral tissue to insulin. The other three options contain factually incorrect statements.
Early signs of hypoglycemia and lactic acidosis include hyperventilation, myalgia, malaise, and unusual somnolence. The client should learn to recognize these signs in order to check blood glucose levels and take corrective action.
Glycosylated hemoglobin concentrations are representative of a client's average blood glucose levels over the last 2–3 months, not in recent hours or days (option 1). It does not diagnose anemia or kidney damage (options 2 and 3).
Psoriasis is a common, chronically recurring skin disease with scaly patches of varying size most commonly seen on elbows, knees, and scalp. Pityriasis rosea is a common skin generally localized to chest and trunk of young adults and characterized by erythematous discrete lesions (option 2). Option 3 is a vague description unrelated to psoriasis. Contact dermatitis (option 4) develops after exposure to an irritant or allergen.
Mupirocin is a topical antimicrobial agent effective against impetigo caused by <i>Staphylococcus aureus</i>, beta-hemolytic streptococci, and <i>Streptococcus pyogenes</i>. Ketoconazole is an antifungal agent; capsaicin is a topical agent that has been useful in certain painful syndromes; and acyclovir is an antiviral agent.
Hand washing and gloves are the only precautions needed for administering an IM medication IV. Masks, face shields, and gowns are appropriate for procedures that may result in body fluids splashing.
Option 2 is correct because physical illnesses can create psychiatric symptoms. Options 1 and 3 conclude that the origin of the client’s symptoms are psychiatric in nature, and this conclusion is premature. Option 3 may or may not be appropriate for this client.
Synthetic detergent bars are milder on the skin. Dove is classified as synthetic detergent bar. Dial and Safeguard are deodorant soaps of a more harsh nature. Ivory is classified as a true soap.
The effectiveness of a sunscreen when compared to no use of sunscreen is usually indicated by its sun protection factor (SPF) (e.g., 6, 15, and 30). Option 1 is a false interpretation. Sunscreens also may be classified as water-resistant (option 2) or waterproof (option 3), but the SPF number does not indicate this information.
Lindane has long been considered an appropriate treatment for pediculosis (lice). Terbinafine is an antifungal agent for tinea infections. Collagenase is an enzyme used as a debriding preparation. Chlorhexidine is a skin and wound cleanser.
Permethrin is preferred treatment for scabies at present time. A variety of treatment protocols are suggested, but the greatest success is reported when product is left on for at least 8 hours. If the treatment is repeated, it is repeated at 7 days, not 6 hours (option 3). Household articles in direct contact with the client need to be thoroughly washed or disinfected or both, but the human is the host for this parasite (option 4). Kwell can be used for pediculosis or scabies, but two similar agents would not be used together (option 2).
Benzoyl peroxide has bactericidal activity against <i>Propionibacterium acnes</i>. It is available in over-the-counter and prescription formulations, including bar soaps, washes, gels, and lotions, and in a variety of concentrations. Mafenide (option 1) is a preparation used in burn therapy. Chlorhexidine (option 3) is a skin and wound cleanser, and it might be used for preoperative preparation of the skin. Cryotherapy (option 4) is a treatment used for some warts.
Isotretinoin is available in capsule form. The other products are also used for acne, but are topical preparations.
Silver sulfadiazine reacts with DNA and releases sulfadiazine. The silver replaces the hydrogen bonding between strands of DNA and prevents replication of the bacteria. It does not facilitate skin cell replication, and it is not of small molecular size. It is not classified as an antifibrinolytic agent.
Salicylic acid preparations are useful for the removal of common warts. Povidone-iodine (option 2) is used to prepare or cleanse skin preoperatively; masoprocol (option 3) is indicated for actinic keratosis; and crotamiton (option 4) is an antiparasitic drug.
Closed soaks lead to heat retention and are not used for a cooling effect. They are typically applied for 1–2 hours at a time, 2–3 times a day. They are not impermeable to air.
A cream is an emulsion of oil in water. An ointment is considered to be a water-in-oil product. Lotions are suspensions of powder in water or a liquid emulsion of thin consistency. A cream might or might not contain an antimicrobial agent, and it is not a drying agent.
Although occupation (option 1), number of siblings (option 3), and income (option 4) may be of interest when considering lifestyle, substance abuse is of primary interest as a maladaptive coping strategy and is also associated with depression.
Iodine preparations stain skin and clothing. Benzalkonium, hexachlorophene, and hydrogen peroxide do not cause staining.
DuoDerm is indicated for ulcers with moderate drainage that are uninfected. Agents like Iodosorb might be used for ulcers with necrotic material (option 3) and Hydrasorb with ulcers with heavy drainage (option 2). Antimicrobials might be used to treat infected wounds.
Minocycline can lead to development of a lupus-like syndrome and also may cause pigmentation changes. Minocycline does not suppress serum production (option 1), lead to spontaneous abortions (option 4) or have low/lack of treatment efficacy (option 3).
Potent topical steroid therapy should be tapered within 2 weeks. Very high-potency topical corticosteroids may induce atrophy, telangiectasis, and striae as early as 2–3 weeks following daily application. High-potency topical corticosteroids and use of occlusion might induce hypothalamic-pituitary-adrenal (HPA) axis suppression and adverse reactions typically associated with chronic oral therapy. Dosing of topical corticosteroids more frequently than 2–3 times daily is neither indicated nor has proven benefit.
Adverse reactions of acne preparations might include erythema, burning or stinging, excessive dryness, and increased susceptibility to sunburn. Directions include using a thin application twice a day. Excessive use would be more likely to result in evidence of adverse reaction than would use as per product directions. Adverse reactions do not include extreme pruritus (option 2), non-healing lesions (option 3), or localized infection (option 4).
Accutane is an oral preparation that is a known teratogen. Strict adherence to avoidance of pregnancy is mandatory. Accutane is contraindicated in pregnancy because of the occurrence of spontaneous abortions as well as major abnormalities in the fetus at birth such as hydrocephalus. Elevated triglyceride levels might occur, but changes in hormone functioning (option 4) are not anticipated. The medication should be applied thinly (option 1) and sun exposure provides no added benefit (option 2).
Mafenide acetate is a water-soluble cream that is used to treat burn injury. It might cause a stinging or burning sensation after it is applied, and this is considered to be normal. Options 1 and 2 are inappropriate actions, while option 4 will not prevent stinging of the medication.
The two most common organisms causing infection are <i>Staphylococcus aureus</i> and <i>Streptococcus pyogenes</i>. Herpes simplex and herpes zoster are members of the herpes virus family. Dermatophytes cause fungal infections of the skin, such as tinea capitis and tinea pedis. <i>Haemophilus aegyptius</i> causes pink eye. <i>Haemophilus influenzae</i> can cause meningitis, pneumonia, and serious throat and ear infections.
Emollients contain petrolatum, oils, propylene glycol, or other substances and make the skin soft and pliable by increasing hydration of the stratum corneum. It does not dry the skin (option 2) or contain corticosteroids (option 3). Option 1 is not always necessary.
Burow's solution is an astringent that coagulates bacterial and serum protein. It is classified as a soothing solution for the relief of inflammation associated with some skin problems. It is useful for conditions with vesicles where there is oozing, as might occur with poison ivy or allergic reactions. It is not an emollient (option 2), a detergent (option 3) or a balm (option 4).
Denial (option 1) is most accurate because denial is a typical stage of grief related to loss. Options 2, 3, and 4 are isolated events that could possibly occur but would be based on individual client characteristics rather than anticipated general patterns of response.
Side effects associated with the use of topical corticosteroids include: acneiform eruptions, allergic contact dermatitis, skin atrophy, burning sensation, dryness (option 2), itching, irritation, hypopigmentation (option 1), alopecia, and hypothalamic-pituitary-adrenocortical (HPA) axis suppression. It does not stain the skin (option 4).
Hydroxyzine hydrochloride is an antihistamine that is a competitive inhibitor of the H<sub>1</sub> receptor. It is used to treat various reactions that are mediated by histamine. It will decrease the pruritus produced by the release of histamine. Cimetidine is an H<sub>2</sub> histamine antagonist and these agents are not effective against hypersensitivity reactions. Lorazepam is a short-acting benzodiazepine that is indicated for anxiety. Bupivacaine is a local anesthetic for nerve blocks.
Mafenide is a carbonic anhydrase inhibitor that can rarely cause metabolic acidosis. In that situation the body would try to compensate to maintain a balanced pH. Hyperventilation or labored respirations and difficulty in breathing would be evidence of the body's attempt to compensate. Mafenide would not cause diarrhea (option 1), hypertension (option 2) or abdominal pain (option 4).
Wound infection is a potential complication with burns. Microorganisms proliferate rapidly in burn wounds. Monitoring arterial blood gases and intake and output are essential for the hospitalized client with the more severe burns, but are not key observations for clients being managed on an outpatient basis. The nurse removes any topical agents at the beginning of the dressing change to allow for adequate wound examination.
Topical corticosteroids have vasoconstrictive action as well as anti-inflammatory effects. They do not have fibrinolytic, emollient, or proteolytic effects.
Medications that have ointment bases have enhanced penetration of skin lesions when used as topical preparations. The other options have less penetrating action.
The treatment of many skin disorders might take several weeks. A realistic timetable should be presented to clients. Drying soaps should not be used. It is unnecessary to use gloves for all preparations. Non-adherance to the prescribed regimen is sometimes a problem in managing skin conditions.
Anthralin is an antipsoriatic agent available as either a cream or ointment for the treatment of psoriasis. Hexachlorophene is a topical antiseptic that is incorporated into soaps, detergents, and other vehicles for topical use. Chlorhexidine is a skin and wound cleanser. Capsaicin is a topical agent that has been useful in certain painful disorders.
Determination of allergies and reactions to medications is essential when administering a new medication. Hypersensitivity responses can occur with ophthalmic medications, and severe adverse reactions might occur with hypersensitivity to the medication because it is systemically absorbed. Options 1, 2, and 4 are important to the nursing management of the client; however, avoiding reactions to the medication is the priority.
Correct technique for administration of ophthalmic medications includes pulling the lower eyelid down and instilling medication into the conjunctival sac. Options 1, 3, and 4 each contain information that is either partially or totally incorrect.
The correct answer is option 2; communication patterns within the family should be assessed for flexibility and support. Option 1, recent life-changing events, relates to something occurring recently. Option 3, lifestyle patterns, refers to an overall way of living; and option 4, community resources, refers to support outside of the family.
For an external ear canal obstructed with edema, a gauze wick is inserted past the edematous segment. The medication is then applied to the outside wick, allowing the medication to be absorbed along the path of the wick. Option 2 delays treatment. Option 3 is unnecessary, and option 4 is a hazardous activity that could cause damage to the client's ear.
Acetazolamide should not be mixed with alcohol or glycerin. To minimize gastrointestinal distress, the client might take the medication with milk or might crush it and mix it with juice. Acetazolamide is taken in the morning to avoid nocturnal diuresis.
Carbonic anhydrase inhibitor agents such as dorzolamide decrease aqueous production by approximately one-half of baseline, thereby lowering intraocular pressure. Dorzolamide does not cause pupil constriction (option 2), increase aqueous humor production (option 3), or increase outflow of aqueous humor (option 4).
Precipitation of an asthmatic attack is a systemic side effect of pilocarpine. Other side effects include salivation, hypotension, diarrhea, nausea, and vomiting. Dry mouth (option 1), hypertension (option 2) and constipation (option 4) are opposites of known side effects.
The adult client pulls the pinna up and back for administration of otic solutions. The pinna is pulled down in the child (option 1). Droppers should never be inserted into the ear canal (option 3), and the head should be tilted toward the unaffected side (option 4).
Ophthalmic beta-blockers are administered to reduce intraocular pressure by decreasing production of aqueous humor. The medication must be continued as lifelong therapy to maintain a stable intraocular pressure (option 2). Some glaucoma can be surgically treated (option 4).
