Magnesium sulfate is a cathartic used to stimulate peristalsis and increase elimination of stool. It is not used to treat vomiting, anorexia, or fever. The continuance of pain is related to reinforcement of the symptoms, such as the caring responses of others, which give the client benefits that otherwise might not occur. There is no organic basis for the pain. High endorphin levels are associated with feelings of euphoria. Magnesium deficiency may contribute to decreased levels of phosphates, calcium, and potassium. For this reason, each of these electrolyte levels should be monitored. Tapping on the facial nerve below the temple is the method of testing for Chvostek's sign. A positive sign would be a twitch of the nose or lip. Effects of hypomagnesemia are mainly due to increased neuromuscular responses and are manifested by neuromuscular irritability, increased deep tendon reflexes, and signs of tetany. A decreased or normal deep tendon reflex indicates the treatment was effective. Options 1, 2, and 3 are incorrect because they are evidences of continued neuromuscular irritability. Due to a lack of adequate calcium for neuromuscular transmission, hypocalcemia produces neuromuscular irritability, which is first manifested by paresthesias, or a sensation of numbness and tingling circumorally (around the lips) and in the fingertips and toes. The other options pertain to symptoms of hypercalcemia. Fosamax must be administered on an empty stomach with a full glass of water to ensure proper absorption. Presence of food, juices, or other medications will interfere with adequate absorption. All of the other options would be inappropriate. Primary hyperparathyroidism is the most common cause of hypercalcemia in the general population. There is excessive secretion of PTH by one or more of the parathyroid glands. Excess thyroid-stimulating hormone (TSH), not PTH, is associated with a hypoactive thyroid gland. Metastasis rarely produces excessive PTH. Sarcoidosis is associated with unregulated conversion of activated vitamin D. Citrate binds with calcium, decreasing ionized calcium levels. Acidosis leads to decreased binding of calcium, thereby increasing the calcium level. Options 1 and 4 are incorrect because blood transfusion therapy would not warrant the clinical usage of rapid infusion of crystalloids, and hypomagnesemia is not a related consequence of blood therapy. Pancreatitis causes hypocalcemia because by-products released from the inflamed pancreas chelate calcium. Numbness and tingling around the mouth and extremities are characteristics of tetany from hypocalcemia. All of the other options do not relate to this finding. Due to the inverse relationship between calcium and phosphorus, one would expect low phosphorus when the calcium is elevated. In most cases, when there are elevated total serum calcium and ionized calcium levels, then hyperparathyroidism needs to be considered. In this case, the alkaline phosphatase and PTH would also be elevated. Potassium is often low in cases of hypocalcemia. A client in renal failure exhibits hypocalcemia in the presence of increased phosphate, potassium, and creatinine levels. Option 1 is incorrect because due to the inverse relationship between calcium and phosphorus, one would expect to see decreased calcium levels and increased phosphate levels in renal failure. Option 3 is incorrect, as potassium levels would be increased in renal failure. Option 4 is incorrect, as creatinine levels would be increased as renal function deteriorates. The client with a conversion disorder is characteristically indifferent to the symptoms (<i>la belle indifference</i>) rather than being depressed, anxious, or blunted in affect. In chronic hypocalcemia from dietary deficiencies, oral calcium and vitamin D supplements may be all that is needed. Calcitriol has a more rapid onset and more rapid clearance from the body and is especially useful in renal failure. Option 1 is incorrect as glucocorticoids increase absorption of calcium in the intestines as well as increase calcium excretion, worsening the hypocalcemia. Option 2 is incorrect because aluminum preparations should not be used due to aluminum accumulation in the bone, resulting in osteomalacia. Option 4 is incorrect because bisphosphonate therapy is used to treat hypercalcemia and osteoporosis. A common cause of hypocalcemia after parathyroidectomy is lack of blood supply to the remaining parathyroid gland, with a resultant decreased PTH level. To prevent complications and to indicate that goals for this client have been met, the calcium and PTH levels must be closely monitored. The serum creatinine and magnesium are important laboratory levels to monitor but are not the priority. Option 3 is incorrect, as calcitriol is the activated form of vitamin D. Hypocalcemia becomes symptomatic when ionized calcium levels fall below normal, which this laboratory value indicates. The astute nurse is aware that seizures are signs of hypocalcemia and anticipates complications. All of the other options are pertinent to hypercalcemia. Furosemide (Lasix) is a loop diuretic that promotes potassium excretion. A weak pulse is seen in clients with hypokalemia and could be attributed to the effects of Lasix administration. It could also be due to excessive diuresis of sodium and water. Decreased neck vein distention and decreased adventitious breath sounds are suggestive of fluid volume reduction and would be beneficial in a client with heart failure. A BP of 120/78 is within the normal range. Hypokalemia can result from corticosteroid use. Hypokalemia causes cardiac problems that are manifested on an ECG as flattened T waves, depressed ST segments, and prominent U waves. Peaked T waves and prolonged, depressed ST segments are seen in clients with hyperkalemia. DKA leads to an increase in the loss of potassium due to diuresis, and insulin leads to potassium being shifted into intracellular fluid. Administration of insulin to a client with DKA causes transcellular shifting that promotes potassium uptake back into the cell. This action may result in hypokalemia. Low calcium is seen with alkalosis, not acidosis. Hyponatremia is usually seen in clients with DKA. A client who is on long-term diuretic therapy is more likely to suffer effects of potassium depletion. Tetany is associated with low levels of calcium (hypocalcemia), which can accompany hypokalemia. Respiratory depression is not associated with use of this medication. Nausea and vomiting are nonspecific complaints not directly associated with loop diuretic therapy. Diabetes is not related to Lasix administration, although the use of this loop diuretic can cause the client to become hyperglycemic. Hypokalemia causes decreased gastrointestinal motility, which can lead to constipation. Hypokalemia does not promote fluid loss in the gastrointestinal (GI) tract. The effect of potassium in the GI tract is on the smooth muscle with imbalances causing hyper- or hypomotility. Large doses of penicillin, aminoglycosides, and glucocorticoids can lead to hypokalemia. ASA, Tylenol, and antibiotics are not associated with hypokalemia. It is important for the nurse to be aware of potential drug effects on serum electrolyte levels in order to participate effectively in the client's plan of care. A client receiving continuous IV therapy containing KCl may become hyperkalemic and require immediate action. All of the other options reflect a hypokalemic state. While it is important to monitor response to treatment and notify the physician, the priority information would be to notify the physician that the client has dyspnea and specific ECG changes that are suggestive of hyperkalemia. Exploration of the client’s decision is nonjudgmental and affirms the client’s personal power. This reponse also helps the client understand connections in her own decision-making process. KCl is never administered as an IM injection or as an IV push medication. These methods could cause development of potentially lethal cardiac arrhythmias. KCl should be diluted in the correct amount of IV solution and administered via an infusion pump. Monitoring output is an expectation of any IV therapy. The client with hypokalemia may develop muscle weakness and therefore require assistance with ambulation. Monitoring ECG for changes does not directly relate to injury potential related to general weakness. Medication and dietary interventions may be necessary to restore normal serum levels but do not directly relate to injury potential. Potassium (K<sup>+</sup>) in the extracellular fluid (ECF) is responsible for conducting nerve impulses, which contribute to cardiac rate and rhythm. The amount of potassium in the ECF is actually a very small amount, explaining why even minor changes can have a major impact on the body. While K<sup>+</sup> is an important electrolyte in the body, it does not increase the metabolic rate of tissues in the body. K<sup>+</sup> levels are not the regulators of salt and fluid retention. The body relies on a balanced level of electrolytes, and K<sup>+</sup> is just one element in the body's ability to maintain homeostasis. A TURP procedure can place a client at risk for developing hyponatremia in the postoperative period due to increased fluid irrigation used during treatment. Clients with a TURP procedure have a continuous bladder irrigation (CBI) as a routine part of their postoperative care. The other options do not place a client at risk for the development of sodium imbalances, as they do not require lengthy fluid and dietary restrictions or excessive fluid irrigation. Hyponatremia can also be referred to as dilutional hyponatremia or water intoxication. Water restriction would be an important part of the treatment plan when caring for a client who has hyponatremia. The restriction of Gatorade (electrolyte-rich solution), eggs, cheese products, and salt on the diet tray is not indicated because the client is experiencing a sodium deficit. Clients with hypernatremia are thirsty and need water replacement to balance the increased sodium levels. Cough medication and lactulose can further increase sodium levels and should not be administered unless there is sufficient clinical information to warrant their use. Three percent saline is a hypertonic solution that would also increase serum sodium levels and should not be given to this client. Pork contains high amounts of sodium. Clients with CHF are prone to hypervolemic hypernatremia and should decrease their salt intake. The other options list foods containing relatively small amounts of sodium that could easily be incorporated into the client's diet. Blood pressure, intake and output, and skin turgor are physical parameters the nurse would consider when monitoring fluid and electrolyte balance in a client who has experienced prior sodium imbalances. Options 3 and 5 would not be necessary for a routine fluid and electrolyte evaluation. When hyponatremia is severe, hypertonic IV solutions may be used as part of the treatment plan. Three percent saline is an example of a hypertonic solution. In SIADH, hypotonic and isotonic solutions are not indicated because urine output is minimal and water is retained (options l and 3). Option 4 is also incorrect because D<sub>5</sub>W is not an isotonic solution, but rather a hypotonic solution. It is important to know not only the correct type of solution indicated but also the types of solutions that fall under each category. Weight loss of more than 0.5 pound in 24 hours is considered to be due to fluid loss. A weight loss of 0.25 pound is not significant enough to be considered fluid loss. Although 1 pound and 1 kilogram may indeed reflect a significant fluid loss, these are greater than the minimum level that denotes a fluid loss. When stressors and anxiety are decreased, there remains no need for conversion symptoms, and normal function resumes. Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration, thus an increase in sodium intake is part of the treatment. Decreased sodium intake will result in an even lower sodium level, because hypotonic FVE is associated with low sodium. Fluids are restricted, and an intake of potassium-rich foods is not related to the treatment of hypotonic FVE. The client's clinical presentation suggests that hyponatremia is occurring (tachycardia, hypotension, and dry skin/membranes). Obtaining information relative to intake and output can help to identify potential/actual fluid losses and possibly identify the etiology of the sodium deficit. It will also give vital information relative to the hydration status of the individual. While the other options should be addressed, they are not the priority at the present time unless there is an acute presentation. It is vital to notify the physician with a laboratory value that is critical. A sodium level of 175 mEq/L requires immediate medical attention and intervention. Option 1 is incorrect as a hypertonic solution is not indicated in the treatment of hypernatremia. Option 2 is incorrect because the TPN may be causing the client to experience hypernatremia as a source of salt excess/concentrated hypertonic solution. Option 3 may be indicated at a later date, but it is not a priority at the present time. Prompt recognition and treatment with appropriate fluids (free water, NS, or D<sub>5</sub>W, depending on the client's volume status) should be instituted per protocol. Remember that cerebral cells are adaptive to different sodium levels and that rapid correction can lead to further complications. Mental status changes and concentrated urine are common signs of dehydration or FVD in the elderly. Clear lung sounds with unlabored breathing and hand veins that fill within 3 to 5 seconds are normal findings. Tenting and dry, flaky skin are consistent changes seen with normal aging. D<sub>5</sub>W has a hypotonic effect when infused intravenously, providing free water to cells after glucose is metabolized. Ice chips contain no solute and also provide free water through the GI tract. This client has received an excess of free water without electrolytes and thus is at risk for hypotonic overhydration (water intoxication). The client is not experiencing deficit or dehydration. A history of heart failure increases risk for fluid volume excess and pulmonary edema. The priority is to detect signs of pulmonary edema by monitoring for adventitious lung sounds (auscultation for moist crackles). The other options provide useful information, but are not the priority. Postural hypotension, a greater than 10 mmHg drop in systolic BP after rising from lying to standing, is a sign of decreased circulating blood volume. Elevated temperature is associated with fluid volume deficit. Falling pulse oximetry readings indicate a problem with oxygen delivery from the lungs to the blood, which occurs with pulmonary edema, not fluid volume deficit. The presence of S<sub>3</sub> heart sounds in an adult is indicative of venous congestion and fluid overload. Options 1, 2, and 3 are indicated to maximize compliance with fluid restriction. Ice chips are a source of fluid intake but, if taken in unlimited amounts, they can easily contribute to excess fluid intake. Fluids taken with medications must be included with measurements of intake and output. High serum glucose increases blood osmolality, causing water to be pulled from the cells into the vessels. The excess fluid volume in the vessels is then excreted by the kidneys, resulting in hypertonic dehydration of the cells and its associated symptoms. Monitoring for low urine output (number of wet diapers) helps determine how severe the child's fluid losses are. Dietary intake (including solids and fluid) is important in maintaining fluid balance, but the greatest concern is to focus on urinary output as a measure of volume status. Although an elevated temperature can affect fluid balance by increasing basal metabolic rate, it is not the most accurate determinant of fluid status at the present time. Verbal communication should be clear, concise, and unhurried. Shouting may be interpreted as anger; therefore, a pleasant, calm, supportive tone of voice should be used. The use of sign language or mostly nonverbal gestures would be frustrating to the client who may not understand what is being said. Infants and the elderly are the age groups at greatest risk for FVD, in part because they cannot compensate for fluid losses as easily as older children and younger adults can. The 2-month-old is losing fluid from vomiting and cannot compensate. Arthritis does not directly increase the risk for FVD. Adults usually handle fluid changes efficiently unless there are prolonged symptoms and/or underlying disease processes. Fluid gains cause acute weight gain, which should be explored with clients taking diuretics. Missing doses can lead to fluid gain, or the dosage may need to be adjusted if the heart failure is worsening. A change in eating habits would not cause such rapid weight gain. Options 2 and 4 are inappropriate remarks. Edema that is still present after lying down all night is more likely to be of cardiac origin. Local edema is caused by local obstruction or poor lymph flow (sitting, standing, lymph node removal). Dependent edema is more reflective of localized obstruction or valvular incompetence. Phosphorus is a critical mineral in the development of teeth and bones. It also plays a role in acid-base balance, and it assists in regulating calcium, not potassium, levels. Phosphorus is found in the cell membranes as phospholipids and is essential in the metabolism of carbohydrates, fats, and proteins. The kidneys are responsible for 90% of phosphate excretion to maintain normal phosphate balance. Impaired renal function usually results in decreased phosphorus excretion. The other options are incorrect. Hypophosphatemia causes platelet destruction and dysfunction from lack of adenosine triphosphate (ATP). Myocardial contractility is decreased leading to shock (option 1); muscles are weakened leading to respiratory failure (option 2); and granulomatous activity is depressed leading to signs of infection (option 3). The level reflects hyperphosphatemia, and there is a reciprocal relationship between phosphorus and calcium. Because the symptoms of hypocalcemia are often most prominent, the client should be monitored for signs of tetany. The other options are associated with hypophosphatemia. Acute renal failure impairs the ability to excrete phosphorus normally, because the kidneys are the major organs for excretion of phosphorus. Asthma, pituitary tumor, and peripheral vascular disease are incorrect. Eggs are high in phosphorus content, as are dairy products, poultry, organ meats, red meat, legumes, and whole grains. For this reason they should be limited in the diet when hyperphosphatemia is present. Orange juice, white bread toast, and pancakes have less phosphorus content. A client who has had thyroidectomy may accidentally have removal of all or part of the parathyroid gland, which regulates calcium level. If the client becomes hypocalcemic, then serum phosphorus levels will rise. A client who has had tonsillectomy, total knee replacement, or open reduction of a fracture would not require monitoring for hyperphosphatemia. The most important area of concern identified by both family and staff is the safety of clients with dementia. The risk for injury is always present in clients with dementia, and as the disease progresses, the need for a safe and secure environment increases. The other options are appropriate for dementia but are not the first priority. A client who has had hypercalcemia is at risk for hypophosphatemia, because calcium and phosphorus have an inverse relationship in the body. The normal value range is 2.5–4.5 mEq/L, making option 1 the value that is below the normal range. Muscle spasms and tetany accompany hyperphosphatemia because of the corresponding drop in serum calcium level. Profound muscle