Atropine, an anticholinergic agent, can precipitate acute glaucoma as a result of pupillary dilation; therefore, clients with pre-existing glaucoma or a predisposition to acute glaucoma should not receive atropine. There are no contraindications for diphenhydramine, hydroxyzine, or promethazine in the client with glaucoma.
Carbonic anhydrase inhibitors such as brinzolamide may exacerbate the potential for renal calculi. Increasing fluid intake to 2 liters per day might reduce this risk. Diet recommendations include increasing potassium and reducing sodium.
If the client is monitored properly, the beta-blocking agents will not mask symptoms of hypoglycemia, but might reduce the effect of some oral hypoglycemics (option 2). A serum glucose level significantly lower than normal can place the client at great risk more rapidly than does elevated blood pressure. Many clients live for long periods with hypertension without immediate risks to their health (option 1). NSAIDs might reduce the antihypertensive effect of the drug (option 3). The diarrhea needs to be controlled because of the potential fluid and electrolyte loss, but is not the <i>first priority</i> (option 4).
Warming eardrops (if not contraindicated) makes administration of the medication more comfortable. Warming can be achieved by running the bottle under warm water, placing the bottle of medication in a cup of warm water (not cool, as in option 1), or by carrying in the hand or pocket for 30 minutes (option 4). The medication should <i>never</i> be warmed in the microwave (option 3) because serious injury to ear canal and tympanic membrane can occur.
Option 4 encourages the nurse to broaden the definition of spirituality and what this might mean to clients. Option 1 implies that communication should be closed, option 2 is not a correct assumption under the circumstances, and option 3 is inappropriate.
Clients with pulmonary disease are generally prescribed Betoptic for glaucoma because it is Beta<sub>1</sub> selective (i.e., cardioselective). However, the client must still be monitored for pulmonary side effects and respiratory difficulties that may occur with systemic absorption. The explanation in options 1, 2, and 3 do not address this effect.
The symptoms the client reports might indicate a ruptured tympanic membrane. The ear canal and tympanic membrane should always be evaluated before instilling otic medications, making options 2, 3, and 4 incorrect.
Crust from eyes is cleansed using cotton balls wiping from the inner canthus to the outer canthus. Swabs (options 3 and 4) should not be used as damage to eye could occur. Option 1 represents incorrect technique.
Otic Garamycin is not approved for use in the United States. It is a safe and accepted practice for clinicians to prescribed <i>ophthalmic</i> Garamycin for otic use. The client should be informed of this practice. Options 1 and 3 are incorrect because no error was made. Option 4 is incorrect because the client has not indicated inadequate knowledge of medication administration.
Carteolol is a beta-blocking agent with side effects of hypotension and bradycardia if systemically absorbed. The other medications, acetazolamide and dorzolamide, carbonic anhydrase inhibitors, and latanoprost, a prostaglandin, do not affect heart rate and blood pressure.
The blink reflex is lost when ophthalmic anesthetic agents are used; therefore the eye is at risk for injury. Priority is given to protecting the cornea from irritants, debris, and rubbing. Generally, an eye patch is applied for protection. Since the medication is local and the client is not anesthetized, the airway not compromised (option 1) and the body temperature should remain at pre-procedure reading (option 3). Clients are questioned for allergies or past hypersensitivity reactions (option 2) before the medication is administered.
Atropine sulfate is commonly used preoperatively in outpatient procedures such as a colonoscopy. The client needs to alert the staff about the diagnosis of glaucoma, since the use of atropine is contraindicated in narrow-angle glaucoma because it could precipitate acute glaucoma.
Maintaining pressure on the lacrimal sac for 1–2 minutes is recommended for dipivefrin to minimize systemic absorption of the medication. Eye drops are instilled into the conjunctival sac, never directly onto the eye.
To promote absorption, the client should not blink for 30 seconds after the administration of dipivefrin. Options 1, 2, and 4 are incorrect for the administration of dipivefrin.
Confusion and increased heart rate are signs of toxicity or adverse side effects of hydroxyamphetamine. Stinging, headache, and brow ache are usual side effects of hydroxyamphetamine.
Option 1 refers to difficulty with adjustment to the current situation. Although options 2 and 3 might be occurring, it is not evident by the scenario described. Option 4 does not apply in this situation either.
Ophthalmic epinephrine is used to produce mydriasis for ocular examination. Dilation of pupil further constricts ocular fluid outflow, possibly causing an acute attack of glaucoma in a client with narrow-angle glaucoma. Systemic absorption also causes hypertension and tachycardia. Brow ache is a typical side effect of adrenergic agonists such as epinephrine (option 4).
Clients receiving ophthalmic corticosteroids have an increased risk of infection. Contact lenses should not be used during ophthalmic corticosteroid therapy. Options 2, 3, and 4 indicate an appropriate understanding of ophthalmic corticosteroid therapy.
Eye drops are considered sterile. To reduce the chance of introducing organisms into the eye, the dropper should not touch the eye, eyelashes, or any other object. The dropper should not be rinsed with water (option 2). The eyes should not be squeezed tightly shut after instilling the medication (option 3). The medication is instilled into the conjunctival sac, not directly onto the eye (option 4).
The internal ear is sensitive to temperature extremes. Administration of cold medication into the ear may cause dizziness and nausea. To avoid these conditions, the client should warm the medication to body temperature before administering the eardrops (option 2). The dizziness is unrelated to hypersensitivity (option 3) or speed of administration (option 4).
Latanoprost is a prostaglandin agonist that increases the outflow of aqueous humor to decrease intraocular pressure (not decreasing outflow, as in option 1). Beta-blockers, adrenergics, and sympathomimetics decrease intraocular pressure by decreasing aqueous humor production (option 3 and 4).
Dry mouth may be a sign of toxicity in the client receiving scopolamine hydrobromide. Tachycardia is also a sign of toxicity. For these symptoms, the client is instructed to withhold the medication and seek immediate evaluation for toxicity. Options 1, 3, and 4 are incorrect instructions which place the client at risk.
Systemic absorption of beta-blocking agents such as carteolol can lead to serious cardiovascular and pulmonary side effects. Nasolacrimal pressure is done to prevent systemic absorption of ophthalmic medications. Options 1, 3, and 4 are incorrect techniques.
Dipivefrin lowers intraocular pressure by decreasing aqueous humor production and increasing aqueous humor outflow. Options 1, 3, and 4 are either partially or totally incorrect.
Administration of vitamin B<sub>6</sub> is recommended during therapy with isoniazid (INH) to reduce the incidence of peripheral neuritis, which may be associated with isoniazid. Monitoring motor reflexes would not be indicated (option 1). Paresthesia is not usually a clinical manifestation of hypercalcemia (option 2). Antacids interfere with absorption of INH when taken within 1–2 hours of the INH, but would not cause the symptoms reported by the client (option 3).
Rifampin causes an orange-red discoloration of body fluids including urine. The client needs to be aware of this. The drug is being ordered prophylactically to prevent the development of meningitis, not to treat it (option 1). Adverse effects are generally minor with rifampin (option 2). Because the drug is metabolized by the liver, regular liver function tests should be monitored (option 4). Rifampin should be used with caution in the presence of elevated liver enzymes or hepatic dysfunction.
Option 3 is correct because there is nothing wrong with complementary medicine, and it can be very helpful in coping with illness. Furthermore, it supports the client’s right to autonomy and self-determination. There is no rationale for option 1, option 2 is inaccurate, and option 4 is a false assumption.
Amantadine (Symmetrel) can cause anticholinergic effects, one of which is bladder relaxation and detrusor muscle contraction. Urinary retention might become more of a problem for a client with BPH on this medication. Hypermotility of the bowel and increased lacrimation are cholinergic effects, not anticholinergic effects (options 2 and 3). Amantadine is not particularly nephrotoxic (option 4).
Agents for herpes virus as herpes zoster can be nephritic. Important interventions include monitoring renal function and ensuring good hydration to decrease toxic effects. This drug is not reported to be particularly hepatotoxic (option 1). Sexual intercourse is to be avoided if the client was being treated with the acyclovir for genital herpes (option 2). Insomnia is not a side effect of acyclovir (option 3).
A full course of antibiotic therapy must be taken in order to decrease the risk of resistance to the antibiotic or reoccurrence of the infection. Missed doses should be taken as soon as they are remembered, but the dose should not be doubled by taking two doses at the same time (option 2). Antibiotic doses are to be taken at regular intervals spaced throughout the 24 hours, without interrupting sleep when possible, in order to maintain effective therapeutic blood level of the antibiotic (option 3). Chewable tablets must be crushed or chewed, or the drug might not absorb adequately (option 4).
More than 4–6 watery stools per day and/or stools with blood is a clinical manifestation of pseudomembranous colitis. <i>C. difficile</i> is the causative microorganism for this superinfection. The client is at risk for developing metabolic acidosis because of increased loss of bowel contents with loss of base (option 1). Antiperistaltic agents can promote retention of toxins and should not be given (option 2). Antidiarrheal agents can be given for mild diarrhea but not when toxins need to be eliminated (option 3).
Specific indicators of improvement, such as the resolution of pulmonary infiltrates, improved breath sounds, and normalization of pulse oximetry, are important outcomes to monitor in pneumonia. Systemic signs including fever as well as malaise, and leukocytosis are expected to demonstrate improvement within 48–72 hours of antibiotic therapy (option 1). Option 2 does not indicate therapeutic effectiveness, and option 3 is unrelated to the question.
The penicillins are structured with a sodium or potassium salt. When high sodium content penicillin is administered, serum sodium may be elevated, which often results in hypokalemia. This client is demonstrating clinical manifestations of hypokalemia. With the elevated sodium, the accompanying anion would most likely be chloride resulting in hyperchloremia and not hypochloremia.
A cross-allergenicity with penicillin may exist. Cephalosporins cannot be assumed to be an absolutely safe alternative in penicillin-allergic clients. If the cephalosporin is administered to this client, the nurse needs to administer it cautiously observing for manifestations of hypersensitivity, especially respiratory difficulty. Emergency equipment should be readily accessible. The BUN is within normal limits. It is expected that the granulocytosis would occur in response to a bacterial infection. To wait several hours for the results of the C & S might compromise the client's response to the treatment. If the C & S findings reveal the bacteria are resistant to the prescribed antibiotic, the drug can be changed to one that will be effective against the organism.
A "shift to the left" refers to an increase in neutrophils, and immature neutrophils called bands or stab cells. Production of these white blood cells is stimulated by an acute bacterial infection. Lymphocytes, T cells and B cells, are increased primarily in viral infections. Monocytes also fight bacterial infection by phagocytic action. Eosinophils and basophils are elevated in allergic reaction.
Filgrastim (Neupogen) is contraindicated with a hypersensitivity to <i>E. coli</i> products. It is important for the nurse to monitor for any contraindications prior to the administration of this medication because of the risk of allergic reaction. Option 1 constitutes changing a medication dosage and is unsafe. Options 2 and 3 do not provide for client safety.
Adult respiratory distress syndrome (ARDS) can develop because of the toxicity of colony stimulating factors. The other options do not reflect concerns specific to this medication.
Option 4 relates to assisting the client with ways to effectively cope with stress, which may limit exacerbations of the disease. Options 1 and 3 are not healthy ways to cope with stress. Option 2 is not indicated by the information provided.
Medications used to treat the symptoms of rheumatoid arthritis increase the client's susceptibility to infection. Fever accompanies infection and requires further management. Options 2 and 4 are incorrect because they do not reflect a concern related to this type of medication. Option 3 is incorrect because infection is harmful to the client and needs to be treated.
Immune serum globulin will irritate tissues and the application of heat will reduce pain and discomfort. The other responses are unrelated to the issue of the question, which is local discomfort at the injection site.
Anticonvulsant medications administered concurrently with cyclosporine will cause decreased therapeutic levels of the cyclosporine medication. For this reason, the cyclosporine dose will need to be increased. The anticonvulsant dose needs to be given at standard dosage to maintain therapeutic blood levels.
The client and family should be instructed to watch for fluid retention and an irregular heart rate. However, with the client complaining of shortness of breath and edema 2 days after chemotherapy and administration of oprelvekin (Neumega), the nurse should suspect that the client is in cardiopulmonary insufficiency requiring medical attention. Options 1, 2, and 4 delay necessary medical attention and place the client at further risk for complications.
The only food interaction of significance with cyclosporine (Sandimmune) is grapefruit. This combination will result in an increased serum cyclosporine level. The other options are completely false.
Exposure to hepatitis A from a restaurant worker necessitates the administration of immune serum globulin to prevent hepatitis A following exposure. The other options do not address this concern and fail to address the client's need for protection against possible exposure.
Childhood illnesses possess a high rate of mortality and morbidity. The use of immunizations assists in the promotion of health and prevention of illness. Immunizations are begun shortly after birth and are required before a child can attend school. Option 3 is false. Options 1 and 4 are true but do not address the reason they need to be administered.
Atropine, which is an anticholinergic medication, should be administered to counteract the cholinergic reaction of the medications used to treat myasthenia gravis. The other options are incorrect because they do not have anticholinergic activity.
Metronidazole (Flagyl) has several gastrointestinal side effects including metallic or bitter taste. It can be taken with food except Flagyl ER, which should be taken 1 hour before or 2 hours after meals. There is no evidence that Flagyl causes visual disturbances or urinary retention (options 2 and 3). Alcohol taken during drug therapy or within 48 hours after the drug is discontinued may induce a disulfiram-like effect (option 4).
A different gloved finger or a different finger cot should be used to apply acyclovir to each lesion not only to prevent spread on client's own body, but also to prevent transmission to others. Caution needs to be taken as well not to contaminate the ointment in the container by obtaining ointment with a contaminated finger cot/glove. Hand washing is important but is not a barrier protection (option 1). Acyclovir is the drug of choice for primary herpes lesions in the immunosuppressed client, but it has not been proven that acyclovir benefits the immunocompetent client, although it may reduce viral shedding (option 2). Option 4 is a false statement.
Option 3 is correct because a client’s appropriate behavior should be acknowledged and reinforced. Option 1 is incorrect because the client is already living with the disease process and an attempt to avoid drawing attention to it is not reasonable. Option 2 is incorrect because the client’s adjustment is not maladaptive. Option 4 is incorrect because it patronizes the client.
The nurse monitors hydration status, intake and output, creatinine, BUN, creatinine clearance, and other laboratory tests for renal dysfunction. The nurse also questions for concurrent nephrotoxic agents being taken since these drugs could increase the risk for nephrotoxicity developing with administration of acyclovir (Zovirax). The bilirubin differentiates jaundice caused by liver impairment or by hemolysis (option 1). Bowel pattern and hypokalemia are not particular to acyclovir therapy (options 2 and 4).
Almost all clients receiving IV amphotericin B experience adverse reactions involving fever, chills, piloerection, hypotension, tachycardia, malaise, myalgia, arthralgia, anorexia, nausea, vomiting, and headache. The other agents listed do not cause this cluster of severe side effects. Meperidine (Demerol) can also be given to help manage the side effects.
Complete proteins are higher quality proteins and contain all nine essential amino acids in sufficient amounts to meet the body's needs. Sources of these proteins are of animal origin, such as eggs, milk, cheese, and meat. Gelatin, an animal product, is an exception since it is an incomplete protein. The pudding contains milk, but the egg custard contains the largest quantity of animal proteins such as eggs and milk.
The most significant adverse effects related to the aminoglycosides, of which gentamicin (Garamycin) is a member, are nephrotoxicity and ototoxicity. Risk for ototoxicity is increased in the presence of nephrotoxicity.
The most common adverse effect of isoniazid (INH) is peripheral neuritis manifested as paresthesia of the extremities. The items in the other options are not side effects of this therapy.
"Red man syndrome" or "red neck syndrome" is flushing of the face, neck, and upper chest associated with too rapid IV administration of vancomycin (Vancocin). Hypotension with shock (not hypertension) also can result from the histamines released with too rapid infusion (option 1). Option 2 does not occur. Pseudomembranous colitis (option 4) is the result of a superinfection.
Tetracycline should not be given to children under 8 years of age. The drug forms deposits in the bone and primary dentition in growing children that can cause underdevelopment of the child's bones and teeth, temporary stunting of the child's growth, and discoloration of the teeth of the child. Discoloration of the teeth is not caused by direct contact of teeth with the medication, as can happen with iron preparations (option 1). Since the drug should not be administered to a child less than 8 years of age, options 3 and 4 are less important and therefore incorrect.
Photosensitivity is a side effect of these two classes of antibiotics. The client must avoid sun exposure and tanning beds. Milk or food interferes with effectiveness of the tetracyclines so they are taken on an empty stomach (option 3). These drugs are not associated with increased bleeding or orthostatic hypotension (options 1 and 4).
X = 4.5 ml
X = 2
Subjective complaints of panic level of anxiety include choking or smothering sensation, dizziness, chest pain or pressure, and fear of loss of control and death. Feelings of “butterflies” in the stomach are seen in the fight-or-flight response. Feelings of fatigue and inability to remain awake may be seen in the exhaustion stage of the general adaptation syndrome. Obsessive thoughts and compulsive behaviors are common in obsessive-compulsive disorder.
Monitoring strategies of care, particularly the ability to fill syringes and administer insulin, is a nursing priority. The diagnosis of rheumatoid arthritis might limit fine motor movements of the hands that are needed for self-administration of insulin, and this client might need further assistance from family or other caregivers. The other options are also important, but the ability to manage medication therapy takes priority.
Immunosuppressant agents reduce the client's ability to fight all infections, including inflammation and infection in the mouth (stomatitis). The client is at risk of developing infection from organisms normally found in controlled numbers in the oral cavity. The other options do not relate to this particular effect of immunosuppressants.
Sargramostim (Leukine) increases the production of granulocytes and macrophages. It also mobilizes stem cells to allow for stem cell collection. The information contained in the other options does not correctly describe the action of sargramostim.
AST and ALT, which are liver enzymes, are of importance to monitor since tacrolimus (Prograf) and other immunosuppressants are hepatotoxic. The other responses do not relate as specifically to this adverse effect.
Hepatitis B is administered in three doses. The second dose follows one month after the first dose and the third dose is given 6 months after the original dose. If too much time elapses between doses, as in this case, the series may need to be restarted. Options 1 and 4 might result in incomplete or insufficient vaccination. The nurse does not set up immunization schedules independently (option 3).
For all clients, immunizations are contraindicated during a moderate to severe febrile illness. The nurse should withhold the vaccines and have the mother bring the infant in to receive them after the illness has subsided. The actions in the other responses are incorrect.
Cyclophosphamide (Cytoxan) combined with digoxin (Lanoxin) may result in digoxin toxicity, thus the health care team must continually monitor for signs and symptoms of toxicity. Nausea is an early sign of digoxin toxicity, making option 4 the best action. Option 1 does not help the situation; options 2 and 3 treat the symptom rather than the problem.
A side effect of cyclosporine (Sandimmune) is hirsutism, thus the nurse should monitor for signs and symptoms that relate to disturbed body image. Options 2, 3, and 4 do not apply to the client with the information given in the question.
To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin (Rifadin), and pyrazinamide (Tetracid). The combination therapy lessens the risk of drug resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents are administered orally (option 4).
Administering very thick preparations as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be administered over 12–15 seconds to separate the muscle fibers more gradually. Cold compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety since muscles contain larger blood vessels (option 4). Injection into the deltoid might also result in prolonged discomfort resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to site may also be employed to limit discomfort.
Option 2 does not have a medication dosage listed. All other options have required information for dispensing medications.
Agoraphobia involves fear of being away from home and being alone in public places. Specific phobia involves unrealistic fear of a particular object or situation. Social phobia is excessive fear of embarrassment and humiliation in public settings. Fear of loss of control is common in most phobias.
Jaundice in the dark-skinned client can best be observed by examining the hard palate. Normally, fat may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles might appear jaundiced but, instead, calluses on the surface of their skin can make the skin appear yellow.
A serum specimen for peak level is drawn 15–30 minutes after IV administration to test for toxicity. Trough drug levels are drawn just prior to administration of the next IV dose to measure whether satisfactory therapeutic levels are being maintained. If the peak is too high, toxicity can occur and the dose needs to be reduced and/or the frequency of administration extended. If the trough is too low, then the dosage and/or frequency of administration need to be increased.
Candidiasis may be treated with oral antifungal agents. The vaginal tablet used as a lozenge delivers a slow rate of dissolution over 15–30 minutes which extends the length of contact with infected areas; the client is to swallow the saliva but not to chew or swallow the troche whole. The troche can be offered one-half at a time if needed. If the client wears dentures, they are to be soaked overnight in oral suspension of the antifungal agent to destroy the fungus on the dentures and prevent reinfection (option 2). Rinsing the mouth frequently with warm sodium chloride solution might be palliative, not therapeutic or curative, but should not be performed when the antifungal agent is still in contact with the oral mucosa (option 3). The oral antifungal therapy must continue for 48 hours after signs and symptoms have been resolved in order to prevent relapse (option 4).
Both of these drugs can cause bone marrow depression adversely affecting the immune system. The glucocorticosteroids also can mask clinical manifestations of infection. Observe for paleness, capillary refill greater than 3 seconds, sore throat, suprapubic pain or pressure, low back pain, low-grade fever, bruising, bleeding, petechiae, and fatigue. Serum levels of chloramphenicol (Chloromycetin) should be maintained in the range of 10–25 µg/mL (> 30 µg/mL increases risk for bone marrow depression). Hypercalcemia is more likely than hypocalcemia to occur as an adverse effect of steroid therapy (option 3). Taste alterations and hallucinations are not particular adverse effects of these agents (options 2 and 4).
Food will stimulate secretion of gastric enzymes increasing the gastric acid environment, which is needed for absorption of ketoconazole. Water will not stimulate gastric secretions (option 2). Antacids and H<sub>2</sub> histamine blockers should be avoided, or ketoconazole (Nizoral) should be given 1 hour before or 2 hours after these agents (options 3 and 4).
The nurse ensures the urine specimen for C & S is collected prior to the initial administration of the urinary tract anti-infective agent so that the causative microorganism and the anti-infectives to which the organism is sensitive can be identified. The results of the urine C & S will become available in several hours, but delaying anti-infective therapy may cause the UTI to worsen (option 4). If the results of the test do not affirm the drug's efficacy, the nurse will collaborate with the prescriber. Checking the bilirubin would be appropriate only if attempting to differentiate cause of existing jaundice as being hepatic impairment or hemolysis (option 1). The urine specimen should be a clean-catch or catheterized specimen for more accurate results (option 4). Option 2 is not essential prior to initiating drug therapy.
The client is demonstrating classic clinical manifestations of pseudomembranous colitis. It is important to identify whether this is a superinfection caused by <i>C. Difficile</i>. Cisapride (Propulsid) is a GI stimulant and would not be indicated as therapy for this condition (option 1). Hepatotoxicity and diet are not directly related to pseudomembranous colitis (options 2 and 4).
Because ciprofloxacin can cause photosensitivity, clients are advised to use sunscreen, wear protective clothing, and to limit exposure to sunlight, especially since sunscreens might not protect the skin from this type of reaction. When Cipro first became available, it was believed it would be effective against MRSA but resistance has developed (option 2). Cipro is processed through the liver and kidneys for elimination (option 1). Renal failure does extend the half-life of each of the fluoroquinolones. Ciprofloxacin achieves serum levels that are effective against several systemic infections caused by gram-negative bacilli (option 4).
The nurse should monitor for signs and symptoms of hypersensitivity reaction following the administration of all vaccines. Wheezing is a sign of a hypersensitivity reaction and warrants immediate further intervention and emergency action to prevent possible death. Local discomfort (option 1) can be expected and is treated if necessary with acetaminophen. Anxiety and vomiting (options 3 and 4) are not associated with administration.