weakness, malaise, and muscle pain and tenderness are signs of hypophosphatemia. Rhabdomyolysis is the breakdown of striated muscle, which causes large amounts of phosphorus to enter the bloodstream. Options 1, 3, and 4 place the client at risk for hypophosphatemia. Use of drugs such as chlorothiazide diuretics can lead to hypochloremia, a decrease in serum chloride, because the client is losing chloride in the urine. Options 1 and 2 indicate increased serum electrolyte levels that would not occur with the use of this class of diuretic drug. Option 4 is incorrect because thiazide diuretics cause retention of calcium by increasing the action of parathyroid hormone on the kidneys, and therefore hypercalcemia would be expected. Bromides may cause a false elevation of chloride levels. The client's serum sodium level is at the high end of normal range and, therefore, given the client's history, a repeat lab draw would be indicated. All of the other options are not warranted, given the client's history of bromide ingestion. It is important for the client to know which foods and other dietary items are high in chloride, such as table salt. All of the other options are inappropriate because they will decrease serum chloride levels. Hemodilution of body fluids can decrease the serum chloride level. Options 1 and 4 are incorrect because both increased adrenocortical hormones and bottled sports drinks will increase serum chloride levels. Option 2 is incorrect because increased environmental temperature causes perspiration and loss of fluids. Chloride loss occurs with oozing at the burn surface. Option 1 is incorrect because sodium is lost with body fluids, causing hyponatremia. Option 2 is incorrect because calcium is lost in the edematous fluid. Option 3 is incorrect because potassium leaves the cells as sodium shifts into the cells, causing hyperkalemia. Large doses or prolonged use of oral cortisone therapy increases serum chloride and sodium levels and decreases magnesium and potassium levels. The nurse should be aware that the client is exhibiting symptoms of hyperchloremia due to a fluid deficit. A hypotonic solution should be administered to increase the extracellular fluid (ECF) and decrease the serum osmolality. All of the other options would not be indicated because they are high in saline and chloride and could cause the client to develop further fluid and electrolyte complications. Alzheimer’s disease is diagnosed by ruling out causes for the client’s symptoms. The only definitive method of diagnosis is postmortem examination of brain tissue. The client with bulimia often purges or uses excessive laxatives, resulting in the loss of sodium, chloride, and potassium. Excessive water intake can lead to dilutional hyponatremia and hypochloremia. All of the other foods and fluids would provide needed salt and chloride. Fruit has the lowest amount of chloride and is an appropriate item for intake as part of a low chloride diet. Rye, seaweed, and canned vegetables are incorrect because they are all high in chloride. Compliance with medication administration schedule will influence effectiveness of the medication. Diuretics should reduce chloride levels if taken appropriately. Further data collection is needed prior to intervention. Option 1 is incorrect because merely drawing another blood sample would provide no additional information at this point in time. There is no reason to suspect that there has been a laboratory error or that the initial result is inconclusive. Options 3 and 4 are also incorrect because there is not enough information to warrant the change of diuretic therapy or the referral to a specialist at this point in time. Dairy products are naturally high in phosphorus. Although many food sources contain phosphorus, the greatest amounts are found in red and organ meats, fish, poultry, eggs, dairy products, nuts, whole grains, and legumes. Carbonated soft drinks are also high in phosphorus, although they are low in nutrient value. An apple, lemonade, and white bread are not high in phosphorus. Children have higher phosphate levels than adults because of their more rapid bone development rate. Options 1, 3, and 4 are incorrect. Serum phosphate levels vary throughout the day. Replacement therapy would result in an increase in phosphorus level. A venous, not arterial, sample is taken. A plasma level of 1.7 mg/dL reflects hypophosphatemia. Because phosphorus is needed for formation of the red blood cell enzyme 2,3-DPG, deficiency states can lead to anemia, which would be reflected by the low hemoglobin level. The other options are incorrect. Platelets may also be decreased. Calcium and phosphorus have a reciprocal relationship, and therefore calcium would be elevated. Magnesium would be decreased. Clients in diabetic ketoacidosis lose excessive amounts of phosphate in the urine. Clients with first-degree burns do not experience severe fluid shifts that affect phosphorus levels. Hypomagnesemia can result in renal excretion of phosphorus. Decreased urine output results in less renal filtration of phosphorus. Although phosphorus is found in a large number of food items, it is found in greatest quantities in red and organ meats, fish, poultry, eggs, milk and milk products, legumes, whole grains, and nuts. The other options identify foods that have lesser amounts of phosphorus. TPN is a concentrated glucose and protein solution that utilizes phosphorus in metabolism of the nutrients and produces a shift of phosphorus into the cells, thus causing a serum phosphorus deficit. Options 1, 2, and 4 are incorrect. These electrolytes may also be decreased in the refeeding syndrome. Poor nutritional intake, vomiting, diarrhea, and overuse of antacids are related to alcoholism and alcohol abuse. These can lead to hypophosphatemia. During oliguria, the kidneys are unable to excrete phosphorus. Clients with prolonged (not short-term) gastric suction are more likely to experience hypophosphatemia. Prolonged or continuous use of aluminum-containing antacids (not occasional use) leads to hypophosphatemia. Cognitive function will be supported by participation in meaningful activities that the client enjoys. Stimulating activities will also promote self-esteem and encourage the client to attain the highest level of cognitive function possible. Options 2, 3, and 4 could lead to frustration and more confusion. The client has hyperphosphatemia, because the normal phosphate level is 2.5–4.5 mg/dL. Calcium and phosphorus have an inverse relationship in the body. For this reason, when phosphorus levels are high, then calcium levels are low. The other options do not address this relationship. In clients with hyperphosphatemia (normal 2.5–4.5 mg/dL) from use of cytotoxic drugs, allopurinol (Zyloprim) may be ordered to decrease uric acid production, which prevents the formation of uric acid calculi in the kidney and uric acid nephropathy. Aluminum hydroxide (Amphogel) is an antacid that would be useful in binding phosphates (option 1); acetazolamide is a diuretic (option 3); and hydralazine (option 4) is an antihypertensive. Food additives do tend to be high in phosphates. For this reason, clients should be taught to read food labels carefully. Vitamin D, not vitamin A, will enhance phosphorus absorption. Aluminum-containing antacids decrease phosphorus absorption by binding to it. Soy-based foods are low in phosphorus. Newborn levels of phosphorus are nearly twice those of an adult. Phosphate levels vary throughout the day. Normal adult serum phosphate levels in the adult range from 2.5 to 4.5 mg/dL, and newborn levels range from about 4.0 to 7.0 mg/dL. Phosphorus is the second most abundant mineral in the body. A decrease in phosphorus depletes available adenosintriphosphate (ATP) needed for cellular energy production, which will be manifested in the client as fatigue and muscle weakness. Option 2 is incorrect; the kidneys try to reabsorb phosphorus in order to conserve it when levels are low. Option 3 is incorrect; bowel sounds and motility are already decreased with low phosphorus levels. Option 4 is incorrect; the rate and depth of breathing are already increased in response to hypoxemia experienced with hypophosphatemia. Phytate (found in bran and whole grains) and oxalate (in spinach and rhubarb) can interfere with absorption of phosphate by binding with it in the intestines. Milk, orange juice, and chicken do not pose this problem for absorption of phosphate. Severe vomiting and diarrhea deplete the body’s stores of many electrolytes, including phosphorus. Prolonged use of aluminum- and magnesium-containing antacids that bind to phosphorus is a condition leading to hypophosphatemia. Balanced TPN solutions contain adequate levels of phosphorus. Vitamin D deficiencies lead to decreased intestinal absorption of phosphorus. Hypophosphatemia results in decreased ATP production, decreasing enzyme levels of 2,3-DPG, which in turn keeps oxygen bound to hemoglobin and less available to the tissues. Clients with hypophosphatemia will experience hypoactive bowel sounds, muscle weakness, and paresthesias and anemia due to RBC fragility from low ATP levels. Hypophosphatemia leads to a decline in 2,3-DPG levels, reducing the release of oxygen to the tissues. Clients are more likely to have complaints of apprehension than euphoria. Decreased gastric motility leads to anorexia in the hypophosphatemic client. In order to maximize binding of the phosphate, phosphate binders should be given with the meal or shortly after in order for the medication to have contact with the phosphate in the food. Options 1, 2, and 4 are incorrect. The primary responsibility of the nurse is client safety. Removing a client from danger should be the priority. Others can come to help contain or extinguish the fire. Positive symptoms of schizophrenia are those behaviors that a client would not usually exhibit in everyday life, including delusion of being a king (option 2) or echolalia (option 3). Negative symptoms of schizophrenia are those that reflect the absence of what is normally seen in a person’s behavior. These would include energy (option 1), flat affect (option 4), and social withdrawal (option 5). Chronic renal failure impairs the ability to excrete phosphorus normally, because the kidneys are the major organs for excretion of phosphorus. The other options are incorrect. Red meat is high in phosphorus content, along with dairy products, eggs, poultry, organ meats, legumes, and whole grains. For this reason, it should be limited in the diet when hyperphosphatemia is present. Pork chops, white rice, and green peas have less phosphorus content. Enemas can be high in phosphorus, thus making the client at risk for hyperphosphatemia if they are frequently used. Cough preparations, cold preparations, and bedtime sleeping aids do not necessarily contain large amounts of phosphorus. Glucocorticoids cause retention of chloride and sodium, leading to fluid retention. All of the other options, such as decreasing diuretic intake, eating more vegetables, and eating foods such as spinach and celery (high in chloride content), will increase the serum chloride level. Increased use of sodium bicarbonate causes excretion of chloride or hypochloremia; therefore, it would be appropriate to have serum chloride levels monitored for potential deficits. Option 1 is incorrect because D<sub>5</sub>W infusion is hypotonic and will cause further fluid shifting and more potential electrolyte imbalances, given the high rate. This will decrease chloride levels if administered over a prolonged time. Option 3 is incorrect because a magnesium value will not give any additional information and is, therefore, unnecessary. Option 4 is incorrect, because diuretics will decrease chloride levels. When serum osmolality is > 295 mOsm/kg, there are more sodium and chloride ions in proportion to water. Therefore, a higher serum chloride level would be expected. In a client who has Cushing’s syndrome, one would expect to see elevated serum chloride and sodium levels, a decreased potassium level, and an elevated urinary chloride level. Options 2, 3, and 4 are inconsistent with the clinical presentation of Cushing’s syndrome. It is important for accurate results that the blood sample not be hemolyzed. A tourniquet can potentially cause turbulence in blood flow and alter results by hemolyzing erythrocytes. If possible, blood should be drawn without the use of a tourniquet. Option 1 is incorrect because drawing blood from an implanted port used for chemotherapy is not recommended procedure. Option 2 is incorrect because the action of clenching and unclenching the fist can lead to hemolysis of RBCs and cause altered test results. The client does not need to be NPO prior to drawing any electrolyte sample. In CHF, chloride is increased, and the administration of hypertonic saline may cause a lethal hypervolemia. In addition, mechanisms for excreting sodium, chloride, and water are compromised in CHF, causing significant fluid and electrolyte alterations if such a therapy were to be utilized. The clients in options 1 and 2 would benefit from administration of a hypertonic solution in a closely monitored situation. Option 4 is incorrect because a client diagnosed with alkalosis would benefit from administration of a hypertonic solution, because the client would most likely be experiencing chloride and sodium deficits. The clinical symptoms noted above (weakness, lethargy, and fatigue) are associated with hyperchloremia. Option 1 is incorrect because the symptoms related to chloride deficiency can be reversed with clinical treatment that restores serum chloride levels to normal. Option 2 is incorrect because there is no correlation between exercise and increase in serum chloride level. It is likely that increased exercise would lead to a chloride deficiency through sweat and perspiration losses. Option 3 is incorrect, because merely increasing salt intake will not automatically increase serum chloride levels. With severe chloride and ECF losses, the blood pressure drops, potentially leading to shock if not corrected. The nurse should place the highest priority on monitoring the client to prevent development of potential complications and to maintain client safety. Although it may be necessary to assist the client to the restroom, this is not the priority intervention. If there is sufficient ECF loss, then the client would more likely be too weak to ambulate, and bed rest would be indicated. Option 3 is incorrect because starting IV therapy with a hypotonic solution may further exacerbate the client’s clinical condition. Although it would be important to monitor the client’s pulse, this again is not the priority intervention at this point in time. The problem with thoughts of using is keeping them a secret. When keeping things secret, the client is not telling the whole truth and is manipulating something. Engaging in secrets is reminiscent of using behaviors and can trigger using behaviors. It is natural to feel sad (option 2), hungry, or tired (option 3), and to have thoughts of using (option 1). Neurological alteration related to chloride imbalance includes tremors and twitching of the muscles with hypochloremia or weakness and lethargy with hyperchloremia. These manifestations place the client at risk for injury. Options 1, 2, and 4 may be potential diagnoses, but more data would be needed to determine the priorities. Documenting the history can assist in determining the cause of the elevated chloride level. This should occur, if possible, prior to intervention. Option 1 is incorrect because isolation is not indicated for hyperchloremia. Option 3 is incorrect because ambulating independently without evaluation is unsafe as the client will probably have weakness and lethargy. Option 4 is incorrect because infusing saline is an unsafe intervention that would lead to increased chloride levels. Foods high in chloride include bananas and dates, green leafy vegetables, seafood, poultry, and dairy products. Canned soups tend to be higher in sodium, and chloride is combined with sodium as salt. Apples, beef, and pasta are not high in chloride. Infants and the elderly cannot compensate as well for fluid losses. Clients with NG suction (loss of fluids and electrolytes in fairly proportional amounts) are at greater risk for fluid volume deficit. The elderly client with NG suction has both risk factors, while the child’s age is the only risk factor. The client taking glucocorticoids is predisposed to sodium and fluid retention rather than fluid loss. The 30-year-old jogger is a young adult in a moderate climate, which lowers the risk from exertion alone. Items that are liquid at body temperature are also considered part of the fluid intake, so ice pops, gelatin, and ice cream can be considered part of overall fluid intake. The color of urine is only one indicator of hydration, and many elderly people take a diuretic, which would produce more dilute urine, falsely reassuring the client. Fluid intake does not need to be solely water. With aging, the thirst mechanism becomes less effective. Significant fluid can be lost before thirst is triggered, so the elderly should not rely solely on thirst to indicate when they need to drink fluids. The client has symptoms of fluid volume deficit (FVD) and hypovolemia. The presence of postural hypotension when rising from a lying position indicates the presence of significant hypovolemia. The other vital signs are important for general reasons but do not directly reflect circulating fluid volume. Neck veins are normally flat when head of bed is elevated due to gravity. Dyspnea with exertion is often a sign of fluid in the alveoli. Pitting edema reflects fluid in the interstitial spaces. Hand veins would remain full or empty slowly if excess fluid volume (EFV) were present. Peripheral pulses would be bounding with an EFV. Normal saline (0.9% NaCl) is an isotonic fluid that prevents fluid shifts into or out of the GI tract. Option 1 (3% saline) is hypertonic and could pull water from the GI tract, resulting in water loss. D<sub>5</sub>W and sterile water are hypotonic and could be pulled into GI tissue as well as wash electrolytes from the GI tract, resulting in water intoxication. A moist cough, dyspnea, and falling pulse oximetry reading in a client with a history of heart disease are signs of developing pulmonary edema secondary to excess fluid volume (EFV). The first action should be to reduce IV fluid intake to prevent more fluid from accumulating in the lungs. Then further examination can be done, emergency actions taken, and the physician contacted. Option 2 provides accurate information in simple terms without unduly alarming the client. Option 1 offers no explanation to facilitate understanding. Option 3 assigns the client blame for the current condition without providing a clear explanation for the fluid restriction. Option 4 is technically correct but is stated in an abrupt and alarming manner. Checking on the compliance of a family member is an example of codependent behavior. The nurse would focus the teaching on helping the mother detach from her son and his recovery program and focus on her own well-being. Options 3 and 4 would indicate that she is trying to identify and deal with her feelings. Option 2 is an obvious healthy behavior. An excess response to diuretic therapy results in an excess loss of water and electrolytes in the urine, leaving the blood hemoconcentrated, and causes a high BUN (normal 8–22 mg/dL) and Hct (normal approx. 38–45%). The water loss results in an acute weight loss. In option 3, the BUN is normal and the Hct is lower than normal. Weight gain (options 2 and 4) indicates ineffective response to diuretic therapy. NS (0.225% sodium chloride) is a hypotonic solution that provides free water to the cells. Cerebral cells are especially sensitive to fluid gains from hypotonic fluids. If infused too rapidly, the cerebral cells will be the first to gain fluid too quickly, resulting in neurological changes. Monitoring the client for urine output, edema, and oral cavity dryness are important, but this reflects a response to IV therapy rather than detection of a complication. Three percent saline is very hypertonic and, if infused too rapidly, will increase serum sodium and osmolality, causing high volumes of water to be pulled into vessels from cells. This results in cellular dehydration and vascular volume overload. Neurological status, lung function, and serum sodium levels should be closely monitored. Although daily weights are important, they do not provide information leading to early detection of complications of therapy. Vital signs, serum glucose levels, urine specific gravity, oxygen saturation, and peripheral edema provide later indications of complications of therapy. This client presented with deficient fluid volume because of dehydration. Older adults have less cardiac and renal reserve to compensate for acute fluid imbalances and thus are more susceptible to overcorrection when being treated for them. JVD, tachypnea, cough, and dyspnea indicate that this client has received too much IV fluid at too rapid a rate. Older adult clients cannot tolerate rapid rehydration due to decreased cardiac and renal function. Options 1, 3, and 4 are incorrect. Processed and canned foods (bologna, soup, tomato juice), sodas, and pickled foods are high in sodium. Fresh foods (grilled chicken, fruit, vegetables) are lower in sodium. Acute bleeding results in isotonic fluid loss and can quickly lead to shock and vascular collapse. The priority is to expand vascular volume and restore circulation using isotonic IV fluid. Hypertonic (3% saline) and hypotonic (D<sub>5</sub>W, D5GNS) solutions are not indicated. The failing liver does not make enough albumin to keep capillary oncotic pressure at normal levels. Thus excess fluid is lost from vessels into the peritoneum, causing ascites and vascular fluid volume deficit. Orthostatic hypotension, weak peripheral pulses, and delayed hand vein filling are all signs of low circulating fluid volume. There is no excess fluid volume. Options 3 and 4 are incorrect because the cause is not hormonal. The 76-year-old client has more risk factors than the other clients. This client is elderly, losing fluids via the NG tube as well as being NPO, and is postoperative of major surgery. Clients taking steroids usually retain sodium and water. Repair of an inguinal hernia is not a major surgery, and the client is likely to recover quickly and be able to resume fluid intake. Following a sigmoidoscopy, fluids will be resumed. Five percent dextrose in water (D<sub>5</sub>W) has a hypotonic effect when infused, providing free water to cells, which would worsen this client’s cerebral edema. The other options are isotonic and would remain primarily in the extracellular spaces. Hemoglobin and hematocrit can decrease or increase secondary to hemoconcentration or hemodilution. ANP is a cardiac hormone released when atria are stretched by increased blood volume, which would occur in CHF. Glucose and liver enzymes would not be affected by fluid volume. There are three communication rules learned in families in which addiction is present: Don’t talk, don’t trust, don’t feel. While these experiences cause anger, anxiety, or maladaptive coping, they can also contribute to the development of shame, depression, and low self-esteem. Without family healing, these problems can create much pain and suffering for all involved. S3 heart sounds and moist lung crackles are signs associated with fluid overload, not deficit. Because they are resolving, the client is returning to normal status, but has not yet reached complete balance. Option 2 indicates full resolution of fluid balance and is therefore incorrect. Options 3 and 4 show resolving signs of fluid volume deficit and dehydration, not of excess fluid volume. Diabetes insipidus (DI) is a condition caused by insufficient production and/or release of ADH. Inadequate ADH leads to increased excretion of dilute urine. Excessive production of ADH, known as SIADH, leads to fluid retention and excess fluid volume. Changes in glucose levels and insulin production are associated with diabetes mellitus. Commercial oral rehydration fluids, such as Pedialyte or Rehydralyte, are balanced water, carbohydrate, and electrolyte solutions that replace both fluids and electrolytes lost in diarrhea. They also do not have a high osmolality, caffeine, or excess sodium, which can all worsen diarrhea and fluid loss. Replacing diarrhea losses with only water could lead to electrolyte imbalances. Fruit juice and sports drinks are too high in sugar, which can worsen diarrhea and fluid loss. Solid foods, including the BRAT diet, are not appropriate while the client is vomiting. DI is characterized by a decrease in ADH secretion, resulting in loss of fluids through polyuria; polyuria in turn leads to increased thirst. Options 1, 3, and 4 are not characteristic of DI. Too rapid a correction of hypernatremia can lead to changes in vascular tone, which can affect vessels and cause increased fluid entry into the brain, thereby causing cerebral edema. Cellular dehydration is caused by hypernatremia. Options 3 and 4 are not viewed as risks when treating hypernatremia. This client has signs and symptoms of hypernatremia, and the serum sodium level would be greater than 145 mEq/L. Options 1 and 2 reflect decreased serum sodium levels and are considered to be hyponatremic. Option 3 reflects a normal serum sodium level. Near drowning in salt water often results in hypernatremia due to the high sodium level in sea/salt water. Hyponatremia and disturbances in calcium levels are not seen in this clinical situation. In hyponatremia, water is already present in an excessive amount compared to the amount of sodium present. This can result in water intoxication or dilutional hyponatremia; therefore, water restriction is a primary cornerstone of therapy. The other electrolytes (sodium, potassium, and chloride) should not be restricted but rather should be included in the treatment plan so as to prevent further electrolyte imbalances from occurring. Thirst is a primary indicator of sodium excess (hypernatremia) and should be monitored for in a plan of care for a client with hypernatremia. Muscle weakness is not reflective of hypernatremia but is more likely to be found with sodium deficit. Moist mucous membranes are not associated with sodium imbalances and reflect a normal parameter. An elevated temperature would be expected with hypernatremia. In SIADH, the antidiuretic hormone is present in excess amounts. This causes excessive water reabsorption. Water must be restricted to avoid water intoxication. Giving additional fluids would serve only to increase fluid levels and increase sodium deficit further. While it is important to consider a client’s preference in fluid selection, fluid restriction is the major priority. Administering fluids via the intravenous route only is not the preferred method. Although fluid therapy can be given IV, it is important to allow the client to take PO fluids even if they are given on a restricted basis. The client most likely has used one of the “club drugs” or “rave drugs,” these drugs most often are a cross between a stimulant and a hallucinogen. Such drugs are used at dance parties and, along with black lighting or strobe lights, create a surreal experience. The stimulant effect of the drug causes users to grind their teeth. To avoid this, teens often use pacifiers to suck on. The combination of drug, dancing, and dehydration lead to dangerous body temperature increases, which must be addressed immediately. This client may also have an eating disorder, but that would not be the nurse’s primary concern (option 2). Options 1 and 4 are incorrect. The client has exhibited behavior that could indicate a sodium and water imbalance and is actually exhibiting signs of hyponatremia. The nurse would check the electrolyte levels, expecting to find a low sodium level. Monitoring the CBC for a platelet level is not indicated, as there is no correlation between sodium levels and platelet activity. The client’s serum osmolality and urine specific gravity are expected to be low due to water intoxication. The client is exhibiting signs of hypernatremia and dehydration. The most appropriate nursing intervention is to measure and record intake and output and daily weight. Administering salt tablets would further contribute to the client’s hypernatremic state. Withholding feedings and restricting fluid intake could further contribute to the client’s state of hypernatremia with fluid volume deficit (hypertonic dehydration) as the client already has extensive fluid loss due to diarrhea, decreased skin turgor, and elevated pulse rate. Fluid retention can result in hyponatremia through dilutional effect. Options 1 and 2 could lead to hypernatremia. Option 4 would lead to hypernatremia. The combination of high fever and severe dehydration leads to insensible water loss. This indicates a loss of pure water and does not contain electrolytes. Therefore, excessive amounts of insensible water loss result in a hypertonic dehydration, which leads to a state of hypernatremia and hyperchloremia. Calcium levels usually decrease in the presence of dehydration and fever. Phosphate levels usually increase in the presence of dehydration and fever. Potassium levels can usually remain normal in the serum and are increased in the urine. The use of can lead to the development of hypernatremia because corticosteroids cause sodium to be retained and potassium to be excreted. The elderly client drinking 8 glasses of water each day is within a normal range of fluid intake and is not at risk for developing sodium imbalances. The diabetic client whose blood glucose is within normal range is not at risk for developing sodium imbalances. The teenager who is using Gatorade as an oral replacement therapy to compensate for fluid and electrolyte loss during exercise is not at risk for developing sodium imbalances. The thirst mechanism is decreased in the elderly and would normally serve as a compensatory mechanism to provide water intake. Aldosterone production would be decreased in the presence of hypernatremia. Muscle mass may be reduced in the elderly, but the decreased thirst poses a greater risk. ADH is still produced. Clients with hypernatremia (normal 135–145 mEq/L) should be monitored for potential development of neurological complications such as seizures. Blankets are not needed because temperature is often elevated with hypernatremia. Nausea and malaise are symptoms of hyponatremia. Clients with hypernatremia have an increased, not a decreased, need for fluids. Processed foods, some baking products, seasonings, and many over-the-counter cold, cough, and flu remedies contain sodium. Canned fruits would be high in sugar. Salad oil typically does not have sodium added. Clients need to be taught to look for products containing sodium as part of the ingredients. As sodium levels decrease, fluid shifts in the brain can lead to cerebral edema and seizures. Clients should be monitored for headaches, lethargy, decreased responsiveness, and seizures. Hyponatremia will also cause weakness and fatigue, and the client needs to conserve energy, but neurological status is of highest priority. Oral and skin care would also not be of highest priority. SIADH is caused by excessive production of ADH or an ADH–like substance, resulting in decreased serum sodium and hypervolemia. Loop diuretics are given to promote diuresis. Oral fluids are restricted due to the hypervolemia. Dietary sodium is encouraged. Hypertonic or isotonic intravenous solutions are administered to provide needed sodium. While most individuals believe that drugs of abuse enhance their sexual experience, the opposite is mostly true. The four kinds of sexual problems that commonly occur as the result of chemical use are anxiety about one’s sexual performance; decrease or absence of sexual arousal; difficulties in reaching orgasm; and decrease or absence of pleasure in, and/or intensity of, orgasm. An estimate of serum osmolality is obtained by multiplying the sodium level by 2. The normal range of sodium is 135 to 145. Processed foods such as cheese are higher in sodium content. Ham is high in sodium because it is cured as a preservative process. The addition of these types of foods will supply extra sodium in the diet. The other options are lower in sodium content. Hyponatremia is due to an excess of water, which is diluting the amount of sodium present in the plasma. Clients who are experiencing dilutional hyponatremia are in fluid volume excess (FVE). It is important to restrict additional fluids because more fluid can further increase the sodium deficit. In addition, the client already is in an FVE state, which can lead to development of further disturbances of fluid balance. Options 1 and 4 are incorrect, as hypotonic fluids would further complicate the hyponatremia. Sodium usually does not need to be replaced in dilutional states. A client who has diarrhea or nasogastric suctioning will be more likely to develop hypokalemia. A serum potassium of 3.0 mEq/L is considered to be hypokalemic. A level of 3.6 mEq/L is just within the normal range, but one would expect a greater K<sup>+</sup> loss given the client’s history of 3 days of diarrhea. A level of 4.1 mEq/L is within the normal range and does not reflect K<sup>+</sup> loss. A level of 5.8 mEq/L is suggestive of hyperkalemia. Salt substitutes have potassium chloride as their main compound, and individuals with high potassium levels should not use salt substitutes. Bananas, tomatoes, and avocados are all foods that are high in potassium and should be limited in a client with hyperkalemia. Clients should be aware of foods to avoid that are high in potassium if teaching has been successful. A serum level of 2.8 mEq/L reflects hypokalemia, which often manifests as cardiac and respiratory problems related to the ineffective smooth muscle contractions. Option 2 reflects normal findings. The symptoms listed in options 1 and 3 do not indicate severe hypokalemia. A serum potassium of 2.8 mEq/L in conjunction with irregular pulse and shallow respirations is a symptomatic presentation in this client and suggests severe hypokalemia. It is important to look at the whole clinical picture and not just the serum level to determine the severity of an electrolyte imbalance. HCTZ is a potassium wasting diuretic, and its use can lead to hypokalemia. Leg cramps and muscle weakness are two of the symptoms seen in a client with hypokalemia. Diarrhea, fatigue, irritability, and nausea are not usually seen with the use of this class of diuretics. Spironolactone is a potassium sparing diuretic, and clients need to be aware of their intake of foods high in potassium. Cantaloupe is very high in potassium and should be avoided. Bread, green beans, and squash are not considered to be good sources of potassium. These foods do not need to be restricted in the diet. The maximum routine rate of infusion for KCl is 5 to 10 mEq/hr. Clients who are moderately hypokalemic may have potassium administered at a rate from 10 to 20 mEq/hr, but this client is not moderately hypokalemic. Concentrations of potassium in solution can range from 10 to 40 mEq/L and are administered via a peripheral vein with an infusion pump. Higher concentrations of potassium can be administered via a central line in critically ill clients who are hemodynamically monitored. Lasix is a potassium wasting diuretic that can cause the client to become hypokalemic. This can manifest as a weak, thready pulse and onset of orthostatic hypotension. Monitoring of one’s pulse is not required for clients taking diuretic therapy but is necessary for clients taking digoxin or who have a pacemaker. Diarrhea is not usually seen as a side effect of this medication. Bananas are a good source of dietary potassium and may be warranted for this client in order to maintain normal serum potassium levels. Naltrexone is an excellent medication to treat alcohol or opiate dependence. It helps to prevent cravings and triggers to use, and it blocks the euphoric response if alcohol or opioids are ingested (option 1). The nurse should always evaluate the client’s current knowledge level and provide education as needed (option 2). However, if the client is not completely detoxified from opiates, the use of naltrexone can precipitate withdrawal (option 3). Persons should be opiate-free for 7 to 10 days before starting this medication. Aldactone is a potassium sparing diuretic, and the intake of potassium-rich foods should be discouraged. It is important that the client be aware of potassium retaining diuretics because most clients associate diuretics with potassium loss. Diuretics should be taken with food to decrease GI upset. Diuretics should not be taken before going to bed because their primary effect is diuresis. This time frame could cause the client to experience altered sleep patterns due to nocturia. Clients taking diuretics should be aware of their fluid intake and monitor accordingly. A client with metabolic alkalosis is at risk for developing hypokalemia due to the shift of potassium to the ICF from the ECF. Clients with NG tubes not only lose potassium from the stomach but also the NPO status limits their intake. Clients with acute renal failure are usually hyperkalemic due to a decreased ability to excrete potassium. Clients with ARDS are usually hyperkalemic due to compromised ventilation, resulting in metabolic acidosis. Metabolic acidosis is associated with hyperkalemia because potassium shifts from the ECF to the ICF as a result of increase in hydrogen ion concentration. Sodium bicarbonate will temporarily alkalinize the plasma, causing the potassium to move into the cells. Calcium gluconate is given to blunt the effects on the myocardium; it does not decrease the serum K<sup>+</sup> level. Insulin and dextrose are given to decrease K<sup>+</sup> levels by increasing K<sup>+</sup> uptake at the cellular level. NS is an isotonic solution and therefore will not cause fluid or electrolyte shifting. Clients who take furosemide (Lasix) lose potassium, and are in danger of developing hypokalemia. The other choices reflect either a normal potassium level (options 2 or 3) or elevated levels (option 1), which would not be consistent with the action of this loop diuretic. To prevent gastric irritation, oral potassium supplements should be taken with at least 4 ounces of fluid or with food. Oral potassium medication should not be crushed. The use of a salt substitute is not recommended when taking potassium as a medication because it may also contain potassium, leading to hyperkalemia. It is important for the client to have an understanding of potassium medications, potential side effects, and food/drug interactions. Clients in chronic renal failure have diminished or no excretion of potassium from the kidneys, causing hyperkalemia. Clients with cirrhosis, intestinal or nasogastric suction, and/or diarrhea are more likely to be hypokalemic due to potassium losses. Clients with renal failure have impaired excretion of potassium resulting in hyperkalemia. Hyperkalemia leads to cardiac conduction problems and possible fatal dysrhythmias. ECG monitoring is indicated for this type of client. LOC, urinary output, and ABGs are important monitoring aspects for a client in renal failure, but hyperkalemia is potentially life threatening and should be addressed first as the primary intervention. HCTZ and Lasix are diuretics that increase the excretion of potassium, so clients should be taught to increase intake of potassium in their diet. All of the other medications are considered potassium sparing or combination diuretics, and, as such, dietary supplementation would not be indicated. Kayexalate (cation exchange resin) is usually administered rectally and binds potassium in exchange for sodium in the gastrointestinal tract. It is then excreted through the stool. Although Kayexalate can be administered orally, it requires administration with an osmotic agent to prevent constipation and may not be tolerated as well. This drug is not given by the IV or subcutaneous route. Hypokalemia can lead to alterations in smooth muscle functioning. Smooth muscle alterations in the gastrointestinal tract can lead to development of a paralytic ileus. Complications of hypokalemia are usually not associated with a perforated bowel, renal failure, or diabetes because these conditions are more likely to lead to increased potassium levels. Recovering clients may tend to underestimate how difficult it will be to stay sober if they visit with friends who are still using or frequent old “hangout” places where they used to engage in addictive behaviors. In early recovery, clients are encouraged to detach from people, places, and things associated with their addiction. As the person gains sobriety and recovery, he or she may be able to re-engage, on a limited basis, with certain activities, such as being with friends who drink or celebrating an occasion at a bar. Options 2, 3, and 4 demonstrate positive coping measures and good management of potential triggers. Calcium gluconate is given to antagonize the effects of the potassium on the conduction system of the heart. Options 1, 2, and 4 are incorrect because calcium gluconate is not given to promote potassium excretion (in either urine or stool). The medication acts to blunt the effects of elevated potassium on the myocardium. Bran flakes are not a source of potassium in the diet. Bananas and cantaloupe are excellent sources of dietary potassium. Taking potassium supplements on a full stomach will help to minimize gastric irritation, which is commonly associated with this medication. It is important for the client to communicate to the physician if symptoms develop during the course of therapy. Potassium works to maintain cardiac contractility and normal heart rate. Hypokalemia leads to the development of potential arrhythmias, which can result in ischemia and death. While the length of bed rest and actual potassium level could be associated with a complaint of dizziness, it is more likely that the dizziness is associated with orthostatic hypotension and inefficient heart pumping action due to hypokalemia. It is important for the client (and family) to understand that electrolyte imbalances may have significant complications that can affect the entire body. Renal failure can result in hypocalcemia from diminished formation of calcitriol from renal cell damage as well as from hyperphosphatemia. In renal disease, severe hypocalcemia can occur from abnormal renal losses of calcium. Serum creatinine would be high due to nephron destruction in renal failure. Renal colic occurs from hypercalcemia. Thiazide diuretics can cause mild hypercalcemia because they have calcium-retaining effects on the kidney. Increasing urinary output and eating a high-protein diet would lead to hypocalcemia. Bisphosphonates lower serum calcium levels by preventing bone resorption of calcium. The client with hypercalcemia is more sensitive to the toxic effects of digoxin (Lanoxin). Frequent apical and radial pulse checks by the nurse will aid in detecting potential complications. Options 1 and 4 are priorities in treating hypocalcemia. Auscultation of bowel sounds is appropriate, but not of high priority with digitalis therapy. Hypocalcemia frequently results from accidental removal or destruction of parathyroid tissue or its blood supply during surgery. Clinical manifestations of tetany include laryngospasm postoperatively. The other options are criteria representative of hypercalcemia. Tetany and seizures are clinical manifestations of hypocalcemia. The nurse must be aware of all potential risks to the client based on physiological factors of the presenting illness and must plan for the client’s safety. The other options are nursing diagnoses appropriate for hypercalcemia. Ionized calcium is approximately 40% to 50% of the total serum calcium. Ionized calcium is the portion of the serum calcium that is not bound to protein and is physiologically active and clinically important. Hypocalcemia (normal 9–11 mg/dL) that is due to reduced protein binding is asymptomatic. The question states that the total serum calcium is low; therefore, option 1 is incorrect. Ionized calcium levels may remain normal even when total calcium levels are low. Option 2 is incorrect, as hypocalcemia may be a result of hypomagnesemia, not hypermagnesemia. Option 3 is incorrect, as phosphorus and calcium are inversely proportional, so phosphorus would be high. Ten percent calcium gluconate is the treatment option for symptomatic severe hypocalcemia. All IV calcium preparations are administered slowly to prevent dysrhythmias and damage to veins. Normal saline and IV phosphorus are used to treat hypercalcemia. Addiction affects the entire family system: communication roles and boundaries. Some problems that individual family members experience are low self-esteem, guilt, shame, insecurity, and preoccupation with the chemically dependent family member. Families need treatment to facilitate their own healing. If they get involved in a treatment facility–operated family program, a spiritually centered family recovery program, or any of the family 12-step programs, active healing can take place whether the addict is using or not. Options 1 and 3 are incorrect. If the family is not engaged in its own treatment, it may not make any difference how many meetings the addicted member attends (option 4). Calcium levels of 11 to 12 mg/dL indicate hypercalcemia. The mainstay of treatment of hypercalcemia (normal 9–11 mg/dL) is to increase renal calcium excretion with extracellular volume expansion. Chvostek’s sign indicates hypocalcemia, which would not be an overcorrection of treatment. Serum creatinine elevation indicates that renal function is diminished and is therefore not an effective response to therapy. Although all systems are impacted by calcium imbalance, the major clinical manifestations of calcium imbalance are due to either increased or decreased neuromuscular irritability. The client with hypercalcemia (normal 9–11 mg/dL) should increase fluid intake to 2 to 3 liters a day. Hydration leads to increased calcium excretion and prevents the development of kidney stones. Tums is a calcium carbonate supplement that can be used to increase calcium; the client in the question already has hypercalcemia so this is not indicated. Phosphorus supplements can decrease calcium, but need to be taken more than once a day. Strict bed rest leads to increased calcium from osteoclastic activity. Calcium plays a unique role in the regulation of many enzymes and intracellular signaling. Although calcium does play an important role in acid-base balance, other electrolytes do this as well. Sodium and potassium are also needed for heart muscle contraction. Sodium is primarily responsible for shifts in body water. In hyperparathyroidism, the ionized calcium is almost always elevated. In hyperparathyroidism, the level of intact PTH is elevated and is best interpreted in conjunction with ionized calcium. PTH is suppressed in clients with most other causes of hypercalcemia, which makes the other options incorrect. Prolonged NG tube suctioning leads to metabolic alkalosis. Changes in pH will alter the level of ionized calcium. Alkalosis increases calcium binding to albumin, leading to a decrease in ionized calcium. There may be fluid shifts from hypoalbuminemia, but this would not be from NG tube suctioning. Hypomagnesemia can be a cause of hypocalcemia, but it is not indicated in this case. Metabolic acidosis decreases calcium binding to albumin, leading to more ionized calcium. Many malignant tumors produce chemicals that are carried in the blood to cause release of calcium from the bones, most commonly in association with ovarian cancer, renal cell carcinoma, and breast cancer, among others. Several antineoplastic medications cause hypocalcemia; lack of dairy products and pancreatitis also cause hypocalcemia. Large doses of glucocorticoids decrease calcium absorption in the intestines, leading to a further decrease in serum calcium levels. A positive Chvostek’s sign indicates hypocalcemia and hypomagnesemia. A positive Trousseau’s sign would be seen with hypocalcemia. Muscle weakness and polyuria are seen with hypercalcemia. Hypercalcemia causes decreased neuromuscular irritability, while hypocalcemia has clinical manifestations that indicate increased neuromuscular irritability. Options 1, 2, and 4 all demonstrate increased neuromuscular irritability signs of hypocalcemia. The cardiac effects of hypercalcemia include shortened plateau phase of the action potential, which causes shortening of the QT interval. Atrial fibrillation may develop, but heart block (with prolonged PR interval) is more of a concern with hypercalcemia due to delayed atrioventricular conduction. Peaked T waves are associated with hyperkalemia. The client is spending a great deal of time on the Internet, which seems to be interfering with not only her parental relationships but also her relationship with her husband. If the client does not stop using marijuana and start practicing recovery, and if her Internet problems are not addressed, they are unlikely to “go away on their own,” and her family problems may get worse (options 1, 2, and 4). Hypoparathyroidism is characterized by hypocalcemia and hyperphosphatemia, and is often associated with tetany. Hypoparathyroidism usually results from accidental removal of or damage to parathyroid glands during thyroidectomy. Because hypocalcemia may be severe, prolonged parenteral administration of calcium may be necessary to avoid serious postoperative complications. Hypoparathyroidism results from a deficiency or absence of PTH, therefore option 2 is incorrect. Immobility results in hypercalcemia, making option 3 incorrect. Hypophosphatemia is not a result of this surgery, making option 4 incorrect. Symptoms of fatigue, headache, and increasing muscle weakness are clinical manifestations of hypercalcemia. Increased hydration is needed to reduce the serum concentration and aid in elimination. All of the other options will worsen client’s symptoms and increase hypercalcemia. Thiazide diuretics inhibit calcium excretion; vitamin D supplements will increase absorption of vitamin D in the intestine; and fluid restriction will cause hemoconcentration, leading to increased serum calcium. Tingling or numbness around the mouth is called circumoral paresthesia and is a sign of impending tetany. A healthcare provider should be notified immediately. Tums is a brand name for calcium carbonate, which can be used as a calcium supplement when calcium intake is inadequate. To prevent hypocalcemia, the client should increase the protein in the diet. Kidney stones are a sign of hypercalcemia. Weakness and lethargy occur with hyperchloremia (normal 95–108 mEq/L). All of the other options reflect manifestations that are associated with hypochloremia. In metabolic alkalosis, bicarbonate ions are retained, and the kidneys respond by excreting chloride ions, which in turn causes reciprocal hypochloremia. Muscle tremors and slow, deep respirations are symptoms of hypochloremia. Option 2 is incorrect because deep, rapid respirations and stupor are symptoms of hyperchloremia. Options 3 and 4 are incorrect because serum chloride levels are decreased, and the restriction of salt and administration of diuretics will normally cause further chloride losses to occur, which could further compromise the client’s status. The client presents with hypochloremia and most likely is experiencing other electrolyte deficiencies as well, most notably sodium and potassium. A solution with 0.45% saline with added potassium would be an appropriate option, because this would correct all fluid and electrolyte imbalances. Option 1 is incorrect because these fluids can further dilute the plasma and the serum chloride level. Option 2 would not be appropriate because it does not address the issue of additional electrolyte deficiencies. Option 4 is incorrect because hypertonic saline is usually administered in cases of severe hyponatremia. Dates and bananas are high in chloride and therefore can be included in a dietary pattern to increase chloride levels. Option 1 is incorrect: Foods containing rye should be included in the diet because they are high in chloride. Option 2 is incorrect because diuretics can increase the excretion of chloride and thereby reduce serum chloride levels. In addition, the nurse cannot tell a client to alter prescribed medication therapy. In option 3, although increasing the amount of citrus fruit in the diet provides nutritional benefit, it does not increase chloride levels. Citrus is high in potassium. A serum value of 110 mEq/L reflects an elevated serum chloride level. Cushing’s syndrome causes retention of excess sodium and chloride and potassium deficit. Option 1 is incorrect because Addison’s disease is associated with decreased levels of sodium and chloride and potassium excess. Option 3 is incorrect because elevated chloride levels are usually associated with metabolic acidosis. Option 4 is incorrect because SIADH is associated with chloride deficit. The stated value represents an elevated chloride level. Increased use of table salt will cause increase in both sodium and chloride levels. Option 1 is incorrect because the use of NG suctioning causes HCl acid to be lost, thereby decreasing chloride level. Option 2 is incorrect because it is not a nursing diagnosis and the client has hyperchloremia, not hypochloremia. Option 4 is incorrect because it is not a nursing diagnosis, and chloride excess is associated with metabolic acidosis and is seen in clients who have acute renal failure. Chloride levels are typically drawn as part of general serum electrolytes and do not require that the client is NPO prior to the test; in addition, the client does not need to alter typical salt intake. Caffeine and hormones will not interfere with test results. The primary action of the nurse is emergency assessment and first aid. If the nurse contacts the nursing supervisor, there will be nursing help to contact the physician and speak with witnesses. After caring for the client and assessing the situation, the nurse is prepared to fill out the incident report. Environment and peer pressure play very strong roles in the development of addiction. Most smokers (90%) are addicted to nicotine by age 20. Although only 28 percent of the U.S. population smokes, the vast majority of new smokers are under age 18. The Federal Drug Administration (FDA) is trying to reduce smoking among children and teens by regulating tobacco advertisements near schools and youth centers. The rationale is that by restricting tobacco advertising to youths, the desire to smoke will be reduced. It is good for the public to be educated about the hazards of smoking, including secondhand smoke. This law does not specifically address options 1 and 3. Option 4 is part of the tobacco industry response to the proposed FDA regulation. An admitting clinical diagnosis of metabolic alkalosis, hypokalemia, and hyponatremia is usually associated with chloride deficit. It would be prudent to check serum chloride levels in order to ascertain client’s baseline in the presence of multiple electrolyte deficiencies. The other test results do not reflect serum electrolytes and therefore will not change in proportion to the electrolyte changes. The use of acetazolamide (Diamox) can lead to the development of hyperchloremic acidosis because it increases chloride levels. All of the other options are incorrect, because they would lead to chloride deficiencies that would result in an alkalotic state. Options 1 and 2 are correct. A low urine sodium and chloride indicates chloride retention in the body, especially with overhydration or fluid excess. Option 3 is incorrect because it indicates fluid deficit. Option 4 is incorrect because calcium is not altered by fluid retention due to cardiac disorders. Option 5 is incorrect, as phosphorus would not be affected. Many laxatives are magnesium-based compounds. Overuse could result in increased absorption of magnesium and decreased kidney excretion. The problems listed in the other options do not elevate magnesium levels. Deep tendon reflexes (DTRs) may be diminished or absent when magnesium levels are high (normal 1.4–2.1 mEq/L). This is because magnesium diminishes acetylcholine activity at the myoneural junction, thus impairing impulse transmission. It would not be necessary to monitor for diarrhea, hyperreflexia, and hypertension. Clients should be instructed to eat foods that are high in magnesium in order to raise blood levels to within the normal range. Read each option carefully, and analyze need for teaching to correct the magnesium imbalance. Recognize that option 3 will help to provide correction of the condition, and choose it. Options 1, 2, and 4 are incorrect. Magnesium deficiency often coexists with other electrolyte imbalances, especially decreased calcium and potassium. Leg cramps are a manifestation of hypomagnesemia. The calcium and phosphorus levels are elevated, and chloride would not be causing leg cramps. A magnesium level of 2.8 is elevated (normal 1.4–2.1 mEq/L), most likely as a result of inadequate renal secretion secondary to the chronic renal failure. Foods high in magnesium include whole grains, legumes, oranges, bananas, green leafy vegetables, and chocolate. Apples, pork sausage, and Swiss cheese are not high in magnesium. Decreased magnesium levels also contribute to reductions in potassium, calcium, and phosphate because all are cations and involved in cellular metabolisms. Options 1, 2, and 3 are incorrect. Magnesium decreases the amount of acetylcholine activity, thereby causing muscle relaxation. The other options are incorrect. Antidepressants regulate dysfunction in the neurotransmitter system, which results in mood equilibrium. Alcohol is a depressant that causes dysfunction in the neurotransmitter system, which can cause depression and/or anxiety. Use of alcohol or other mood-altering drugs while taking antidepressants is contraindicated. Hyperactive reflexes are early signs of tetany; the low magnesium level (normal 1.4–2.1 mEq/L) could lead to tetany and seizures and should be reported to the physician. The other symptoms can be related to electrolyte imbalances but may also be secondary to the surgery and effects of anesthesia and narcotic analgesics given for pain. The RDA for magnesium is 310 to 320 mg for young adult women and 400 to 420 mg for young adult men. Extra requirements beyond this amount are needed during pregnancy and lactation. Sources of magnesium in the diet include green leafy vegetables, nuts, legumes, whole grains, seafood, bananas, oranges, and chocolate. Poultry, tomatoes, and dairy products are not sources of magnesium. Excessive or too rapid infusion of magnesium sulfate can result in a rapid rise of serum magnesium, which may be manifested by respiratory depression or decreased deep tendon reflexes. Abdominal cramping may occur secondary to diarrhea with oral magnesium sulfate supplementation. Respirations would decrease, not increase. Headaches would not be caused by high magnesium. Magnesium binds calcium to tooth enamel and thus helps to maintain the health of teeth. The other options are incorrect statements. Seafood, legumes, and whole grains are high in magnesium. The other options contain either low or trace amounts of magnesium. Treatment for hypermagnesemia is to promote urinary excretion of magnesium to decrease serum levels, so a diuretic may be indicated. Laxatives and antacids (option 1) often contain magnesium, which could worsen the imbalance. Calcium carbonate would not be useful to treat hypermagnesemia (option 3). Fluid restriction would be contraindicated, because it would prevent flushing of excess magnesium from the body (option 4). Renal failure interferes with excretion of electrolytes, including magnesium. All of the conditions listed in the incorrect options increase risk of hypomagnesemia by interfering with magnesium absorption in the small intestine. The hyperglycemic diabetic client experiences osmotic diuresis and polyuria, which then increase risk of excess urinary excretion of magnesium, leading to lowered magnesium levels. Liver toxicity, kidney failure, and low serum osmolarity do not cause low magnesium levels. Oral administration of magnesium may cause diarrhea, which would then further decrease magnesium absorption. Decreased appetite, decreased urine output, and increased thirst would not be side effects. Persons can experience tolerance or tolerance-like symptoms in response to taking certain OTC medications. OTC sleep medications, or psychoactive sleep medications, are meant for short-term use, no longer than 1 week consecutively (options 2 and 3). The FDA does not regulate herbal products, and it is difficult to know what dose to recommend or how the product might interact with the client. Providing education on sleep hygiene and validating experiences proves helpful in addressing this problem (option 4). Sleep difficulties are often a problem for people in early recovery. Gentamicin is one medication that may lead to hypomagnesemia. All the conditions or circumstances listed in the other options increase serum magnesium levels by enhancing the absorption of magnesium by the small intestine or interfering with its excretion by the kidney. Neuromuscular symptoms such as depressed deep tendon reflexes are among the most common clinical manifestations of hypermagnesemia. Ventricular arrhythmias, decreased respirations, and hypotension may also occur in some clients but are not the most common signs. The repeat serum magnesium level is very high. Calcium gluconate is an antagonist of magnesium and is used intravenously to counteract toxicity. Dextrose, potassium chloride, and sodium chloride would not be indicated as treatment. As people age, respiratory function decreases and the alveolar exchange surfaces become less effective in controlling respiratory acidosis. Options 1, 3, and 4 are incorrect because changes consistent with aging reflect a decrease in respiratory function and gas exchange. The PaO<sub>2</sub> is not the only determinant used to measure oxygen saturation. Oxygen saturation reflects the total oxygen concentration that is carried on the hemoglobin molecule. There is a relationship observed between the PaO<sub>2</sub> and the SaO<sub>2</sub> indicating safe and dangerous levels as the PaO<sub>2</sub> level drops. Options 2, 3, and 4 are consistent with the concept of SaO<sub>2</sub>. Clients who take potassium wasting diuretics, such as Lasix, are at risk for developing hypokalemia and metabolic alkalosis. Options 1 and 2 are incorrect because they reflect an acidotic state. Option 1 is a respiratory acidosis, and option 2 is a respiratory acidosis with partial compensation. Option 4 is incorrect because the primary disturbance is a respiratory alkalosis due to the increased PaCO<sub>2</sub> level. The pH is elevated, the HCO<sub>3</sub><sup>-</sup> is elevated, and the PaCO<sub>2</sub> is low. This indicates that there is a mixed respiratory and metabolic alkalosis. Clients with pneumonia are prone to develop respiratory alkalosis. Option 1 is incorrect because the HCO<sub>3<sup>-</sup></sub> level alone would be decreased. Options 2 and 4 are incorrect because the ABG values do not reflect these conditions. Antacids contain a high proportion of HCO<sub>3</sub><sup>-</sup>. Overuse of these agents places clients at risk for developing metabolic alkalosis due to high concentrations of bicarbonate. Option 2 reflects metabolic alkalosis (pH alkalotic, HCO<sub>3</sub><sup>-</sup> elevated, normal PaCO<sub>2</sub>). Option 1 is incorrect because it reflects respiratory acidosis (pH acidotic, HCO<sub>3</sub><sup>-</sup> normal, elevated PaCO<sub>2</sub>). Option 3 is incorrect because it reflects normal ABG values. Option 4 is incorrect because it reflects respiratory alkalosis (pH alkalotic, HCO<sub>3</sub><sup>-</sup> normal, decreased PaCO<sub>2</sub>). A client with type I diabetes who does not take prescribed insulin is at risk for developing diabetic ketoacidosis, which leads to the formation of ketone bodies and the development of metabolic acidosis. Blood gas results indicate that no compensation is occurring because the PaCO<sub>2</sub> is normal, the pH is acidotic, and the bicarbonate level is decreased. Options 2 and 4 are incorrect because the ABG values are not consistent with a respiratory disturbance, as the PaCO<sub>2</sub> level is normal. The major disturbance rests with the HCO<sub>3</sub><sup>-</sup> level, which indicates a metabolic disturbance. Option 3 is incorrect because with compensation a rise in PaCO<sub>2</sub> would be expected. Clients with metabolic alkalosis are at risk for developing hypocalcemia. The client's symptoms are consistent with hypocalcemia. Options 1, 3, and 4 are not consistent with the client's presenting symptoms. The client acknowledges her problem and has tried to stop on her own; this puts her in the action stage. She is actively trying to change. The correct action of the nurse, then, is to assist. Option 1 demonstrates precontemplation; option 2, contemplation; and option 3, determination and preparation. NG suction removes H<sup>+</sup> ions from the stomach and can lead to a client's developing metabolic alkalosis. Options 2 and 3 are incorrect because removal of GI drainage leads to acid loss and bicarbonate excess. Option 4 is incorrect because respiratory alkalosis is more likely to occur with hypoxic states, central nervous system disorders, drugs, or hyperdynamic states. Lower gastrointestinal (GI) tract fluid loss leads to a loss of HCO<sub>3<sup>-</sup></sub>, resulting in the development of metabolic acidosis. Option 1 is incorrect because respiratory acidosis involves a primary disturbance in CO<sub>2</sub> levels. Options 3 and 4 are incorrect because a client with an ileostomy does not retain bicarbonate. Due to long-term lung disease, clients with COPD tend to develop respiratory acidosis because they compensate for and adjust to a higher level of PaCO<sub>2</sub>. The pH reflects acidemia, and there is an elevated PaCO<sub>2</sub> and a normal HCO<sub>3</sub><sup>-</sup>. Option 1 is incorrect because the pH is acidotic and there is a normal PaCO<sub>2</sub> and a decreased HCO<sub>3</sub><sup>-</sup>. Option 3 is incorrect because the pH is normal, but PaCO<sub>2</sub> is increased and there is a normal HCO<sub>3</sub><sup>-</sup>. Option 4 is incorrect because the pH is alkalotic, and there is decreased PaCO<sub>2</sub> and normal HCO<sub>3</sub><sup>-</sup>. The respiratory acidosis in this client is secondary to retention of carbon dioxide. Cough and deep breathing will stimulate expectoration of secretions, allowing for improved gas exchange. Medicating the client frequently with narcotics may decrease respiratory drive, but a nonnarcotic medication may enable the client to breathe deeply. Option 1 is incorrect; fluids will help to liquefy secretions and do not need to be restricted to water. It would be helpful to ambulate the client, which would promote lung expansion, but not as much as in option 2. Option 5 is incorrect because magnesium has no effect on acid-base imbalances. Symptoms of alkalosis include irritability, confusion, cyanosis, irregular pulse, slow respirations, and muscle twitching. These symptoms warrant discontinuing the medications and notifying the primary healthcare provider because the client may have received excessive sodium bicarbonate. Option 2 is incorrect. Options 3 and 4 would be carried out after the physician has been notified. Apnea and hypoventilation result in rising carbon dioxide levels, which lead to acidosis. The ABGs would likely reflect respiratory acidosis without compensation, which is indicated in option 2. Option 1 is incorrect because it reflects a normal pH, a slight increase in the PaCO<sub>2</sub>, and a normal HCO<sub>3</sub><sup>-</sup> level. Option 3 is incorrect because it reflects normal values in all three parameters. Option 4 reflects an alkalotic state because the pH and the HCO<sub>3</sub><sup>-</sup> are elevated, and the PaCO<sub>2</sub> is decreased. The kidneys respond more slowly to acid-base imbalances but are more effective than the lungs in restoring acid-base balance to the extracellular fluid. The primary response to acidosis is with lung compensation. Option 1 is incorrect because the kidneys do not respond immediately to correct acid-base imbalances. Option 3 is incorrect because the kidneys utilize several mechanisms to restore acid-base balance involving phosphate buffer salts, reabsorption of bicarbonate, and excretion of ammonia. The bicarbonate buffer system is a very strong buffer system in the body and also helps to regulate the respiratory response to acid-base imbalance. Option 4 is incorrect because the kidneys help to restore acid-base balance by reabsorbing bicarbonate by ionizing carbonic acid. Ion exchange occurs between Na<sup>+</sup> and H<sup>+</sup>, which leads to bicarbonate formation, which is then absorbed into the blood. Diarrhea leads to loss of bicarbonate from the intestinal tract. This can cause metabolic acidosis. With metabolic acidosis, the pH is low and the HCO<sub>3</sub><sup>-</sup> is also decreased. Option 1 is incorrect because the pH is alkalotic, the PaCO<sub>2</sub> is elevated, and the HCO<sub>3</sub><sup>-</sup> is slightly elevated. These values reflect metabolic alkalosis. Option 3 is incorrect because the pH and the PaCO<sub>2</sub> are within normal limits and the HCO<sub>3</sub><sup>-</sup> is slightly elevated. These values do not reflect a cause for concern at this point in time. Option 4 is incorrect because the pH is alkalotic, the PaCO<sub>2</sub> is normal, and the HCO<sub>3</sub><sup>-</sup> is slightly elevated. These results reflect metabolic alkalosis. Clients who are extremely anxious tend to hyperventilate and have a rapid, shallow respiratory pattern. Cardiac rhythm and regulation are independent of respiratory function, and the rate may vary depending on the client’s medical condition and/or treatment. A rapid, deep respiratory pattern is associated with further respiratory compromise. Anxious clients hyperventilate, which leads to alkalosis because of a depletion of carbon dioxide. Options 1 and 2 reflect normal pH values. Option 4 reflects acidemia and is associated with clients who hypoventilate. Alcohol and benzodiazepines are both depressants. Persons often use two drugs within the same class to enhance their effects. The capacity of other psychoactive substances within the same class of drugs to enhance the effect of the primary drug is called cross-tolerance. Options 1 and 4 are examples of combining a stimulant with a depressant, while option 2 has only a stimulant. A client with metabolic acidosis will have an increase in respiratory rate and depth in an attempt to compensate for the acidosis. Increases in heart rate, urinary output, and temperature are all metabolic responses that are not directly associated with maintaining acid-base balance. Initial compensation with metabolic acidosis will be via the lungs. Due to a lack of insulin, diabetic clients are more likely to use fats as an energy source. During the metabolism of fats, free fatty acids are released, leading to the accumulation of fatty acid fragments and the development of diabetic ketoacidosis. Diabetic clients are likely to develop metabolic acidosis characterized by decreased pH and HCO<sub>3<sup>1</sup></sub> levels. Options 1, 2, and 3 are incorrect. The pulse oximeter measures the amount of oxygen in the blood and is a good indication of oxygenation status. It is not meant to replace needed ABG monitoring, but rather, it is used in conjunction with appropriate respiratory monitoring to provide important information on a continuous basis. Pulse oximetry does not determine or reflect ventilatory effort, regardless of client positioning. A pH of 7.30 indicates acidosis. A PaCO<sub>2</sub> of 51 indicates a respiratory acidosis is occurring. Since the PaCO<sub>2</sub> is elevated with a normal HCO<sub>3</sub><sup>-</sup>, an uncompensated respiratory acidosis is occurring. Options 2 and 4 are incorrect because the pH value does not indicate that alkalosis could be present. Option 3 is incorrect because the bicarbonate level is normal, indicating that compensation has not taken place. With compensation, you would expect an increase in the bicarbonate level. A client with a chest injury is likely to hypoventilate (have a shallow respiratory pattern) as a result of pain due to associated trauma. It is unknown at this time whether there are any internal injuries that could affect the client’s oxygen saturation. This type of respiratory pattern is associated with respiratory acidosis. Options 1 and 4 reflect normal lab values. Option 3 reflects metabolic alkalosis (increased pH and HCO<sub>3<sup>1</sup></sub>, decreased PaCO<sub>2</sub> and SaO<sub>2</sub>). One of the first things a nurse should do when a client is hyperventilating is to give the client a paper bag to breathe into. This prevents the CO<sub>2</sub> level from decreasing, and rebreathing the gas in the bag will also help to decrease the respiratory rate. Hyperventilation is associated with respiratory alkalosis. Although sedatives may be indicated to decrease anxiety and decrease hyperventilation, the use of a paper bag may stop the breathing pattern response by redirecting the client’s focus. Telling the client that he or she may pass out may make the client change the breathing pattern, but it could also make it worse by increasing anxiety. Notifying the physician may be indicated to further assist in client treatment, but the initial response should be to interrupt the present breathing pattern of the client. DKA is associated with an increase in acid production. Diabetic clients with DKA are unable to metabolize glucose, and the liver responds with an increase in fatty acid metabolism. These fatty acids are oxidized, leading to ketone body formation and increased acidity. Option 2 is incorrect because metabolic alkalosis is the opposite imbalance. Option 3 is unrelated, and option 4 would occur as a secondary compensatory mechanism for the client in DKA. The pH indicates alkalosis and the HCO<sub>3<sup>1</sup></sub> is elevated, indicating a metabolic basis. The PaCO<sub>2</sub> is slightly elevated, indicating that compensation is occurring. Options 1 and 2 are incorrect because the client’s pH reflects alkalosis. Option 4 is incorrect because compensation is occurring due to the increased PaCO<sub>2</sub> level. During a cardiac arrest, the client develops profound respiratory acidosis and needs to be ventilated, first with a bag-valve-mask device and then by mechanical means once intubation is accomplished. The interventions in the other options will be instituted during the course of the code, but the nurse should always respond to any emergency situation with the ABCs (airway, breathing, and circulation). Loss of acidic contents via NG drainage (option 1) can lead to alkalosis and so can intake of antacids, which are frequently alkaline substances (option 4). Option 2 is incorrect because diarrhea leads to a loss of alkalotic fluids, predisposing the client to acidosis. Option 3 is incorrect because salicylate toxicity results in acidosis. Option 5 is incorrect because the client with asthmatic bronchitis retains carbon dioxide, leading to respiratory acidosis. Tactile disturbances are a symptom of alcohol dependence, and if the client reports stopping alcohol use abruptly, he may be starting to experience withdrawal symptoms. However, the client may also have used and stopped other substances abruptly as well. The nurse must assess for other substances used. Multiple drug use is the rule more than the exception. Waiting (option 1) places the client at risk, and stimulants are not indicated (option 4). The slightly elevated pH (alkalosis), the low PaCO<sub>2</sub> (respiratory origin), and the low HCO<sub>3<sup>1</sup></sub> indicate compensation is starting but is not yet fully complete, since the pH is still abnormal. In addition, the SaO<sub>2</sub> level is decreased significantly, which is not consistent with aging alone. Option 1 is incorrect because the pH is alkalotic. Option 3 is incorrect because in an uncompensated respiratory alkalosis, the bicarbonate level would be normal. Option 4 is incorrect because the bicarbonate level is not elevated. The pH is low (acidosis) and the PaCO<sub>2</sub> is high (respiratory origin). The HCO<sub>3<sup>1</sup></sub> is normal, indicating that compensation has not occurred. The client is experiencing hyperventilation, but blood gases reveal a respiratory acidosis, probably because of prior hypoventilation. Option 2 is incorrect because the bicarbonate level has not increased in an attempt to restore balance. Options 3 and 4 are incorrect because the bicarbonate levels are within normal limits and yet the PaCO<sub>2</sub> level is still elevated. The pH is normal (but is nearer to the acidotic end), while the PaCO<sub>2</sub> is low (compensation has occurred), and the HCO<sub>3<sup>1</sup></sub> is low (indicating metabolic origin). The oxygen saturation of 100% indicates the blood is well oxygenated, making options 2 and 4 incorrect because the client is not hypoxemic. Because the pH is within normal limits, it is more likely that there are mixed acid-base disorders occurring that are compensating each other. Because the PaCO<sub>2</sub> and the HCO<sub>3</sub><sup>1</sup> are low, metabolic acidosis is occurring with a respiratory alkalosis. COPD clients have low oxygen and high carbon dioxide levels. Therefore, hypoxia is the main stimulus for ventilation in persons with chronic hypercapnia. Increasing the level of oxygen would decrease the stimulus to breathe. Options 2, 3, and 4 are incorrect. A combined low PaO<sub>2</sub> and low Cal SO<sub>2</sub> represents hypoxia. The pH, the PaCO<sub>2</sub>, and the HCO<sub>3</sub> are normal. ABGs will not necessarily be altered in TB or pleural effusion. Initially, in pneumonia, both the PaO<sub>2</sub> and the PaCO<sub>2</sub> are usually low because the hypoxia leads to hyperventilation. The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth. The first three symptoms in the question could be indicative of any of the conditions. The distinguishing symptom is the lack of breath sounds in the lower-right base when a portion of the lung has collapsed. Options 1, 3, and 4 are incorrect. The effects of the respiratory treatment should break up the congestion and cause bronchodilation; thus the change in lung sounds and more productive the cough effort is. As the pneumonia resolves, the lungs should begin to clear and the cough should diminish. Notice that the question asks about an <i>acute case</i>; be careful to note the situation in the stem. Options 2, 3, and 4 are incorrect. Option 3 is indicative of a tension pneumothorax, which is considered a medical emergency. The respiration system is severely compromised, and venous return to the heart is also affected. The mediastinal shift is to the unaffected side. Option 1 contains symptoms of pleurisy, and option 2 lists symptoms of bronchitis; neither are emergencies. The client in option 4 should expect difficulty breathing after exercise when asthma is an existing condition and may need immediate attention if the rescue