Liver function includes the regulation of blood clotting. Thus, the client should be instructed to report signs and symptoms of increased bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a physiological basis. Options 2 and 3 do not reflect the vascularity of the liver and the associated risk of bleeding.
The onset of a panic attack is sudden, and the client may not be aware of the source of the anxiety. Agoraphobia is fear of being incapacitated by being trapped in an unbearable situation from which there is no escape. Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive behaviors. Posttraumatic stress disorder is associated with exposure to an extremely traumatic, menacing event.
Immunizations should be withheld during leukemia exacerbations because the immune system is compromised and the client cannot manage an appropriate response to the immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question.
An inspiratory stridor is indicative of a hypersensitivity reaction to the DPT immunization and epinephrine should be administered to counteract the symptoms of the allergic response. Options 2 and 3 are irrelevant, and option 4 places the infant at risk for injury or death.
Dysuria and bleeding are consistent with hemorrhagic cystitis, an adverse effect of cyclophosphamide. This data should be reported to the physician or nurse practitioner. The other options represent incorrect conclusions from the manifestations listed.
Women of childbearing age should not become pregnant for 3 months after receiving a rubella immunization. The other options are incorrect statements regarding aftercare.
Prednisone is a corticosteroid medication. When corticosteroids are given with medications to treat myasthenia gravis, they decrease the effect of anticholinesterase medications. Because of this, symptoms of the disease might reappear, including respiratory difficulty. The other options do not address the interactive effects of these medications. In addition, the nurse does not instruct a client to change a dose of a medication (option 4).
Gold salts suppress the activity produced by prostaglandins that contributes to the destruction of joints. The statements in the other options do not reflect the action of this type of medication.
Because of hepatotoxic effects of azathioprine and alcohol, the two substances should not be administered together. Thus, the client should be instructed to avoid products containing alcohol. The client should not take acetaminophen, which is also toxic to the liver (option 1). Azathioprine should not be taken with grapefruit juice (option 2) because it reduces its effectiveness. Option 3 is a good general measure but does not address the issue of hepatotoxicity.
The implementation of a high-fiber diet will reduce the risk of constipation, a common side effect in clients taking filgrastim (Neupogen). Option 1 is hazardous because it could cause dependency in the client. Option 2 indicates an insufficient amount of fluids to maintain regular bowel function. Option 3 is irrelevant to the issue of the question.
Low albumin levels are commonly seen in diseases of the liver, since proper liver function is needed to synthesize albumin. Low levels also are seen in conditions in which adequate protein is not ingested or absorbed. Albumin levels often appear elevated in dehydration. Albumin levels would not be affected by ketoacidosis or pericarditis.
Troponin levels greater than 2.2 ng/mL are diagnostic for an MI. Abnormal potassium levels can contribute to cardiac arrhythmias, but are not diagnostic for a MI. An elevated triglyceride contributes to coronary artery disease, but also is not diagnostic for MI. Although elevated creatinine kinase levels are used to support a diagnosis of MI, the fractionated portion of the enzyme, CK-MB, is preferred, since it is specific to the heart muscle.
Because coping resources are depleted, the client can no longer deal with stressors. Stage of alarm is characterized by the fight-or-flight response, and increased alertness is focused on the immediate task or threat. Stage of resistance occurs when the body mobilizes resources to combat stress.
Administration of an intramuscular injection could cause a false elevation of the isoenzyme levels secondary to muscle trauma. Catheterizing the client, administering oxygen, and inserting an intravenous cannula would not affect levels of the isoenzymes.
Therapeutic levels of heparin therapy are measured by checking the activated partial thromboplastin time (APTT), which should be 1.5–2.5 times the normal of 20–35 seconds. Thirty-four seconds would be within the normal value, but less than a therapeutic level to provide anticoagulation. Sixty seconds is within the therapeutic range. Prothrombin times are used to measure therapeutic levels of Coumadin therapy.
Calcium levels are low in clients with renal failure secondary to the kidneys’ inability to activate vitamin D, which in turn is needed to absorb calcium. Levels of potassium, phosphorus, and magnesium are elevated secondary to the kidneys’ inability to excrete excess amounts.
Antinuclear antibody is a screening test for collagen disorders, and is specific to SLE. Amylase levels are elevated in pancreatitis. IgE is released in response to allergic and anaphylactic reactions. C-reactive protein is present with acute bacterial inflammatory conditions.
A potassium level of 2.8 is indicative of hypokalemia. Muscle weakness and fatigue frequently are seen in hypokalemia. Hyperactive bowel sounds and diarrhea are seen in hyperkalemia. A positive Chvostek’s sign is seen with hypocalcemia and hypomagnesemia. Blurred vision is not associated with hypokalemia.
Bilirubin levels above 2.0 mg frequently are evidenced by a yellow discoloring of the sclera and skin. Dark green stools are not associated with elevated bilirubin; clay-colored stools are. Peripheral edema and dry mucous membranes can be associated with causes of elevated bilirubin, but information about the cause of the abnormal level is not provided in the question.
Glycosylated hemoglobin measures the amount of glucose attached to a hemoglobin molecule. Measurements up to 7.5% indicate good diabetic control. Measurements greater than 9% indicate poor control.
Pancreatitis produces an inflammation of the organ, which causes an elevation in the white blood cell count and the pancreatic enzymes (amylase, lipase, and trypsin). The blood glucose would be elevated secondary to impaired insulin production from the pancreas. Triglycerides are not reflective of pancreatic function.
Allopurinol is a uricosuric drug that inhibits reabsorption of uric acid in the kidney, thereby decreasing serum levels. The white blood cell count also might decrease as the inflammation is reduced, but this is not due to the action of allopurinol. (Colchicine, also given for gout, reduces migration of leukocytes.) Elevated alkaline phosphatase levels are seen with bone metastasis and bone disease. An increase in neutrophil count might be seen with improvement of bacterial and viral infections and leukemia.
Chronic cigarette smoking can produce elevated CEA levels. Alcohol, a high-fat diet, and aerobic exercise do not have an impact on the level.
Anxiety in a client may be empathetically experienced by the nurse. It is imperative that the nurse recognize these symptoms. There is not enough data to support the client being angry. Even a nurse with high self-esteem is receptive to experiencing anxiety empathetically.
Urine-specific gravity is a measurement of the solute concentration and diluteness of the urine. 1.035 is greater than the norm of 1.005–1.030, indicating the urine is concentrated with a low water content and/or high solute content. It will be darker than normal, pale yellow urine, and more concentrated. The urine might have a high specific gravity secondary to a urinary tract infection, but that cannot be determined by specific gravity. It would be malodorous secondary to certain medications or infections. It does correspond to frequency of urination.
Hyperparathyroidism is associated with hypercalcemia and hypophosphatemia. Normal serum calcium levels are 8.5–10.5, and normal serum phosphorus levels are 1.7–2.6. Sodium is not affected.
The range of magnesium is narrow (1.7–2.6). Low levels of magnesium predispose the client to premature ventricular contractions and dysrhythmias. The sodium is slightly low, but does not present as great a danger, and also could be dilutional. The sodium and carbon dioxide levels are within normal limits.
Serum osmolarity is decreased in SIADH secondary to fluid retention. The serum sodium level will be decreased due to fluid retention and excess losses through kidney excretion. The BUN would be low due to fluid retention. Potassium is not affected.
Serum carbon dioxide reflects the precursor to bicarbonate levels in the body. It is combined with another hydrogen and oxygen molecule to make bicarbonate. Elevated levels indicate alkalosis, and decreased levels indicate acidosis. Osmolarity measures the percentage of solutes in the blood. Carbonic anhydrase inhibitors help to eradicate uric acid stones by producing alkaline urine, but the urine pH would not be the best indicator of serum acidity or alkalinity. Serum ammonia levels reflect liver functioning.
Thiazide diuretics can cause reabsorption of calcium, leading to hypercalcemia. The value of 11 mEq/L is above the normal value of 8.5–10.5. Thiazides would cause loss of potassium and sodium. The sodium level is low, but still within normal limits. The potassium is at a high normal level. Magnesium is within normal limits.
PSA levels are elevated with enlargement, inflammation; and cancer of the prostate; or when the gland has been manipulated, as in a rectal examination. Levels are not elevated with other cancers or urinary tract infections.
Step 3: divide both sides by 10,000 to end up with 0.9=X
Potassium is contraindicated in clients with renal dysfunctions. It cannot be filtered out if there is decreased renal filtration. With increased damage in tissues, additional potassium is released, causing an even greater level of potassium that can be life-threatening.
Since potassium is an intracellular ion, higher levels will alter the electrical pattern of the EKG. The peaking of a T wave is an indication that potassium is too high.
The client always needs to be treated with dignity and respect. There is no reason to bring the client to the treatment suite on a stretcher (option 2), nor does the client usually need to have a procedure explained many times by the physician or the nurse (option 3). The client with major depression <i>can</i> receive ECT (option 4) if medication therapy is not effective.
Packing the sample in ice will minimize the changes in gas levels during the transportation of the specimen to the lab.
Prothrombin time is the test that measures the coagulation times related to Coumadin management. The time that is preferred is 1½–2 times the time of normal clotting without drug usage. Therefore, for a therapeutic level, the prothrombin time is expected to be between 20–30 seconds while on Coumadin.
A low T cell count (normal is 1,500–4,000/mm<sup>3</sup>) indicates that the T lymphocytes have been damaged or destroyed by the AIDS virus, causing immune suppression. CD4/CD8 ratios are altered with AIDS virus damage, causing the ratios to decrease significantly (normal 1.0–3.5). This result is within normal range, and does not reflect a decreased T cell count.
The blood of red meat can be identified with the guaiac test; therefore, it often is recommended to avoid meat for several days prior to the exam, to minimize the risk that a false positive might occur.
Type O has antibodies against both the A and B antigen (but not antigens on the RBCs). Type AB has no antibodies against A or B, but does have A and B antigens on the RBC. Therefore, type O blood antibodies would agglutinate the RBCs of type AB blood.
Coombs’ test tells us that the maternal blood has exposed the fetus’s red blood cells to antibodies or globulin complexes that can cause agglutination of the RBCs. Agglutination of RBCs means that the red blood cell can be broken apart or hemolyzed by these foreign antibodies from the mother as they cross the placental barrier.
Graves’ disease is an overproduction of thyroid hormone, usually from an autoimmune attack on the thyroid gland. The lab results would be an increase in the total thyroxine (T4) and a decline in the TSH from the pituitary glands, as it works by negative feedback based upon the blood levels of T4.
Hospital-acquired infections are spread by cross-contamination between clients. Simple handwashing and/or antiseptic foam use between clients will prevent the spread of both types of bacteria.
The first morning specimen is more concentrated, and is easier to analyze. Mouthwash contains antiseptic solution that would change the flora present in the specimen. Rinsing with water will remove secretions of the mouth without contamination by the mouthwash (option 1). Spitting only removes saliva, and does not require the depth of respiration and coughing that is needed to produce a specimen of lung secretions. Letting the secretions set for several hours could cross-contaminate the specimen with bacteria in the air. Specimens should be taken to lab for analysis immediately.
Aspiration of a wound by sterile needle and syringe is preferred due to the lower likelihood of contamination from skin flora. Both the needle and syringe are sterile, and the surface area that the needle touches is the least possible source for contamination from skin flora.
The only possible correct answer is option 2. Hypomania is a mood of elation (option 1), while cyclothymia (option 3) is a disorder of at least 2 years’ duration with episodes of hypomania, and dysthymia (option 4) is a depressive disorder of at least 2 years’ duration.
To prevent cross-contamination from any other source, a sterile container is used to collect the tip of the catheter that has been cut with sterile scissors to minimize cross-contamination from any other sources. Sterile-to-sterile is always the rule to prevent contamination from other sources.
Anxiety reduction is needed when the client is waiting for the outcome of tests, to assist her in processing her feelings and exploring her options based upon the results of the test.
When testing with a PET scan, the client is injected with a radionuclide that emits positrons, which are special isotopes. The emissions are translated into color-coded images. It is effective to evaluate stroke, epilepsy, migraine headaches, Parkinson’s disease, dementia, and schizophrenia. The isotopes are removed through renal excretions, and precautions are needed to prevent exposure risks. The other tests listed do not require isotopes for analysis of body tissue. Therefore, none of them require precautions after the testing related to isotope excretion from the body.
A full bladder is necessary so sound waves bounce off other tissues or structures being assessed. If done during pregnancy, the fetus must be older than 26 weeks in order to not have the restriction for the full bladder, since the amniotic fluid would be used at that point.
4 squares X 0.2 sec
The EEG measures electrical brain wave activities, and allowing the client to take a nap prior to the test will alter the outcome of the brain activities.
With obstructive disorders, there is retention of CO<sub>2</sub> by constriction at the alveolar levels. By using pursed breathing techniques, the air is pressurized between the atmospheric pressure and the alveolar pressure by reducing the air flow on exhalation, thus allowing for more CO<sub>2</sub> to be released into the atmospheric air.
When removing the fluid or tissue from the lungs, the diaphragm might have been irritated, causing the spasms of coughing episodes. If this cannot be minimized, more respiratory efforts will deprive the client of the needed oxygen/carbon dioxide exchange that is necessary for life.
With decreased oxygen saturation, more oxygen is needed, but the best choice is to stimulate the client who still has some anesthetic effects after surgery. The other options will not have this beneficial effect.
Preoperative teaching should be reinforced postoperatively. By asking to take the TED hose and SCDs off, the client does not comprehend that the purpose is to maximize blood flow to the legs at all times, especially when lying in bed.
The client would be safest in a closed-door seclusion room (option 4) or in a locked unit (not an option here). The client would not have the continuous monitored care if he or she were in a respite home (option 1). He or she would have less safety or care in the home of a relative in another state (option 2). In an open-door seclusion room (option 3), the client could leave the area and harm others if there were distractions to the staff on the unit.
The complication that could have been avoided was deep vein thrombosis (DVT). Repositioning every 2 hours, avoiding crossing one’s legs, and wearing TED hose/SCDs all will increase the blood flow to the legs and minimize venous status that causes the clots to form.
The symptoms are of possible dehiscence and evisceration. The nurse cannot report to the physician what has occurred without first examining the problem. Secondly, a sterile towel and sterile normal saline are used to maintain a moist environment until the client goes back to surgery. Staying with the client is essential to calm him down and explain the circumstance. You should have a second nurse call the doctor to report the problem.
The calf is the most common place for a deep vein thrombosis to develop. The classic symptom is pain on dorsiflexion; as the calf muscle compresses the thrombus, pain is initiated.
A three-way urinary catheter is used to irrigate the bladder after surgery most of the time. The common data collection factors will indicate the rate of flow, bleeding, and other possible problems. A common problem with surgery on the bladder is bladder spasms that create pain with the cramping. The B & O suppository is the most common treatment to relax these spasms, since it is a belladonna-and-opioid combination drug.
Atelectasis is collapsed lung tissue from decreased breathing. The sounds that would be heard over the collapsed tissue would be diminished or absent, depending upon the amount of tissue involved. Since most clients lie in bed on their backs, the collapsed tissue usually bilaterally is in the posterior lower lobes.
The elderly are more prone to congestive heart failure when their systems are overloaded with fluids that cannot be adequately pumped. The symptoms are classical symptoms of congestive heart failure. Reducing the IV flow rate will not do harm, and will allow further evaluation without increasing the strain on the heart.
Postoperative management of any eye surgery client includes avoiding activities that might increase intraocular pressure. Straining at stool and lifting heavy objects both raise the intraocular pressure, and should be avoided. Stool softeners are used to present this straining.
Urinary output should be at least 30 milliliters per hour, and 150 milliliters per shift does not show adequate renal perfusion or functions.
The client who already has impaired respirations due to increased weight would be at greater risk for respiratory complications when receiving a narcotic that suppresses respirations. Snoring loudly reflects poor air exchange. Narcolepsy suggests that he is sleep-deprived from respiratory obstruction at night. Close monitoring should be given to this client.
Whenever the client states she is choking or having difficulty breathing, further data collection should be done immediately. The tubing could be coiled at the back of her throat, or swelling might have occurred to limit the air flow.
Options 1, 2, and 4 may be correct intervention terms, but option 3 is the most correct terminology for the nursing intervention described to prevent increased anxiety and stress.
Delegation to UAP can include any activity that is within their role. Ambulating the client and administering an enema are within this role.
Drug management includes knowing what the counteragent is for common dangerous drugs. Narcan is the acceptable antidote for narcotic overdose.
The symptoms of red spots might be indicative of an allergic reaction. The nurse’s first priority would be determining any potential compromise to the airway. Collecting vital signs and calling the physician will be important priority actions, but airway is always the first priority. Determining the effectiveness of pain control, while important, is not a priority action when the client is having an allergic reaction.
Option 1 is not the best question initially as it focuses not on the client but on the doctor. Option 2 is not an appropriate initial question. Option 4 is challenging and not appropriate as an initial question. Option 3 is correct as it will lead to the nurse's further exploration.
Respiratory and circulatory depression is a disadvantage of general anesthetics because there is a greater risk for complications, especially for clients with chronic illnesses. General anesthetic agents are rapidly excreted and produce amnesia. General anesthetics produce central nervous system depression so clients do not feel the pain of surgery.
Benzodiazepines such as lorazepam and diazepam decrease anxiety and produce side effects such as hypotension and sedation. Major tranquilizers such as chlorpromazine produce extrapyramidal symptoms, but benzodiazepines do not. Hypocalcemia is not an adverse effect of this class of drugs.
An increased hemoglobin and hematocrit might be a result of dehydration. Immune deficiency is an indication of decreased white blood cell count (option 1), while an increase in electrolytes such as potassium, sodium, or chloride indicate kidney dysfunction (option 2). Malignancy might be suspected in increased platelet count.
The anesthetic agent is injected into the subarachnoid space for spinal anesthesia and into the epidural space (which is outside the dura mater) in epidural anesthesia. Regional anesthesia can include local or topical anesthesia or nerve blocks and do not require clients to have sedation or produce amnesia.
Option 1 is the correct answer as in this position, gravity keeps the tongue forward, which prevents aspiration. A pillow elevates the head, semi prone position is unsafe in most cases as it may interfere with breathing.
Excessive bloody drainage on dressings or the bedclothes often underneath the client (because of gravity) indicates hemorrhage. This technique would not be useful in determining tube drainage, fluid balance in the general sense, or perspiration.
The client who demonstrates a calm, focused exchange of information and self-care information would demonstrate control of the disorder, which is expected following discharge from an inpatient setting. The client in a manic state would present with the option 1 or 2 behaviors, while the client with depression would present as option 3 indicates.
Option 2 is the correct answer as the client has inability to retain the information therefore has a deficiency in knowledge base and is the first action for the nurse to take. Self-care deficit is incorrect as there is no indication of inability to perform self-care activities such as bathing and eating. Options 3 and 4 are definitely incorrect.
The drain allows for drainage of excessive fluid and purulent material that may have accumulated during the surgery. Healing is promoted, but not necessarily at a rapid rate, and not all drains have to be shortened or connected to suction.
Option 2 could indicate wound infection. All other options indicate normal wound healing or characteristics.
Data collection in the preoperative phase includes anticipating any health problems that might occur during and after surgery. Option 2 is applicable during the intraoperative phase where specific specialized activities are carried out in the operating room. Option 3 is a very general activity that should occur at any time. Prevention of complications (option 4) occurs in the postoperative stage.
Ablative surgery involves removal of diseased body parts. Option 1 involves reconstructive surgery, option 2 is carried out for a diagnostic purpose, and option 4 is completed for palliation.
Risk is not associated with the place where surgery is performed; also, this is not a client-related factor. Risk is associated with poor nutritional status, so option 3 is incorrect. The higher the likelihood of complications, the greater the risk making option 4 incorrect. When surgery is performed on vital organs and when there is a greater likelihood for complications due to client age and condition, there is a greater likelihood for complications and therefore the risk is higher.
The infant has immature vital organs that affect the infant's ability to metabolize medications such as the anesthetic and the ability to resist infection. Infants do not suffer from declines in functioning (option 1). Hypothermia is more likely to occur than hyperthermia since the infant has an immature temperature regulation and large body surface area (option 3). The volume of blood in an infant is limited and does not fluctuate (option 4).
Option 1 is correct. Since preschool children have a very limited understanding of cause and effect, they often interpret illness and related procedures such as surgery as punishment for bad behavior. The other options are incorrect: appearance is not a primary concern at this age, anticipating inability of doing things is not a concern at this developmental level, and children at this age are unaware of competency issues of medical personnel.
Although all the options contain aspects that need monitoring, initially all of the parameters in option 1 are the most important to determine because they relate to both physiological needs and are more global indicators of overall functioning than the other options.
The color of the skin, nails, and lips are indicators of tissue perfusion and pallor and cyanosis indicates alteration. Mobility, pain, and fluid loss are incorrect as they are not signs of tissue perfusion.
Voicing doubt about the delusions is the most therapeutic intervention. The client will continue to voice a delusion even though the evidence would suggest otherwise (option 1). A paranoid client cannot use logic to dispel delusions (option 3). Option 4 challenges the client’s belief instead of voicing doubt. Providing evidence will not usually sway a paranoid client.
Turning side to side allows the lungs alternatively to expand properly. Peristalsis increases with movement even if it is not turning, and muscle weakness can be lessened with movement. Turning does not necessarily induce sleep.
The first sign of healing is absence of bleeding and wound edges bound by fibrin in the clot. Inflammation at the wound edges follows the first sign and then when the clot diminishes, inflammation decreases and collagen forms a scar.
Absence of pain indicates that the client is comfortable. The other options may be useful in the overall management of the client but are not directly related to the stated problem (pain).
Anemia increases the cardiac workload and should be avoided by clients with heart disease. The client should discuss medications with her caregiver, but she might be allowed to take acetaminophen or a few other OTC medications. The client with Class II cardiac disease is slightly compromised with ordinary activity levels and would not tolerate exercise. There is a 2–4% chance the baby will inherit a congenital defect.
The placenta produces human placental lactogen (HPL) and increased amounts of estrogen and progesterone. These hormones interfere with maternal glucose metabolism and require increased insulin production or supplementation. As soon as the placenta is expelled, these hormone levels fall dramatically and the mother may require no insulin at all or a very reduced dose in the first 24 hours.
The glycosylated hemoglobin (HbA<sub>1c</sub>) test provides an indication of what glucose levels have been over the past 4–8 weeks because glucose attaches to the red blood cells (RBC) and remains there for the residual life of the RBC. Increased blood glucose levels will be reflected in an increased percentage of HbA1c. The other tests indicate current blood glucose levels only.
Pregnancy presents an ideal time for nurses to reach out to substance-abusing clients in a caring way since the client herself recognizes that she and her baby will benefit from prenatal care. Option 1 is unrealistic, option 2 is punitive, and option 4 is judgmental.
The client with a suspected ectopic pregnancy might be at risk for the development of hypovolemic shock. Data collection is the first step of the nursing process and airway, breathing, and circulation are the priorities. Options 1 and 4 are possible later interventions, and option 3 is the surgeon’s responsibility.
The client requires frequent monitoring to rule out development of malignancy after experiencing trophoblastic gestational disease. Weekly HCG measurements are done until normal levels are recorded for 3 weeks. Option 2 is a possibility for this client. The client should use contraception for at least 1 year during the follow-up care (option 4), and expressions of sadness are appropriate for any pregnancy loss, even if no fetus developed (option 1).
Urinary frequency, without other symptoms, is not uncommon in the last trimester of pregnancy as the fetus grows in size and applies pressure to the bladder. Proteinuria and hypertension are symptoms of preeclampsia, not placenta previa. Therefore, the only correct answer is option 4.
Full bed rails are a type of physical restraint. A confused client may attempt to climb over the rails, increasing the risk for fall and injury. The other options are positive interventions for reducing risk for falls.