inhaler is ineffective. A young person needs to know the triggers of asthma. Physical exercise in school and as a part of life will be ever-present, and prevention of an attack before exercise is essential at this time in the client's life. It is not necessary to supply detailed information on the incidence of asthma. Sports do not have to be limited in all asthmatic people. Living a productive, normal life should be stressed. The client may have to use preventative medications before participating in a sport of his or her choice. The fear associated with asthma is common and may take a while to overcome. Instructions on identifying triggers and using the rescue inhalers need to be taught, and the fear will eventually subside. It takes the average person 1 hour to metabolize 1 ounce of alcohol or a 4-ounce glass of wine. If three to five glasses of wine are consumed within an hour, the average person becomes intoxicated. Options 1 and 2 are insufficient, while option 4 is greatly excessive. As the upper airflow obstruction occurs in sleep apnea, the CO<sub>2</sub> rises, and cardiac arrhythmias and angina can occur because of the lack of oxygenated blood supply to the heart. Option 1 is incorrect because the obstruction is not in the lower airway. Option 2 is incorrect because clients with sleep apnea do not get adequate amounts of REM sleep and are often awakened frequently during the night in order to make breathing possible. Option 3 is incorrect because muscle tone is not affected. The most common sign of cancer of the lung is a persistent cough that changes. Other signs are dyspnea, bloody sputum, and long-term pulmonary infection. Option 1 is common with chronic obstructive pulmonary disease (COPD), option 3 is common with asthma, and option 4 is common with tuberculosis. Adult respiratory distress syndrome is common after a trauma or shock situation. Clients will often become hypoxic and alkalotic with pulmonary edema. Options 1, 2, and 4 are incorrect, as they would not result specifically from this injury. A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, examination would be targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than the conditions indicated in the other options. Option 1 is common with pneumonia, values in option 2 are not alarming, and option 4 is typical of someone with chronic obstructive pulmonary disease (COPD). Option 2 is the pathophysiology behind emphysema. Option 1 explains asthma, option 3 explains bronchitis, and option 4 explains cystic fibrosis. Cystic fibrosis is diagnosed with a high chloride level (normal: less than 40 mmol/L) on the sweat test, hypoxemia on the ABGs, and atelectasis or hyperinflation on the CXR. Options 1, 2, and 3 do not reflect these findings. Barotrauma (decreased cardiac output and damage to lung tissue) is a common complication of PEEP. A drop in BP is associated with a decreased cardiac output. The sinus tachycardia may be a compensatory mechanism to raise BP or a response to the ARDS. Anxiety is to be expected with intubation, and a small rise in temperature may or may not indicate an infectious process. Exposure with a positive TB skin test usually requires 6 months of prophylactic treatment unless contraindicated. The TB skin test should not be repeated; the results will always be positive. Monitoring for signs and symptoms over the next year is not appropriate. A CXR is usually not required annually in the event that the skin test was positive. The deprivation of oxygen during the night often leaves individuals tired during the day. Any activity increases the need for oxygen, which is already limited in a client with this disorder. Sleep apnea has no bearing on options 1, 3, and 4. Pleuritic pain is typically sharp and stabbing. Pleurisy is common in smokers. Pleural effusion (option 2) and atelectasis (option 3) can cause pain but usually have other symptoms such as dyspnea and diminished or absent breath sounds. Tuberculosis (option 4) causes chest pain along with other symptoms such as night sweats and is usually a more generalized pain and is not capable of localizing to one area. Impaired control is the defining symptom that moves someone’s use or abuse category to the dependence category. The symptom of “use despite negative consequences” fits in both the abuse and dependence category (option 1). Withdrawal (option 3) and/or tolerance (option 4) may or may not be present for someone who has dependence. If the blockage is large enough and blood flow is hindered to the lung, the tissue will die. This usually occurs when a large clot blocks the entire main pulmonary artery. Option 1 is rather vague because blood flow is decreased to the heart, lung, brain, and other vital organs because of the blockage, but the amount of decrease can be variable. Option 2 is incorrect; dead space is increased with PE. Option 3 is indicated in pulmonary embolism but is not usually the cause of death. Without any evidence of a blood clot or PE, LMWH is usually used for prevention purposes, especially because the client is elderly and will be on bed rest for a period of time. Thrombolytics are used when a clot needs to be immediately dissolved (option 1). Coumadin and heparin are used when a confirmed clot exists. Barrel chest and clubbing of the fingers are classic symptoms of COPD-induced hypoxemia (options 1 and 5). Rust-colored sputum (option 2) is usually indicative of lung cancer. Thick, viscous mucus (option 3) can be significant in a number of disorders. Absent breath sounds (option 4) are indicative of many pulmonary disorders. Chronic lung disease causes hypertrophy of the right ventricle; eventually the right ventricle fails, mainly because of the increased pressure within the pulmonary artery that results from the lung disease. Signs and symptoms of right-sided heart failure will occur. Options 1, 3, and 4 are incorrect. ARDS is a problem with impaired diffusion, whereas upper airway obstruction (option 1), rib fractures (option 2), and drug overdose (option 3) are problems with impaired ventilation. incorrect. Options 1, 3, and 4 are incorrect. The relief of pain is of top priority in order to allow the client to rest and cough effectively. An antibiotic may be ordered if another respiratory infection such as bronchitis is present. A cough suppressant may be prescribed for nighttime only but should not be ordered if a productive cough occurs. Bed rest would increase the risk of complications and is not likely to be ordered unless complications occur. A properly working system should have fluctuation in the water-seal compartment that increases with inspiration and falls with expiration, and intermittent bubbling should be noted. Options 1, 2, and 3 are incorrect. The action of theophylline is bronchodilation, which should relax respiratory efforts. Eupnea is normal respirations that should be a direct result of bronchodilation. While the heart rate may decrease, this is a side effect of easier respiration. Theophylline is more likely to increase the heart rate. Secretion color should not change, and an increase in respiratory rate is a sign the theophylline is not working therapeutically. The behavior of drinking and driving fits in the abuse category as “recurrent substance use in hazardous situations.” Option 1 is incorrect. Option 2 demonstrates the category of dependence. Option 3, “black out,” is a symptom of intoxication. The trapping of air causes the typical barrel chest appearance and the pink color of the skin (unless in the later stage of emphysema). The clubbing of the nails is related to chronic hypoxia. The other options describe findings that are not typical for this problem. Side effects of the theophylline are headache, seizures, diarrhea, muscle twitching, and anorexia. A normal theophylline level is between 10 and 20 g/mL; the client should be closely monitored for toxicity, in which levels exceed the high end of the normal range. Options 1, 2, and 4 are incorrect. Although 250 (option 1) and 210 (option 4) are better than the reading during an asthmatic attack, therapeutic medication effects should return the client to a fairly normal value, if not what the average reading is in a normal day. 350 would be ideal, but 300 is certainly an improvement and is at least 80% of the client's potential (350 x 0.80 = 280). Option 3 is too low a value. In conditions such as emphysema or asthma, in which airways are constricted or airflow is limited, pursed-lip breathing keeps the airways open by maintaining positive pressure. Options 1, 2, and 4 are not reasons to use pursed-lip breathing. Decreasing anxiety, which lessens oxygen demand, as well as abdominal breathing to improve lung expansion assist the client to breathe more easily and relieve some of the air hunger that accompanies obstructive breathing disorders. Options 1, 3, and 4 are incorrect because they are not reasons to use abdominal breathing. All of these answers are appropriate and correct for an individual who has respiratory problems with productive sputum. However, the stem of the question asks which option is most effective with thick secretions. Increasing fluid intake can be as effective as an expectorant or mucolytic. This measure assists the client in eliminating the anesthetic gases that can eventually lead to pneumonia. It also promotes lung expansion and rids the lungs of secretions that could be a medium for growth of microorganisms. The inflammatory process in the pleural cavity (which usually has a thin layer of serous fluid) can cause a friction rub when auscultating lung sounds. This symptom is unique to this health problem. A hemothorax is the presence of blood in the pleural cavity; a pneumothorax is the presence of air in the pleural cavity. The cause (e.g., knife wound, crushing injury, or other thoracic trauma), signs and symptoms, and treatment are basically the same. Heparin (an anticoagulant) is the initial treatment for a confirmed PE to prevent the extension or propagation of thrombi and inhibit the formation of new clots. Coumadin is usually started after the heparin has been infused for several days. LMWH is not the drug of choice for this client, and t-PA is a thrombolytic drug that dissolves clots that are already formed. Any substance, legal or illegal, that activates the pleasure center in the brain has the potential to cause dependence. Nicotine takes only 10 seconds to reach the brain. Nicotine causes both physical and psychological dependence. For a therapeutic effect of heparin, the PTT value should be 1.5 to 2.0 times the normal control level. Options 1 and 3 show subtherapeutic levels, and option 4 shows an excessively high level. The pulmonary vascular system has low pressure, high blood flow, and low resistance; therefore, it takes more to raise the pressure within the pulmonary artery. This is not reflected in the systolic pressure as readily. Because of the action of a neuromuscular blocking agent, movement and communication are blocked, and this can be frightening to a family member. However, the effects of the medication will subside as soon as the drug is discontinued. Although option 3 is true, it is an inappropriate answer for a concerned family member who probably will not understand what was said. Options 2 and 4 are unacceptable. With flail chest, the classic chest wall movement is for the wall to collapse on inspiration because of the negative pressure exerted within the lung cavity. The positive pressure causes the chest wall to expand on expiration. This does not happen with the disorders listed in the other options. With bronchiectasis the smaller bronchi and bronchioles become dilated as a result of the infection in the respiratory tract. As the dilation occurs, pockets form where infectious material is trapped, and this allows abscesses to develop. The walls of the bronchi are weakened and become necrotic, resulting in foul-smelling sputum. These symptoms do not pertain to options 1, 2, and 4. In emphysema, air is trapped and causes hyperinflation of the lung, thus causing the barrel chest. Although chronic bronchitis and asthma may also be a part of COPD, these diagnoses do not account for the appearance of the chest. A barrel chest is not a sympton of option 4. In a newly diagnosed client, the consolidation may be so dense that the client is ineffective in removing the sputum and lung sounds are quite diminished. Options 1 and 2 are correct but are not necessarily going to help with coughing, which can be very painful. Movement will help the client, although planned rest periods are needed (option 3). Respiratory failure in a COPD client is manifested by a drop in oxygen of 10 to 15 mmHg from the previous level. Although the other ABGs are not adequate, the values must be compared to previous values for the COPD client, who is already hypoxic and hypercapnic. Pain management is a primary consideration in any end-stage cancer. Although all of the other options are important when caring for a client with lung cancer, palliative support is essential and should include around-the-clock pain relief. This is not the appropriate time to be concerned about opioid addiction. Oxygen is drying to the nasal passageway, and under the positive pressure of CPAP, a nosebleed is likely to occur in individuals who are already prone to this. Applying a small amount of antibiotic ointment in the nostril prone to bleeding before bedtime may help. Cardiac conditions such as hypertension or arteriosclerosis, as well as medications such as anticoagulant or antiplatelet drugs, can also cause nosebleeds. The stem of the question, however, does not give enough information as to the type of cardiac problems that the client has; avoid reading into the question. Options 1, 2, and 3 are incorrect. The medical record belongs to the client and should contain all of the facts related to the client and the incident. The incident report belongs to the hospital and should contain all of the facts and supportive data related to the client and the incident. The medical record should not refer to the incident report. Methadone maintenance therapy seems to be an effective treatment regimen for a select population. Clients with heroin and/or other opiate addictions receiving oral methadone do not receive the euphoria associated with their drug of choice (option 1). The person on methadone maintenance who works a recovery program and is abstinent of all other mood-altering substances is in good recovery (options 2 and 4). The etiology is not fully understood, but tall, young, thin-chested men who smoke are more prone to developing a spontaneous pneumothorax. Option 1 is more likely to be positive for tuberculosis (TB); option 2 may experience sleep apnea; and option 4 is more likely to experience pulmonary hypertension. Because of the obstruction to airflow, bronchoconstriction is associated with all of these diagnoses, mostly because of damage to the lung or inflammation. The symptoms in the other three options are specific to one particular disorder. The excessive mucus production from cystic fibrosis blocks the ducts of the pancreas, which prevents the digestive enzymes from being released. In the absence of these enzymes, digestion is impaired. Options 1, 2, and 4 are not causes of this condition. An intact gag reflex indicates that topical sedation has lost its effect and the client is able to swallow, a major safety consideration prior to discharging the client from the healthcare facility. The ability to swallow would precede consumption of oral intake. Knowing symptoms to report to the physician following discharge is important, but the physiological condition takes priority in this case. The client's ability to verbalize discharge instructions prior to discharge is not a good predictor of postdischarge memory; therefore, it is essential that written instructions be sent home with the client. Fever, if present, may take hours to days to resolve; the client may have been febrile at the onset of the procedure. The medulla and pons are the areas of brain tissue that control breathing. Injury to these tissues would produce alterations in the client's breathing rate and pattern. The other options are incorrect areas of the brain. With unilateral lung disease, the example to remember is "good lung down." Because ventilation and perfusion are gravity dependent, enhancing ventilation and perfusion to healthy lung tissue and alveoli will enhance oxygenation. Perfusion refers to the circulation of blood into the tissues and cells. Prone positioning would not be indicated. Supine positioning would provide near equal ventilation and perfusion to both lungs. In the diseased lung, excess fluid and fibrosis inhibit gas exchange at the pulmonary capillary membrane, thereby diminishing oxygenation. Bilateral crackles throughout the lung fields indicate excessive pulmonary fluid requiring acute intervention. The etiology of the fluid excess in the lungs needs to be explored in depth. Increased anterior-posterior diameter of the chest, pursed-lip breathing, and circumoral cyanosis are chronic findings in clients with emphysema. They do not indicate acute changes in the client's condition. Carbon dioxide level is one of the primary stimuli for breathing in clients with chronic obstructive pulmonary disease (COPD), who adjust to higher than normal carbon dioxide levels. Abrupt elevation of the oxygen level will depress the stimulus for breathing and can even produce respiratory arrest. Administration of 100% oxygen to the client with COPD who is not receiving mechanical ventilation is highly likely to lead to depressed breathing and respiratory arrest. The spouse's presence may be providing comfort and support for the client. Psychological distress caused by her absence may worsen the dyspnea. Pain medication may depress breathing. Productive cough is compatible with bacterial pneumonia and differentiates it from viral pneumonia. Excessive sputum is produced as pulmonary bacteria die. White blood cell count is elevated in bacterial pneumonia compared to viral pneumonia. Atelectasis is not expected. Chest X-ray findings with bacterial pneumonia usually show consolidation, whereas the chest X-ray is often normal with viral pneumonia. Many foreign particles inhaled from the environment are nonbiodegradable and cause chronic inflammation of lung tissue. The chronic inflammation leads to progressive scarring and fibrosis of lung tissue, thereby impairing the gas diffusion capabilities of the lungs. Antigen-antibody reactions are related to exposure to protein substances. Options 3 and 4 do not apply. Clients need to have communicated to them that they are in control of their own behaviors and that “acting out” will result in consequences. Reassuring the client that the staff will make sure nothing happens (option 1) takes away responsibility from the client. Just explaining that violence is unacceptable and not explaining to the client that he or she is in control (option 3) is nontherapeutic. Acting out is usually not allowed (option 4) because of safety of client and others. Mycobacterium tuberculosis is transmitted via airborne droplets, so use of a properly fitted particulate filter mask is indicated to prevent its spread. The other options do not represent methods of preventing airborne droplet transmission. Emphysema is a chronic disease with progressive destruction of alveoli and loss of alveolar area available for gas exchange. Paralysis of respiratory muscles, airway obstructions, and pleural effusion would diminish ventilatory capacity, which could ultimately lead to decreased oxygen supply. Clients with rib fractures should be examined periodically for the possible complication of pneumothorax. Decreased or absent breath sounds are related to pneumothorax because pneumothorax compresses functional lung tissue. Pink, frothy sputum is a possible (but unlikely) finding in clients with pneumothorax. Hoarseness is indicative of