Minimal self-care is a behavioral negative symptom of schizophrenia. A delusion is a cognitive positive symptom (option 2); hallucination is a perceptual positive symptom (option 3); and inappropriate affect (option 4) is an affective positive symptom.
One mL of blood weighs approximately 1 gram. Therefore, 50 grams equal 50 mL.
The client with hyperemesis gravidarum is anxious or even fearful about the effects of her condition on the fetus. The etiology of hyperemesis is unknown but the incidence is increased in conditions with increased hCG. There may be an emotional component, but there is no indication that this is an unwanted pregnancy. With appropriate treatment, the prognosis is favorable for the fetus. The client experiences excessive vomiting and would have the diagnosis of imbalanced nutrition: less than body requirements.
The Rh-negative client whose partner is Rh-positive may carry an Rh-positive fetus and would be at risk for Rh-sensitization, which could create risks for future pregnancies. This father of the baby needs to have his blood type determined. The client is not anemic based on these hemoglobin and hematocrit values so options 2 and 4 are false. There is no relationship between the lab values and the client’s weight in this scenario (option 3).
The client has three risk factors of molar pregnancy: Japanese background, brownish "prune juice" vaginal bleeding, and the severe nausea and vomiting associated with excessive hCG found in trophoblastic disease. The client has only one symptom of hyperemesis; placenta previa presents with bright red bleeding; and there is no information suggestive of psychosis.
The Shirdkar cerclage is closure of the cervix with suture material to prevent preterm dilatation. When labor ensues, the suture must be cut so the fetus can pass through the birth canal. Waiting for harder contractions will increase the likelihood of cervical damage from the suture. Option 3 does not address the client's risk, which is the priority. Clients who expect to have several future pregnancies may be delivered by cesarean to avoid repeated cerclage, but there is no necessity to this option.
The risk for placental abruption is increased with cocaine abuse. The other factors make the client high risk for complications of pregnancy but not particularly for abruption.
The client with ruptured membranes prior to the beginning of labor is at increased risk for ascending infection (chorioamnionitis). The client's temperature should be taken every 2 to 4 hours to identify early signs of sepsis.
The infant of an HIV-positive mother will test positive on an ELISA test for the human immunodeficieny virus because the maternal antibodies cross the placenta during pregnancy. This does not indicate that the newborn has HIV. The diagnosis using the ELISA test for the baby is not made until around 15 months when maternal antibodies are degraded and the infant forms antibodies to HIV if infected. The other tests give information about the infant's current condition.
Digoxin is a cardiac glycoside that increases cardiac output by increasing the strength of contraction of the myocardium and slowing the heart rate. A pulse rate of less than 60 is a serious adverse effect of the medication and the dose should be held. The client needs adequate potassium for myocardial function. Antibiotics are not contraindicated with digoxin. The drug may be given with or without food.
The nurse should provide emotional support to all clients experiencing perinatal loss. Offering the client an opportunity to talk with another healthcare professional or clergy for additional help is also supportive. The other answers are insensitive, and option 4 may not be true.
Neuroleptic malignant syndrome (NMS) is a potentially fatal extrapyramidal symptom. Symptoms of NMS develop suddenly and include muscle rigidity, respiratory problems, and hyperpyrexia. Dystonia (option 1) and akathisia (option 2) are both extrapyramidal symptoms that are usually not fatal (option 1). Tardive dyskinesia symptoms include frowning, blinking, grimacing, puckering, blowing, smacking, licking, chewing, tongue protrusion, and spastic facial distortions, which can be socially disfiguring (option 4).
Magnesium sulfate is a CNS depressant used to prevent seizure activity in the preeclamptic client. The other options may occur but are not the intended effect of the drug.
A sinusoidal fetal heart rhythm is associated with fetal anemia, which may be associated with an abruption. The other complications would result in other signs of fetal distress such as tachycardia, loss of variability, and late decelerations.
Option 4 is the only answer that acknowledges the client's intent to cut down on substance abuse while seeking additional information about the client's self-concept. Option 1 places the emphasis on the nurse while options 2 and 3 are demeaning and negative.
The priority diagnosis is related to maintaining circulation and oxygenation. The other options are of lesser importance.
The MacDonald cerclage is a purse-string suture that ties the cervix closed. The suture needs to be removed before vaginal delivery is possible. Options 1 and 2 place the client at risk of cervical injury. The cerclage is usually removed at 37 weeks to allow natural labor to begin.
During pregnancy, only amniotic fluid will dry to a ferning pattern. Urine may occasionally be alkaline and turn nitrazine paper blue or old nitrazine paper may be unreliable. Performing a vaginal exam places the client at unnecessary risk for an ascending infection and feeling for membranes is unreliable. A watery vaginal discharge is not necessarily amniotic fluid.
According to universal precautions, the caregiver should wear goggles when contamination from splashing is possible, as when the membranes are artificially ruptured. The other options place the nurse at risk for contamination from skin contact, necessitating the use of gloves.
The normal platelet value is 150,000 to 450,000/mm<sup>3</sup>. The preeclamptic client is at risk to develop the potentially fatal HELLP syndrome with low platelets as one of the defining factors. The other options are all within normal values for pregnancy.
Rh immune globulin, RhoGAM, must be administered within 72 hours of any event that presents a possibility for the mother to become sensitized to the Rh antigen. This includes pregnancy with an Rh-positive infant, which may be the case in a first trimester abortion (miscarriage), though the blood type is not usually obtained. If the father is also Rh-negative, the fetus will be also and no problems will occur with this pregnancy. The indirect Coomb's test is used to determine maternal Rh sensitization. While option 4 may be correct during this one reproductive event, precautions must be taken during future pregnancies.
Forcing fluids, emptying the bladder, and placing the Trendelenburg position will have no positive effect for this client. The only correct choice is option 4. Creating a low stimuli environment will help to lower blood pressure.
A delusion is a false belief that cannot be changed by logical reasoning or evidence. A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; it is real to the client (option 1). The client is not exhibiting reality orientation (option 2). An illusion is a sensory misperception of environmental stimuli (option 3).
Feelings of anger are commonly experienced during the grieving process. The client who has had a spontaneous abortion is grieving the loss of her imagined child and should receive supportive care.
Previous endometriosis and pelvic inflammatory disease may cause scar tissue formation that may block the normal passage of a fertilized ovum through the fallopian tube. The other options would not interfere with movement of the ovum.
The nurse remains with the client to prevent injury during the seizure. Insertion of a tongue blade is not recommended because of the risk of injury to both nurse and client. The client should be placed on her side to avoid aspiration.
A compound presentation involves two fetal parts. The fetal head and a hand is the most common, although hand and foot presentation is also possible. Option 2 is incorrect unless a head is also presenting, since this could occur with shoulder presentation. Both feet presenting is called double footling breech presentation.
Molding of the fetal head does not occur during labor in the breech presentation. The fetal body can pass through an incompletely dilated cervix, leaving the larger, firmer, fetal head entrapped. The woman may feel a strong urge to push before complete dilatation due to pressure from the fetal body, increasing the risk of head entrapment. Options 1 and 2 are incorrect because prolapsed cord and fetal distress are risks inherent with breech delivery whether the woman pushes or not. Option 4 is incorrect since cervical lacerations most often occur at the time of delivery from the application of forceps or manipulation of the fetus to deliver the after-coming head.
Even with strict adherence to aseptic technique, the risk of infection increases with frequent vaginal examinations, especially if membranes are ruptured or if labor is prolonged. Most authorities recommend keeping the number of vaginal examinations to a minimum for this reason, as well as for client comfort. Cervical lacerations, bleeding and loss of control are incorrect.
If the chin (mentum) of the fetus presents and remains in a posterior position, vaginal delivery cannot occur. The inability of the fetus to flex and extend the head as it moves through the mid-pelvis causes an arrest of descent. A cesarean delivery is necessary. The other answers are incorrect.
The uterus should be monitored for overdistention and an elevated resting tone due to over infusion of solution into the uterine cavity or trapping of infused solution behind a presenting part. The elevation in uterine tone can lead to fetal distress. Maternal vital signs are also monitored to determine physiological status. The other answers do not represent items that require monitoring during this procedure.
External cephalic version involves abdominal manipulation to rotate the fetus from either a breech or shoulder presentation to vertex. Clients need to know that the attempt is not always successful. Option 1 is not correct. Version involves turning the fetal body not just the head. Staying in bed after a version is not necessary. The procedure will be stopped immediately if there is maternal or fetal distress.
Counter-pressure over the sacral area during contractions is helpful in alleviating the lower back pain without the use of narcotics that can be transferred across the placenta to the fetus. Ice packs have not been shown to be helpful. Pelvic rocking has been helpful for back pain in the antepartum period, but patients in labor seem to benefit more from conscious relaxation during contractions (avoiding movement and tension).
The client who gains coping skills reduces anxiety to a level at which dissociation is unlikely to occur. The client does not remember what occurred during the fugue state, nor does he experience depersonalization.
The spiral (fetal) electrode used for internal monitoring penetrates 2 mm into the presenting part. While this does not create a problem on the fetal scalp, the face should be avoided for cosmetic reasons and to avoid eye injury. None of the other actions would be harmful for a patient with face presentation.
Covering the cord with warmed saline-soaked sterile towels will prevent it from drying out and occluding blood flow until the delivery can be accomplished. The other answers do not protect the umbilical cord.
Uterine hyperactivity decreases the oxygen supply to the fetus. The priority of the nurse is to notify the RN who will reduce uterine activity by stopping the oxytocin (Pitocin.) The nurse then acts to increase fetal oxygenation by administering oxygen by face mask to the mother and repositioning the client to the side, left side-lying preferred, to improve uteroplacental blood flow. The nurse would then determine the client’s pain level and then measure the blood pressure for hypotension or hypertension.
Nursing action should be directed toward preventing a rapid and uncontrolled delivery of the infant's head. Directing the client to pant prevents pushing. If time allows, the nurse may don gloves or obtain a towel or blanket to support the fetal head. Delivery is imminent, so there may not be time to obtain sterile gloves or contact the physician. The client should not be left alone, so going to the nursing station to get the precipitous delivery tray is not an option.
Blood transfusions are not routinely given during cesarean sections. Although blood typing and screening is often ordered prior to surgery, it is seldom necessary for a client to receive a blood transfusion. IV lines are necessary for instillation of fluid, medications, and potential blood products during surgery. A Foley catheter is inserted to prevent bladder damage during surgery and an antacid is administered to prevent aspiration of acidic gastric contents, thus reducing the risk of lung damage. The client's husband or primary support person is usually present at the birth except in extreme emergencies.
The pattern described is a variable deceleration, which is associated with umbilical cord compression. During variable decelerations, the FHR drops below 90 beats a minute very quickly as fetal blood flow through the umbilical cord is interrupted. FHR returns rapidly to baseline as soon as the cord compression is relieved. FHR patterns associated with fetal head compression (early deceleration) and utero-placental insufficiency (late deceleration) have a shallower appearance since they do not drop as precipitously. Variable deceleration, unless severe (lasting longer than 60 seconds), does not indicate severe hypoxia.
Meconium passage prior to birth occurs in response to a stressful event for the fetus. Moderate bloody show often occurs late in labor. Pink-tinged amniotic fluid occurs because of a small amount of blood usually from the cervix. Accelerations of FHR are considered a normal response and do not indicate fetal distress.
Findings on palpation are consistent with shoulder presentation or transverse lie. Vaginal delivery is not possible, so the nurse should anticipate cesarean section. Since the client is in labor, version is contraindicated.
Pressure on the cord must be relieved to save the life of the fetus. Applying upward manual pressure to the presenting part and having the mother assume a knee–chest position are appropriate emergency actions, followed by starting oxygen and calling the physician. Options 2 and 3 do nothing to relieve cord occlusion.