an airway obstruction or laryngeal nerve paralysis. Percussion sounds are hyperresonant in the area of a pneumothorax due to collection of air in the pleural space. Expiratory wheezing is a characteristic finding in acute asthma due to airway constriction. Crackles are indicative of excess pulmonary fluid, which is not a typical finding with acute asthma. Diminished breath sounds are not indicated with acute asthma. Rhonchi are related to mucus obstruction of large airways and are a common finding in chronic obstructive pulmonary disease processes. During the later stages of COPD, arterial blood gas findings indicate low pH, elevated PaCO<sub>2</sub>, low PaO<sub>2</sub>, and elevated HCO<sub>3<sup>-</sup></sub>, which indicate the body's attempt to compensate for chronically low pH. Option 1 is indicative of respiratory alkalosis; options 2 and 3 are variations of normal ABG results. Cigarette smoking is the primary etiology of chronic bronchitis, so cessation is the priority for the client. Fluids are often increased. Avoidance of crowds to lower the risk of pulmonary infections is a recommendation that is more individualized and less common than the need for smoking cessation. Teaching the client about potential side effects of any prescribed medications should be included in all discharge teaching. An induration of 5 to 9 mm resulting from a tuberculin skin test is indicative of close contact with an individual infected with mycobacterium tuberculosis. The client with this finding will be prescribed isoniazid for 6 to 12 months as prophylaxis against development of active TB. History of diabetes is not related to false positive tuberculin skin test. The nurse should demonstrate a calm, supportive, and informing manner with this client. For any client with a tracheostomy, maintenance of the airway is clearly the priority. Clients are taught to perform routine tracheostomy care to prevent airway obstruction. Only those clients discharged with a feeding tube will need instruction about operation of a feeding pump. Wound care and use of a Passy-Muir valve for communication are important factors to include in discharge teaching, but the airway is the clear priority. With sudden onset of shortness of breath, the priority is for the nurse to maintain airway patency and gas exchange. Positioning the client supine with a high degree of head elevation will assist with airway maintenance and ventilation. The nurse should then rapidly evaluate the client's heart and lung status before notifying the physician. the collection device to a portable machine. Preventing a client from free mobility is the most restrictive technique. Meeting in a quiet room (option 1) is the least restrictive and most therapeutic. Chemical restraint (option 2) and escorting a client (option 3) are restrictive but less so than full four-point restraint. Tension pneumothorax is a life-threatening condition, so the nurse must recognize potential indicators. Deviation of the trachea toward the unaffected side occurs due to increased pressure within the pleural cavity. Increasing pressure on the great vessels in the chest causes decreased cardiac output, which can be fatal. Tachypnea and hypotension occur with pneumothorax but are also related to numerous other conditions. Unilateral wheezing is indicative of narrowing of the airways. Secondary polycythemia, or increased red blood cell count, develops as COPD occurs, in response to chronic hypoxemia. Of the options, impaired tissue perfusion related to chronic hypoxemia is the only factor related to development of secondary polycythemia. Risk for injury related to venous thrombi or use of oxygen may or may not be present. Impaired gas exchange may also be a factor; however, it is related to hypoxia. Wheezing is a common finding during an acute asthma episode; however, the wheezing is not a consistent predictor of the severity of the attack. Airway obstruction may be so severe that the client is moving little or no air and is experiencing severe respiratory distress. Breath sounds are prolonged in expiration with asthma, but this factor does not alter the plan of care in any way. Frequent coughing and deep breathing is an easy maneuver for the client that has great benefit to optimize ventilation in the postoperative client. Good pain management facilitates effective coughing and deep breathing. Assisting the client out of bed and administering bronchodilators and oxygen are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing. Carbon dioxide is eliminated from the body as exhaled gas. The greater the rate of breathing, the greater the quantity of carbon dioxide eliminated. Normal PaCO<sub>2</sub> levels are 35 to 45 mmHg. Normal HCO<sub>3<sup>-</sup></sub> levels are 22–26 mEq/L. With decreasing PaCO<sub>2</sub> levels, HCO<sub>3<sup>-</sup></sub> should also fall to compensate. For the client with ARDS, placing the client in a prone position allows for expansion of the posterior chest wall, which may be effective in enhancing oxygenation. Transfusing red blood cells or albumin does not increase oxygenation in ARDS. Option 3 should have been done as an initial measure. Carbon dioxide is eliminated from the body as exhaled gas. The faster the rate of breathing, the greater the quantity of carbon dioxide eliminated. Oxygen administered by a Venturi mask can be regulated to deliver between 24 and 50%, which is a benefit for clients who require higher oxygen supplement without mechanical ventilation. The Venturi mask does not prevent rebreathing of carbon dioxide, as does a non-rebreather mask. Oxygen concentration of 100% would be administered to COPD clients only in rare circumstances via mechanical ventilation. Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often associated with oral cancer. Air pollution may also be a contributing factor to development of lung cancer. History of asthma is not associated with greater risk of lung cancer. Increased heart rate and/or respiratory rate within minutes to several hours following central venous line insertion is symptom of a pneumothorax caused by puncture of the pleura. The client will require a chest X-ray to determine whether a pneumothorax is present. If the client does have a pneumothorax, placement of a chest tube is likely. Pain at central line insertion site, fever, and diminished breath sounds in lung bases will require intervention, but the etiology of these symptoms is not likely to be potentially life threatening, as is the development of a pneumothorax. Once a client has escalated beyond least restrictive interventions, the nurse should plan for the next step. Bargaining (option 2) with a client is counterproductive and positively reinforces behavior. Offering a PRN medication (option 3) to reduce anxiety would occur after negotiation for least restrictive interventions is complete. Asking a client to take a time out (option 4) is a least restrictive intervention to which the client is not responding. Pulmonary embolism is the most common complication of hospitalized clients and is due primarily to immobility. Postoperative clients are at risk to the immobility associated with surgery. Infrequent coughing and deep breathing is associated with postoperative atelectasis. Pulmonary embolism originates from deep veins in the extremities, not in superficial varicose veins. All of these nursing diagnoses are appropriate for the client with COPD; however, the primary alteration is related to impaired gas exchange. The alteration in gas exchange is the etiology of the other problems. Clients with COPD are often underweight due to the fatigue associated with eating, making options 1 and 3 unnecessary. Therefore, calorie-dense foods will help them to ingest more calories with less effort in eating. Carbohydrate intake should be about 50% of total calories. Because carbohydrates metabolize to carbon dioxide and water, excessive carbohydrate intake may contribute to carbon dioxide retention. Small, frequent intakes of food should be encouraged. At least one-half of all cases of bronchiolitis are attributed to respiratory syncytial virus. The majority of cases of bronchiolitis are not attributable to <i>klebsiella</i>, <i>mycoplasma pneumoniae</i>, or <i>hemophilus influenzae</i>. Any manipulation of the tongue or throat may stimulate the gag reflex and cause complete obstruction, so this is the action that should be avoided. The other actions are appropriate. The child should be allowed to remain in a position of choice for ease of respiration. Emergency intubation equipment should be readily available before any examination of the throat is attempted. Parents should be encouraged to comfort the child. The child’s respiratory distress makes it difficult for the child to lie down. The child will breath more easily in a semi- to high Fowler’s position. Rocking the child and holding the child in the arms does not specify an upright position, and therefore these are too vague to be useful suggestions. A sleeping pill is not indicated. Peak expiratory flow readings over time indicate the child’s respiratory ability when she is well. Readings of 50% below “personal best” indicate an asthma episode is imminent. Options 2 and 3 are incorrect because it is important to use the peak flow meter properly. Use of the meter does not prevent an attack. Frothy, foul-smelling stools reflect malabsorption and indicate that pancreatic enzymes are not being consumed or dosages may need adjustment. Maintenance of weight and consuming meals and snacks are positive nutrition goals for children with cystic fibrosis. The developmental task of adolescence is to set future goals, including marriage and family. Men are usually sterile, and women may have decreased fertility, as thick cervical mucus interferes with mobility of sperm. The difference between sterility and impotence should also be addressed. The client does not need information about a sweat chloride test (diagnostic test for the disease) or weight reduction. There is no adverse effect of pancreatic enzymes on sex hormones. Both the child and the parents will be anxious about the child’s condition and the need for emergency admission to the hospital. Respiratory distress is an obvious sign of ineffective breathing. The child will need extra fluids due to increased insensible fluid loss and inability to take fluids due to respiratory distress. The parents will want to know the cause of the disease and interventions for future episodes. The outcome for this disease is usually positive, so anticipatory grieving would not be appropriate. Debriefing allows the staff an opportunity to ventilate feelings and to calm down (option 1). It should always occur, and all staff should be encouraged to participate (option 3). Debriefing following a violent episode should occur as soon as possible after the client and others are safe (option 4). Accumulating mucopurulent secretions may provide a medium for bacterial growth or can obstruct the lumen of the tube. Suctioning is another risk for introduction of bacteria. Early recognition of signs of infection is important. The tube does not need to be changed every day (option 1) and cannot be removed (option 3). It is small objects, not large objects (option 4), that pose a risk to aspiration and would need to be avoided. Children with cystic fibrosis have elevated chloride concentrations of sweat because of the dysfunction of the exocrine glands. The sweat test will not provide the information noted in options 1, 2, and 3. Infants and young children have narrower airways and a shorter distance between structures; accessory muscles generally used for breathing are immature. The respiratory rate of infants is faster than in adults, and parents can be taught to evaluate the child for respiratory problems. Newborns are unable to coordinate breathing and sucking simultaneously. They are nose breathers, and anything that interferes with nasal patency impairs feeding as well. The difficulty with sucking does not relate to hunger or selection of formula. In epiglottitis, any manipulation of the throat can cause stimulation of the gag reflex. The inflamed, edematous epiglottis could then completely obstruct the airway. All other examinations should be made. Children with cystic fibrosis require pancreatic enzymes with every meal and snack to counter malabsorption and nutritional problems. They require well-balanced diets with 120–150% of RDA calories and 200% protein. Normal bowel movements indicate that enzyme dosage is appropriate. Chest percussion is a normal part of health maintenance for this child. It is important to avoid other children with infections, but physical activity is encouraged within the child’s capability. Developmentally, small children practice increased hand-to-mouth activity and explore objects with their mouths. Any small toy or food can be ingested and potentially obstruct the airway. All of the other choices are correct, but option 3 is most important. Pulmonary pathogens are particularly detrimental to children with cystic fibrosis. Colonization of the lungs with resistant organisms often leads to poor survival rates. Aggressive intravenous administration of high-dose antibiotics is always a priority. Options 1, 2, and 3 are incorrect. A beta<sub>2</sub> agonist (short-acting) is the drug of choice for acute therapy given via inhalation for emergency relief of acute bronchospasm; action is immediate within 5–10 minutes. Use before inhaled steroid. Methylprednisolone and prednisone are both corticosteroids to reduce the inflammatory process but would not give immediate relief. Cromolyn sodium is a preventive medication. The sudden onset of severe respiratory distress is frightening and very stressful for the family and child. There is no permanent loss to grieve for, and growth and development are not likely to be affected. There is no prolonged hospital confinement. A situational crisis is one that occurs from external life events. An event involving normal stages of development (option 1) is a maturation crisis. A natural disaster (option 3) and an armed conflict (option 4) are examples of community crises. Splinting the affected side with a pillow or stuffed animal lessens the discomfort experienced with bacterial pneumonia. Options 2, 3, and 4 are incorrect. Home oxygen therapy and tracheostomy care require access to emergency equipment typically not available on a camping trip. Additionally, campfires are hazardous. All other options indicate correct information. A trigger for an asthma attack can be exercise, smoke, allergic irritants, or emotions. Each child's trigger is individualized, and identification can afford some degree of protection in avoiding asthmatic episodes. The other options indicate incorrect statements. CPT should be performed prior to meals. Waiting until after the child has eaten may lead to vomiting. The child should wear a layer of clothing between the chest and the hands. A clapping or popping sound is expected. A variety of positions may be used during CPT. The endotracheal tube is inserted through the nose or mouth to maintain a patent airway by bypassing an upper airway obstruction or reducing respiratory distress. While the tube is in place, the child will be unable to talk. The child may or may not require a tracheostomy depending on how long the child is intubated. It does not allow for more accurate blood gas sampling. Bronchopulmonary dysplasia is an obstructive lung disease that occurs primarily when premature infants are subject to prolonged mechanical ventilation and high levels of oxygen therapy. Pneumonia results from bacterial or viral infections. Epinephrine by the intravenous route is a rapid-acting beta-adrenergic agonist that relaxes smooth muscles by opening airways for immediate relief of bronchospasm. Prednisone is a corticosteroid given to decrease inflammation and bronchial hyper-reactivity. Terbutaline is an adrenergic bronchodilator but would take longer to act based on oral or subcutaneous administration. Cromolyn sodium may be used prophylactically to avoid exercise-induced asthma and is of little use once an episode occurs. Sudden temperature change is a common asthma trigger, and snow skiing would expose the child to cold air. Exercise is a trigger in some children, but activities with short bursts such as gymnastics are not usually a problem. Swimming is actually beneficial because of the breathing of moistened air and prolonged expiration required underwater. Restriction from playgrounds would interfere with normal socialization. Pulmonary infections must be treated aggressively with CF patients to minimize the chance for colonization of resistant pathogens. Once colonized, children have a poorer survival rate. Recording vital signs periodically is standard hospital procedure. The sweat chloride test is for diagnostic purposes only. Maintaining adequate hydration helps liquefy secretions. Administering pancreatic enzymes helps the child absorb food substances but is not the priority intervention. Children with CF require pancreatic enzymes before each meal and snack to manage malabsorption and steatorrhea. Enzyme dosage is individualized based on nutritional status and stool consistency. It is also important that the child eats his prescribed high-calorie, high-protein diet to support weight gain. The information in the other options is not necessary to know before the child eats. When a person is threatened and perceives himself or herself to be vulnerable to a situation, coping behaviors are self-protective. Coping behaviors may be ineffective to provide strength (option 1). Coping during a crisis is oriented toward the immediate here-and-now, not mastery (option 2). Coping behaviors may or may not be immobilized (option 4). Clubbing of the fingers is seen in pulmonary disease and is associated with hypoxia and ischemia. In this instance, the clubbing occurs as a result of pulmonary changes due to cystic fibrosis. The responses in the other options are inappropriate. Hand washing is the most important infection control practice. Isolation is unrealistic and limits the child's socialization opportunities. Avoiding animals would be difficult to do. Respiratory infections are generally spread by nasal pharyngeal secretions from infected persons. Seeing a pediatrician weekly will not prevent infection. Angina pectoris is the term for chest pain related to myocardial ischemia (not enough oxygen supply to the tissue for the demand). Any activity that increases the need for oxygen without an adequate available supply can cause angina. Options 1 and 2 are incorrect. Pain from a pulmonary embolus would be abrupt in onset and not necessarily related to activity. Orthopnea is shortness of breath caused by the movement of fluid back into the vasculature when the client lies down. The client may have beginning signs of congestive heart failure and should be checked. Sleep apnea may cause orthopnea but not edema; angina doesn't necessarily cause edema either but should be accompanied by chest pain. A sinus infection is not what the client is experiencing. Left ventricular failure causes pulmonary congestion and increased pressure in the lungs, which leads to tachycardia. Remember Left and Lung—the two Ls go together; two of the symptoms deal with respiratory symptoms, and none of the other options are related to a diagnosis affecting the lungs. Depressed ST segments and inverted T waves represent myocardial ischemia. Options 1 and 4 are incorrect. Injury usually has an ST segment elevation. Left ventricular failure results in inability to empty the pulmonary vascular system, leading to increased pulmonary pressures. Right ventricular failure, diminished left atrial pressures, and low pulmonary pressures are incorrect. Bradycardia decreases the myocardium’s demand for oxygen by decreasing workload of the heart. Heart rates less than 60 bpm are considered bradycardia. However, if