Prolonged latent-phase labor is associated with uncoordinated, hypertonic, and painful contractions that do little to dilate or efface the cervix. Maternal exhaustion and dehydration are concerns. Medical management is directed toward providing rest and hydration and allowing time for contractions to become coordinated. Often clients awaken from sedation in progressive labor. While option 2 is correct, this does little to explain the rationale for sedation. Option 3 is incorrect. There is very little risk to the fetus unless contractions are intense and < 2 minutes apart. Option 4 is not correct, because it is too soon to anticipate the need for cesarean delivery.
This response demonstrates empathy and encourages the client to elaborate further about his experience. Options 2 and 3 dismiss the affective component or miss the point of the client’s statement. Option 4 is helpful in making connections between events but is not the best response to the client’s original comment.
Early signs of magnesium toxicity that may lead to respiratory arrest are loss of patellar reflexes and decreased respiratory rate (< 12/min). Since magnesium is excreted from the body through the renal system, hourly urine output should be measured. Although blood pressure is a standard measurement for most antepartum clients, there is minimal blood pressure change, if any, associated with administration of magnesium sulfate.
Although rupture of the uterus is rare, there is an increased risk for multiparas and clients undergoing induction or augmentation of labor. Early signs include pain and a tearing sensation, signs of shock, and fetal distress. Blood loss is usually severe but may not be visible. Amniotic fluid embolus is frequently associated with cardiac and respiratory distress. Symptoms of precipitate labor and uterine prolapse do not include pallor, diaphoresis, or fetal distress.
In a brow presentation, the fetal forehead and the large, diamond-shaped, anterior fontanelle is palpated during vaginal exam. In vertex presentation, the back of the fetal head (occiput) and small, triangular fontanelle is palpated. In breech and shoulder presentations, fetal parts would feel soft and irregular.
The risk of umbilical cord compression or prolapse increases when amniotic fluid is released. Listening to fetal heart tones after amniotomy will quickly detect the presence of cord compression. Observing color and consistency of the fluid should be done next. Placing a clean underpad on the bed and repositioning the mother is important in providing comfort but is not the first priority. Temperature should be monitored every 1–2 hours for signs of infection.
Gravity may help the fetus rotate to an anterior position for vaginal delivery. The positions in options 1, 3, and 4 enlist the aid of gravity. Option 2 should be avoided because it will not help the fetus to rotate.
Dilatation has stopped (arrested) after considerable progress. Causes may be hypotonic uterine contractions, malposition, or cephalopelvic disproportion. Options 1 and 2 are not correct because prolonged and protracted mean that progress occurs at a very slow rate. Arrest of descent (option 3) occurs when the station rather than cervical dilatation does not change.
Meconium released by the fetus causes amniotic fluid to be greenish-tinged. Although the presence of meconium is associated with fetal distress, there is no evidence of immediate danger to the fetus during labor in this case. However, the infant is at risk for aspirating meconium at the time of delivery. Steps to prevent aspiration include thorough suctioning of the nasopharynx including visualization of the vocal cords to remove meconium particles before the first breath.
Hydration has been shown to decrease premature labor contractions. Therefore, drinking water or other noncaffeinated beverages is recommended. If contractions continue at 10 minutes apart or less for an hour with rest, the client should call her healthcare provider.
A classical incision involves the upper uterine segment and is more likely to separate or rupture with subsequent uterine contractions. Induction is not a contraindication if managed judiciously. The type of abdominal incision is not a concern, since it is not affected by uterine contractions.
Promoting a positive feeling about how well she was able to cope with an emergency cesarean delivery will have an influence on self-image and the client's feelings about her ability to handle future pregnancies and births. In addition, providing an opportunity for the client and her family to ask questions and to express feelings helps in dealing with any disappointment, anger, or guilt they may feel. Other options indicate that the birth was not normal and can promote negative feelings about the infant or the experience.
The goal of care is to eliminate or reduce dissociative experiences, which can be accomplished in part by anxiety-produced stress-management techniques.
Oxytocin (Pitocin) stimulates uterine contractility; exceeding maximum doses or increasing doses too rapidly can result in uterine hyperstimulation. Blood pressure may initially decrease but after prolonged drug administration, it may increase 30% above baseline. The antidiuretic effect of oxytocin decreases water exchange in the kidney and reduces urinary output, leading to fluid overload rather than dehydration. Bradycardia and jaundice are possible adverse effects for the fetus rather than the mother.
Terbutaline, a beta-adrenergic agent, has many maternal and fetal side effects including tachycardia, cardiac arrhythmias, and pulmonary edema. In addition to taking vital signs, the nurse should monitor for pulmonary edema. The frequency of measurement of fetal heart tones and oral temperature depends on the intensity and length of the drug therapy, as well as surrounding circumstances. Deep tendon reflex measurements are not indicated.
With breech presentation, fetal parts do not completely fill the lower uterine segment, allowing more opportunity for the umbilical cord to proceed through the cervix or become compressed by the fetus, especially following rupture of membranes. The incidence of the other options is no higher in breech than it is with vertex presentation.
Heavy bleeding is an abnormal postpartal finding. Early hemorrhage can be caused by uterine atony or by a lacerated cervix. Palpation of the uterine fundus can determine uterine atony. The client did not report excessive perineal pain or pressure which would be caused by a hematoma. Blood is retained in the tissue with a hematoma and not usually visible on the perineal pad. Subinvolution causes the majority of late postpartal hemorrhages occurring after the first 24 hours following delivery.
The infant will not be affected by the infection in the mother's breast; it does not get into the breast milk. The client needs to empty her breasts frequently to prevent stasis of milk that can further cause problems with the mastitis. Stopping the breastfeeding or binding the breasts would do nothing to help with the mastitis.
The client is demonstrating symptoms of depression. Primiparas without support are at higher risk for postpartum depression. Determining her lack of support systems will help to evaluate her risk for depression and the need to develop an appropriate plan to deal with this concern. The client's vital signs and symptoms of pain will not assist the nurse in helping the client with symptoms of depression.
A client with gestational diabetes is more likely to have a large baby that could cause tissue trauma during delivery. The use of forceps during delivery is another risk factor for developing a postpartal hematoma. The age factor does not affect the development of a hematoma nor does a small for gestational age infant.
Late-postpartal hemorrhage occurs anytime after the first 24 hours post delivery. The causes of early postpartal hemorrhage include uterine atony, DIC, hematoma, and lacerations. Retained placental fragments are the primary cause of late-postpartal hemorrhage. The retained fragments undergo necrosis, forming fibrin deposits. These deposits form polyps, which eventually detach from the myometrium, causing hemorrhage.
The client is complaining of symptoms that might indicate a urinary tract infection. Cystitis is not an uncommon infection after delivery. The low-grade temperature, dysuria, and frequent voiding of small amounts are symptoms of cystitis. Several factors place women at risk for postpartal urinary tract infections. These include bladder trauma, stasis of urine caused by hypotonicity of the bladder, and catheterization during labor. Fifty percent of women that are catheterized during labor develop a urinary tract infection. The other answers do not address urinary tract infection.
All of these symptoms are normal findings in the first 24 hours postpartum. The body is beginning to return to the pre-pregnancy state. The nurse can explain to the client that these are normal symptoms and the reasons for the diaphoresis, frequent urination, and low-grade temperature. Offering comfort measures such as a dry gown and linens will enhance the client's feeling of well being.
Amnesia is precipitated by stress related to trauma or conflict. The amnesia occurs abruptly and there is no attempt to cover the memory loss. Confabulation, gradual loss of memory, and disheveled appearance are common in clients experiencing dementia.
Cracked and bleeding nipples provide an entrance for bacteria. Therefore, frequently checking the nipples for cracking will help to prevent mastitis as well as adequate instruction in proper breastfeeding techniques prenatally. Routine antibiotics are not given to prevent mastitis. Clients can develop bacteria that are antibiotic-resistant. Waiting too long between feedings and decreasing nursing time can lead to stasis of milk and clogged ducts, which contribute to the development of mastitis.
The client should take all the prescribed medication and ask her physician about recommending an analgesic. The client should empty her breasts frequently either through nursing the baby or through pumping her breasts. This will prevent stasis of the milk and further clogged ducts, which could cause further complications and development of an abscess.
Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest. Options 1 and 2 increase the risk for thrombophlebitis, while option 4 may not be realistic.
The postpartal woman is prone to develop superficial thrombophlebitis due to increased amounts of clotting factors in the blood during the postpartal period as well as an increased amount of platelets and increased adhesiveness. Any restrictive clothing on the legs should be avoided.
Preventing stasis of the milk and emptying the breast frequently will help prevent mastitis. The other options are false.
The signs of a postpartal infection would include a temperature of greater than 100.4°F on 2 successive days after the first 24 postpartal hours, tachycardia, foul-smelling lochia, and pain and tenderness of the abdomen. The pinkish lochia is normal, and the temperature might indicate a cold or breast milk coming in. Bradycardia would be an unrelated finding.
A full bladder may cause uterine atony and contribute to bleeding. If a client has hemorrhaged, a Foley catheter may also be needed to allow accurate measurement of urine output, which is an indicator for kidney function. Overly aggressive stimulation of the fundus may cause decreased uterine tone; this is detrimental because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A tocolytic agent relaxed the uterus; in this case, an oxytocic drug to contract the uterus would be indicated.
Factors contributing to postpartum endometritis include the introduction of pathogens with invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of endometritis is greatest after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. Options 2, 3, and 4 are neither invasive nor do they increase the client's risk for infection.
Suspect lacerations if the client is bleeding and the fundus is firm. If the cause were uterine atony, the fundus would not be firm. When there are fragments of the placenta or the membranes, the uterus will not contract effectively.
Of the options given the only one that immediately affects the bleeding is uterine massage. It might be important to start an IV with oxytocin at a rapid rate, and to allow the client to empty her bladder; however, the first action is to massage the uterus to stop or slow down the blood flow.
A client with OCD, a cluster C disorder, appears anxious or fearful. Individuals with a cluster A disorder appear odd or eccentric; those with a cluster B disorder appear dramatic or erratic. The category of rigid/critical does not reflect a diagnostic cluster.
Mastitis most frequently occurs at 2 to 4 weeks after delivery with initial flu-like symptoms plus breast tenderness and redness. The client may be describing symptoms of a breast infection. Sleep, lochia, and edema with visual disturbances are not associated with breast problems.
Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. Option 1 raises serum calcium levels. Option 2 is the antidote for warfarin. Option 4 is an iron supplement.
Postpartum psychosis usually becomes evident within 3 months of delivery. Delusions and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic woman's distorted thoughts about herself or the baby. The psychotic woman would typically display agitation, hyperactivity, and confusion. Adjustment reaction with depressed mood, commonly known as maternal or baby blues, occurs in 50–70% of women and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously about the 10th postpartal day.
Women that are parity of 6 or above (grandmultiparity) are at the greatest risk of uterine atony because of repeated distention of uterine musculature during pregnancy. Labor leads to muscle stretching, diminished tone, and muscle relaxation. The client's age is not a factor in uterine atony, the length of labor is not considered to be prolonged or precipitous, and the size of the baby is considered appropriate for gestational age, and is not considered to be macrosomic.
Cervidil is used to ripen the cervix before labor; terbutaline sulfate is a tocolytic, and could cause further muscle relaxation; magnesium sulfate is used to decrease contractions or prevent seizures; and Hemabate is a prostaglandin, used to manage uterine atony. Oxytocin remains the first-line drug, the prostaglandins now are more commonly used as the second-line drug, and carboprost (Prostin 15-M or Hemabate) is the most commonly used uterotonin. As many as 68% of clients respond to a single carboprost injection, with 86% responding by the second dose.
The organisms are localized in breast tissue and are not excreted in the breastmilk. The other answers are not correct.
An abnormal odor of the lochia indicates infection in the uterus. The vital signs may be affected by an infection, but that is not definitive enough to suspect a uterine infection. A distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus. Inspection of the episiotomy site would not provide information regarding a uterine infection.
A temperature elevation greater than 100.4°F on 2 postpartum days not including the first 24 hours meets the criteria for infection. This criteria is the most common standard in the United States. It is not abnormal for a postpartum client to run a low-grade fever in the first 24 hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. Postpartum nurses should monitor for other signs and symptoms of infection in addition to fever and WBCs when evaluating the possibility of infection in mothers who had epidural analgesia.
These are classic signs of thrombophlebitis that appear at the site of inflammation; the other signs listed are not.
An increase in lochia or a return to bright red bleeding after the lochia has changed to pink indicates a complication. The other statements are false.
In caring for clients diagnosed with antisocial personality disorder, it is important to maintain a structured and consistent environment to decrease their attempts to control the situation through manipulation. It is unlikely that they will develop insight as the causes of problems in living are externalized. They are frequently quite sociable and take advantage of others for personal profit. Suicidal ideation is not associated with this disorder.
Bleeding into the connective tissue beneath the vulvar skin may cause the formation of vulvar hematomas, which develop as a result of injury to tissues with spontaneous as well as operative deliveries (use of forceps). One of the first signs of a hematoma may be complaint of pressure, pain, or an inability to void. An ice pack to the perineum can be used to reduce swelling, but a hematoma is abnormal and should be reported to the physician. The fundus should be examined, but the client's complaints warrant a perineal or vaginal exam.
Creating an environment where a client and her family can discuss emotional concerns is essential. Sharing time with the new mother to discuss thoughts and feelings is important to clients. Responding with patronizing answers (options 1 and 4) does nothing to assist the mother to talk about her thoughts and feelings and may increase her sense of isolation and feelings of inadequacy and despair.
Risk factors for postpartum depression include primiparity, ambivalence about maintaining the pregnancy throughout the pregnancy, history of previous depression or bipolar illness, lack of a stable support system, lack of a stable relationship with parents or partner, poor body image, and lack of a supportive relationship with parents, especially her father as a child. Ambivalence regarding pregnancy is a normal response in the first and into the second trimester, but should be resolved by the third trimester. Postpartum blues occurs in approximately 50 to 80% of postpartum women; the blues does not particularly indicate that a woman will develop postpartum depression.
Nasal flaring and retractions could be signs of respiratory distress and requires immediate intervention. The other data are normal findings for a neonate at 2 hours of age.
Maintaining a patent airway is the highest priority when providing care for a newborn. A newborn's condition will deteriorate rapidly without a patent airway.
This newborn is at risk for sepsis caused by prolonged rupture of membranes and maternal fever. A primary sign of sepsis in the newborn is temperature instability, particularly hypothermia. An irregular respiratory pattern is normal. Jitteriness may be a sign of hypoglycemia. Excessive bruising is often related to a difficult delivery with an increased risk of hyperbilirubinemia.
Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period.
A newborn can become infected with gonorrhea as it passes through the birth canal. Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All babies' eyes are treated with an antibiotic prophylactically after birth.
Newborns experiencing macrosomia are more likely to experience birth injuries during delivery. Nursing care after delivery should focus on monitoring for signs of birth injuries and intervening if appropriate.
Reflecting on what the client said offers them an opportunity to share their feelings. Avoid giving false reassurance or asking a client "why" they feel the way they do.
Individuals diagnosed with personality disorders display either functional impairment or subjective distress. Frequently these problems in living are reflected in impaired interpersonal relationships. Flexibility and adaptability to stress (option 1) are incongruent with a diagnosis of a personality disorder. The presence of a physical disorder (option 3) has no relation to the diagnosis of a personality disorder. These individuals may or may not desire interpersonal relationships (option 4).
Infants of diabetic mothers are at risk for hypoglycemia after delivery. A primary sign of hypoglycemia is jitteriness. The newborn is not showing any signs of hypoxia so oxygen would not be appropriate. Putting the newborn under a warmer or on a monitor would not harm the infant, but they are not the priority interventions at this time.
This newborn has a low temperature and the nurse must intervene quickly to prevent complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation and is the most important initial intervention. Babies can lose a large amount of heat from their head, so keeping it covered will help stabilize the temperature.
This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice is considered pathologic if it occurs within the first 24 hours of life, when it is most often caused by Rh or ABO incompatibility. It would be important to determine both the mother's and newborn's blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained.
Neonates generally aren't able to effectively coordinate sucking, swallowing, and breathing until 34–36 weeks' gestation. If fed orally before that time, they are at greater risk of aspiration. Typically they will be fed through a gavage tube until they are able to drink from a bottle or breast-feed. Intake can be accurately measured with oral and gavage feedings. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage through the birth canal and gavage feedings will not prevent it from occurring.
Newborns compensate for hypothermia by metabolizing brown fat. This process requires glucose and oxygen. Preterm newborns are at risk for hypoglycemia and respiratory distress, so hypoglycemia can further increase their needs for oxygen and glucose and cause serious complications. The other concerns are appropriate but not the highest priority.
Jaundice in an infant less than 24 hours of age is often caused by Rh or ABO incompatibility. A direct Coomb's test determines the presence of maternal antibodies in the baby's blood. The other lab tests are not related to hyperbilirubinemia.
Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. Nursing care is focused on supporting oxygenation needs to allow the newborn's body to reabsorb the fluid. TTN causes tachypnea so stimulating respirations is not appropriate. Inadequate surfactant is related to prematurity and respiratory distress syndrome. Meconium in the airway results in meconium aspiration syndrome and is usually associated with fetal asphyxia.
Infants should be unclothed while receiving phototherapy to increase the circulating blood volume exposed to the phototherapy light. However, this increases the risk of temperature instability and infant temperatures should be monitored carefully. Any temperature below 97.6°F is considered hypothermia and requires immediate attention. Loose, green stools and a yellow tint to the skin are expected findings with hyperbilirubinemia. A fine, raised red rash may appear on the infant's skin as a side effect of the phototherapy and does not require intervention.
Reflection allows the client to verbalize his or her feelings. The nurse should not give the client false hope. Clients often do not know why they feel the way they do and it is not helpful to ask them to determine this. Some clients may find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs.
Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapartally, as well as to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by 60–70%. Breast-feeding is contraindicated in an HIV-positive mother because the virus can be passed through breast milk. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated.
The client should be checked at least hourly, and the nurse is required to document status. The IV site should be checked every hour, but documentation may be done only once per shift unless a problem occurs. Physical restraints impede a client’s freedom, and thus their use needs to be ordered every 24 hours. Because restraints may also impede circulation, they should be removed according to agency policy, which is generally every 1 to 2 hours rather than every 8 hours.
Individuals diagnosed with antisocial personality disorder frequently try to play one staff member against the other in order to control their environment. It is imperative that staff present a unified, consistent, and structured approach to care to prevent this. Options 2, 3, and 4 are incorrect because they would result in lack of team unity and an unstructured approach to care.
Any sustained respiratory rate greater than 60 breaths/minute increases the risk of aspiration in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease the risk of aspiration. An apical heart rate of 120 is a normal finding. Although an infant temperature of 97.2°F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice may be considered abnormal, but it alone would not be an indication to withhold an oral feeding.
Infants experiencing neonatal abstinence syndrome (NAS) often have an increased need for non-nutritive sucking and offering a pacifier would help meet this need. Options 1, 3, and 4 are incorrect because they all involve increasing the environmental stimulation. This is contraindicated in these infants because they are already hyperstimulated from the drug withdrawal process. Place the infant on the right side or semi-Fowler's position to avoid possible aspiration of vomitus or secretions.
Increasing occipital frontal circumference (OFC) is an indication of increasing intracranial pressure, which could result from an intraventricular hemorrhage (IVH). It should be monitored in infants at risk for an IVH every 8–12 hours. Changes in blood pressure may also occur, but the changes may not be as noticeable and can be caused by many other problems. Intake and output are routine measurements that are not directly helpful in this situation. Changes in Moro reflex are not an indication of an IVH.
A maternal history of diabetes increases the risk of hypoglycemia in the newborn and this infant should be monitored closely. If the woman received meperidine (Demerol) most of the drug would be metabolized within 3 hours and should not cause respiratory depression in the infant at delivery. A marginal placenta previa increases the mother's risk of bleeding during pregnancy, but should not cause significant complications in the newborn after delivery. Membranes ruptured greater than 24 hours prior to delivery increase the mother's and infant's risk of infection.
Infants born to mothers who are hepatitis B positive should receive a hepatitis B vaccine within 12 hours of birth to decrease their risk of acquiring the infection from maternal exposure. It is appropriate to evaluate for HIV risk factors in all infants, not only those at risk for hepatitis B. An exchange transfusion and isolating the infant are not appropriate in this situation.
Gavage feedings should be administered over 5 to 10 minutes to decrease the risk of GI distress. All of the other options are correct when administering a gavage feeding.
Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can lead to the development of respiratory distress syndrome (RDS), which would be evidenced by signs of respiratory distress including sternal retractions and tachypnea. Abdominal distention, jaundice, and jitteriness are not directly related to RDS.
Adequate hydration is evidenced by urine output of 1–3 mL/kg/hr and specific gravity <1.013. This newborn shows signs of dehydration. Metabolic acidosis and electrolyte imbalance would be determined by serum, not urine, analysis.
Central cyanosis is always considered abnormal and warrants further evaluation. Options 1, 3, and 4 are normal for an infant.
Parents should be given a Polaroid picture of the infant before the baby is transported. Calling the unit to check on their baby may help bonding, but seeing the baby is more effective. Parents are typically allowed to visit as often and for as long as they want. It is important to be honest with parents, even if the prognosis is poor.
Individuals diagnosed with obsessive-compulsive personality disorder become overly involved in details such as rules and regulations related to a need to be perfect. As a result, they fail to see the big picture. Their relationships with others and participation in leisure activities are less important to them than is their devotion to work and productivity.
Infants are obligate nose breathers. A gastric tube may be inserted to keep the stomach decompressed and allow for easier lung expansion. But if it is inserted nasally, it occludes one nare and may make respiratory effort more difficult. All other options are correct interventions for maintaining a patent airway.
The newborn reacts to hypothermia by burning brown fat to produce body heat. This process requires oxygen and glucose. When an infant experiences hypothermia, glucose and oxygen needs increase and hypoglycemia may result. Infants should be rewarmed slowly to prevent hypotension. The infant may require oxygen administration, but the need should always be determined first. Phototherapy is not indicated.
Changes in the gastrointestinal data collection, including abdominal distention, occur with NEC. The other options should be reported to the health care provider, but are not related to NEC.
Parathyroid hormone (PTH) is important in renal magnesium regulation, and hypoparathyroidism is associated with renal wasting of magnesium. The other options do not have this effect.
Calcium competes with magnesium in the loop of Henle; therefore, elevated calcium could decrease renal absorption of magnesium, causing hypomagnesemia. Options 2, 3, and 4 are incorrect.
Furosemide, a loop diuretic, increases urinary output and excretion, therefore decreasing magnesium reabsorption. The following drugs promote magnesium loss: aminoglycosides, potassium wasting diuretics (such as furosemide), cortisone, amphoteracin B, and digoxin. Cimetidine (a histamine 2 receptor blocker), erythromycin (an antibiotic), and aspirin (an antipyretic, analgesic, and antiplatelet agent) do not have this effect.
Low magnesium produces clinical manifestations such as seizures, tremors, spasticity, and increased reflexes. Magnesium sulfate is the preferred agent for prevention and treatment of seizures in preeclampsia and eclampsia due to its efficacy and low neonatal morbidity. The other options are incorrect reasons for administering this drug.
The ECG and actual magnesium level can provide information about the severity of the electrolyte imbalance. A prolonged QT interval may be evident on an ECG due to lengthening of the ST segment. The T wave may be flattened, while the QRS may have diminished voltage. The ST segment is not elevated. Changes in the ST segment and T wave can ultimately precipitate ventricular tachycardia, while a prolonged QT interval can precipitate heart block.
An elevated serum magnesium level is usually due to renal insufficiency and the decreased ability of the kidneys to excrete magnesium. Chronic alcoholism and diabetes may lead to hypomagnesemia. Hypertension is not part of the clinical picture.
No comments:
Post a Comment