the heart rate is too low, blood supply is decreased and oxygen supply may be hindered. Infarction (heart attack) is the term for tissue that has been deprived of oxygen until the cells have died. Immediate attention should be given to the client who has just had a myocardial infarction (MI), which is noted by Q waves on an ECG. Gangrene, ischemia, and infection are incorrect. Occlusion of a coronary artery blocks the blood flow and prevents oxygen from getting to the myocardium. Option 2 indicates ischemia; option 3 could be bradycardia or a block; option 4 could be hypertrophy. Assisting the client in identifying coping patterns and then supporting them is essential to managing a crisis. Identifying the client’s maladaptive coping mechanisms (option 1) may be beneficial after identifying the client’s strengths. Assisting the client to forget (option 3) is not a therapeutic intervention for crisis management. Teaching a client to handle future crises (option 4) is more appropriate once the current crisis has abated. This client's gender and age are nonmodifiable risk factors. Hyperlipidemia (option 2), cigarette smoking (option 3), and lifestyle (option 4) can be changed by modifying behaviors. These risk factors should be stressed and plans made for how to change them. NTG can be taken as a preventive measure prior to activities that trigger angina. This is especially helpful with sexual activity or work-related activities that may need to be continued. Modifying such activities may be necessary, but cardiac clients should not become restricted by their condition and lead sedentary lifestyles. Systolic hypertension over 150 mmHg may occur after the use of over-the-counter (OTC) cold remedies. A warning is placed on OTC medications, cautioning clients with hypertension to consult a physician first. Renal diseases contribute to hypertension, and salt causes fluid volume retention, which increases the blood pressure. Increases in the electrical activity of the heart will cause a variety of arrhythmias, not systolic hypertension (option 1). The failure of the elastic tissue is frequently seen in the skin of the elderly, and side effects of antihypertensives would most likely cause systolic hypotension (option 2). Anaphylactic shock or increased electrical activity of the heart would cause a state of systolic hypotension (option 4). When administering propranolol (Inderal), the client's apical pulse and blood pressure must be monitored. Propranolol is a beta blocker used to treat hypertension and tachycardia. The drug should not be given if the apical pulse is below 60 beats per minute (bpm), if there has been a significant drop in blood pressure, or if systolic pressure is below 100 mmHg. Side effects include bradycardia, congestive heart failure, pulmonary edema, hypotension and edema, depression, memory loss, insomnia, drowsiness, and dizziness. Clonidine (Catapres) is an alpha blocker prescribed to control mild to moderate hypertension. Side effects are drowsiness, nightmares, nervousness, depression, hypotension, and bradycardia. Sulfinpyrazone (Anturane) is a medication used to manage long-term gout, while calcitonin (Calcimar) is used in the treatment of Paget's disease by decreasing the rate of bone destruction (option 1). Glucagon (GlucaGen) is a specific medication for the management of hypoglycemia when glucose is not appropriate (option 3). Hydroxyzine (Vistaril) is used in the treatment of anxiety, pruritus caused by allergies, psychiatric and emotional emergencies, nausea and vomiting (excluding the nausea and vomiting of pregnancy), as a preoperative and postoperative sedation, and as a prepartum and postpartum adjunct therapy (option 4). Family history and age cannot be modified as risk factors in any form of hypertension. Current research suggests there are several genes influencing the development of hypertension. Ethnicity is a nonmodifiable risk factor; however, stress can be modified if the interruption of the stressor is undertaken (option 1). Obesity and substance abuse are risk factors that may be managed through behavioral modification and support groups (option 2). Nutrition and occupation are both modifiable with assistance (option 3). Blood pressure readings from three different positions are helpful in ruling out the presence of hypertension. The difference between each of these readings should be less than 5 mmHg. If the reading difference is higher, repeat readings should be within the follow-up plan for this client. Options 1, 3, and 4 will not provide enough data to determine whether a problem exists. Smoking is the primary etiological factor identified with clients diagnosed with Buerger's disease. Emphasis should be placed on cessation of smoking, use of nicotine (Nicoderm) patches, and support groups. Option 1 is usually required with clients with Raynaud's disease, although clients with Buerger's disease should protect the extremities from cold injury as well. Clients with Buerger's disease should wear comfortable shoes that will not cause blisters or sores, but they do not necessarily have to be flat (option 2). Although pain is present, the use of opioids is usually not indicated (option 3). Frequently, clients perceive and become helpless when confronted with multiple lifestyle changes. The healthcare team and the client need to determine the most significant lifestyle modification needed and begin to work with this one. The other modifications are introduced as the client is able to incorporate them. The major focus is to establish and maintain a partnership with this client. Many times the therapeutic action of the medication will not cause the client to feel or perceive any difference in well-being (option 1); however, client education can help to enlighten a client about the need for lifelong therapy. Option 4 may or may not be true for some clients, and option 2 is not a plausible response by healthcare workers. Cardiac diseases such as congestive heart failure, myocardial infarction, and cardiomyopathy are conditions that coexist with thromboembolism. Each of these conditions creates the possibility of thrombus occurring because of ineffective emptying of the heart during its pumping action. Thromboembolism generally occurs in clients over the age of 40 (option 1). Gender usually does not play a role in embolism; a male who is Jewish and over the age of 40 is more prone to Buerger's disease (option 3). Kidney disease has not been identified as a cause of emboli (option 4). Part of the medical regime will include anticoagulant therapy. The rationale for this is to prevent the development or extension of thrombi by inhibiting the synthesis of the clotting factors or through deactivation of the mechanism. The client's legs need to remain in an elevated position for comfort and to facilitate venous circulation to prevent the development of emboli and thrombi in the lower extremities (option 2). Low molecular weight heparin (LMWH) is usually used as a preventative agent in clients prone to thrombophlebitis, not as a treatment with a confirmed diagnosis (option 3). The treatment is usually to raise the foot of the bed 6 inches off the floor (Trendelenburg's position). The knee lever needs to remain in this position 24 hours per day until the healthcare team considers the need for elevation of the legs no longer exists (option 4). The head of the bed may be elevated for activities such as eating and bathing. Providing support and guidance are the primary objectives of crisis management. The client’s anxiety (option 2) may be needed in order for him or her to be energized to cope with the crisis; the goal is to achieve a manageable level of anxiety. Providing encouragement (option 3) and fostering independence (option 4) are important and may occur during crisis intervention, but they are not the primary task of crisis management. The symptoms exhibited by the client are typical of an abdominal aortic aneurysm. The most significant sign is the audible pulse in the abdominal area. If hemorrhage were present, the abdomen would be tender and firm. There isn't enough information to determine whether the hypertension is secondary or essential (option 1). There is no evidence of congestive heart failure (CHF) in the question (option 3). Signs of Buerger's disease involve the extremities (option 4). The major priority for the nurse is to administer medications that produce smooth muscle relaxation, decreasing vasospasm, and increasing arterial flow to the affected part. The medications commonly used are calcium antagonists. Frequently, the client will be medicated during the cool to cold months when vasoconstriction is a physiological response to the environmental temperature. Options 2 and 3 are a concern, but the highest priority is reducing spasms. If the medicines work, pain will be reduced and blood flow maintained (thus lesions prevented). A client may develop gangrene of the skin of the tips of the digits, but these are in the upper extremities (option 3). Raynaud's disease does not usually cause major disabilities (option 4). Depolarization of the myocardium results in contraction (systole), and that produces the palpable pulse and the corresponding QRS complex on the electrocardiogram. No pulse is palpated during ventricular relaxation, ventricular fibrillation, or cardiac standstill. Stimulation of the SNS increases heart rate and respiratory rate. Remember "fight-or-flight" syndrome is a response by the SNS that increases heart rate. The parasympathetic nervous system is not responsible for this increased heart rate. Options 3 and 4 are incorrect, as they are not part of the central nervous system (CNS). Right-sided heart failure leads to backward venous congestion, resulting in jugular vein distention, portal hypertension, and abdominal venous congestion resulting in ascites. Remember Right means Rest of the body, whereas Left means Lung in identifying where fluids stagnate. Options 2, 3, and 4 are incorrect because their signs do not match those in the question. The client does need another NTG if the chest pain is still present; however, a BP should be measured <i>first</i>. If the systolic is greater than 100, another NTG can be given. If the systolic is less than 100, the physician should be consulted. The situation indicates that the Lanoxin should be given as ordered. Unless specific parameters are given concerning pulse rate, most resources identify 60 as the reference pulse. The Lanoxin should be held for a pulse rate less than 60 bpm (option 1). Nurses cannot arbitrarily give half of a dose without a physician's order (option 2). It is not necessary to call the physician at this point (option 3). Family history is a nonmodifiable risk factor. Although diet and exercise should be encouraged, this may not be sufficient to lower cholesterol and prevent CAD. The inner layer of the heart is referred to as the endocardium. Left ventricular failure leads to pulmonary congestion. When the left side cannot pump the blood out adequately, congestion occurs in the lungs where the blood backs up from the left ventricle. Left ventricular failure does not lead to increased coronary artery perfusion, pulmonary emboli, or increased peripheral resistance. Short-acting antianxiety agents are most useful in helping a client to achieve an effective reduction in level of anxiety. Antipsychotics (option 1) should be avoided. Antidepressants (option 3) require some time to achieve therapeutic levels and are not useful in a crisis situation. Mood stabilizers (option 4) are not indicated. The ischemia that causes the MI can also cause the heart muscle to become irritable, and irritated cells fire early, causing dysrhythmias. Acidosis is usually the shift with MI, if one occurs (option 1). Although options 3 and 4 are true, nothing in the stem indicates that these are specific to this client. A low-fat, low-sodium diet aids in the reduction of cholesterol and/or triglycerides that could have caused the MI. Anticoagulant therapy with aspirin, not thrombolytics, may be recommended. A client who has had an MI should not participate in heavy exercise; a moderate exercise program with daily walking would be sufficient. Clients with an MI should stop smoking completely. The healthcare provider must be sure that the client is aware of the need to eat sufficient amounts of calcium, magnesium, and potassium. Foods high in calcium are milk, cottage cheese, cheese, yogurt, rhubarb, broccoli, collard greens, spinach, tofu, canned sardines, and salmon. Foods high in magnesium are green leafy vegetables, seafood, wheat bran, milk, legumes, bananas, oranges, grapefruit, and chocolate. Potassium-rich foods are fruits and fruit juices, vegetables and vegetable juices, meats, and milk products. These food products are best if they are fresh and not processed. The consumption of alcohol is limited to 1 ounce per day; however, with some antihypertensive medications, the recommendation is that the client not consume any alcohol (option 2). Jogging is a good activity in moderation, that is, 1 mile per week (option 3). Herbal therapies containing licorice cannot be safely used by a hypertensive client. Licorice causes the blood pressure to rise (option 4). By definition, secondary hypertension has some underlying cause. Approximately 10% of all pregnant women develop this condition. The criteria are that the systolic blood pressure rises 30 mmHg and the diastolic blood pressure rises 15 mmHg prior to the 20th week of gestation. Diagnostic tests are conducted to confirm the diagnosis and rule out polycythemia, hyperaldosteronism, and pheochromocytoma. The systematic long-term use of contraceptives containing estrogen may contribute to secondary hypertension (option 1). Coarctation of the aorta is rare; when it occurs, it interferes with the renal blood flow, which stimulates the renin-angiotension-aldosterone system of the kidney (option 2). Endocrine disorders and hypertension are rare and involve the adrenal medullary system (option 4). One of the factors that regulates blood pressure is the amount of fluid volume within the body system. Excess concentration of sodium and water increases the blood pressure and the pressure in the kidney filtration, resulting in diuresis. The baroreceptors respond to the activity of the receptors as well as pressure and chemical composition within the vascular system. Arterial receptors are also involved (option 1). The endocrine system is usually not involved (option 3). Hypertension causes an increased production of sodium and water releasing hormone (option 4). These laboratory studies would be the most helpful and give an estimate of the degree of vascular involvement as well as the degree of damage. An elevated cholesterol level would suggest HTN related to atherosclerosis. Creatinine is the most specific test of kidney function (a cause of HTN) and is not affected by foods as is the blood urea nitrogen (BUN). A hematocrit will be helpful in determining fluid problems, which could account for HTN also. Bone scan (option 1), glucose tolerance (option 2), and prothrombin time (option 3) are not essential tests for diagnosing HTN. An overweight client on bed rest from a hip surgery is at higher risk because of the two risk factors (obesity and immobility). Even though the client will be ambulated and progressively increase weight bearing, the potential exists because of the immobility. HTN does not increase the risk, nor does smoking (option 1). Raynaud's disease is not a factor (option 3); option 4 is vague about the cardiac history, and further information is needed. These are signs and symptoms of PVD; the diagnosis is supported by the pallor noted when the feet are elevated for 30 minutes. The pulse is diminished because it is arterial, not venous, occlusion. Pain and itching are usually felt with varicose veins (option 1). Thrombophlebitis is associated with redness, warmth, and swelling of an extremity (option 2). Raynaud's disease is more involved with the digits of both the hands and feet (option 3). Whenever there is tissue breakdown associated with intermittent claudication, the client will be confined to bed in order to be able to meet the oxygen requirements for the damaged tissues. Activity (options 1, 3, and 4) raises the amount of oxygen required to sustain both healthy and diseased tissues to a point where deficits will occur and healing will be stalled. At the time the client is to be ambulated, the shoe of choice is a supportive, comfortable shoe. These are known as Virchow's triad and are the most commonly associated reasons for a blood clot. A thrombus usually involves the venous, not arterial, system (option 1). Situations that contribute to venous stasis are myocardial infarction and prolonged sitting; however, a stroke is not classified in this manner (option 2). Injury may or may not cause thrombi, whereas continued bed rest can contribute (option 4). Client medications and vital records are needed for a short or extended stay at an emergency shelter. Space is very limited in a shelter. There is no provision for storing food, and animals are not allowed. Loud electronic devices such as radios or televisions may cause disturbance between families or individuals. Electricity may or may not be available. Medications will help decrease the frequency and intensity of suicidal thoughts. Medication may treat the underlying cause of the suicidal ideation but does not necessarily reduce the risk for completing suicide. Medication does not prevent suicide; in fact, many times when clients regain their energy from medications, they are at an increased risk for completing suicide (options 1 and 2). A client may not be currently suicidal, but medications do not assure that they will not be suicidal in the future (option 4). Pain felt in the calf while pulling up on the toes is abnormal and indicates a positive Homan’s sign. If the client feels nothing or just feels as though the calf muscle is stretching, it is considered negative Homan's sign (option 3). A tourniquet test (options 1 and 4) is used to measure for varicose veins. A client with Raynaud's disease needs to be taught to protect the digits from extreme cold by using warm clothing, gloves, and socks. Use of gloves is essential anytime the digits may be cold (such as at night). Smoking should be stopped completely (option 1). Relaxation and stress management are essential (option 2). Diet is not associated with Raynaud's disease (option 4). Decreased workload of the myocardium leads to decreased oxygen demand. Rest periods allow the demand to equal the supply. Although a slower heart rate can decrease workload and oxygen demand, rest does not necessarily lower the heart rate. Option 3 is indicated for hypertension, and option 4 is indicated for congestive heart failure. Marked rales and rhonchi, S<sub>3</sub> heart sounds, and frothy sputum (frequently pink from being blood tinged) are classic pulmonary edema characteristics. A possible side effect of corticosteroids is congestive heart failure. The client is not showing signs of tamponade. Angina pectoris is pain related to insufficient oxygen supply to meet the workload demands of the heart. If the workload demand is decreased (as in rest), the pain goes away. Option 1 may be correct but is not usually the case; option 2 is incorrect. In option 3, a CPK-MB level indicates the amount of muscle damage. Increased pressure needed to push the blood through the stenotic valve causes the left ventricle to enlarge in order to become stronger and bigger to accommodate the increased blood volume and the higher pressure needed. The echocardiogram report does not correspond to symptoms of aortic stenosis, tricuspid stenosis, or acute rheumatic fever. Rales and rhonchi are not characteristic of right heart failure (RHF). All the other options are classic signs and symptoms. If the client entered with RHF and developed left heart failure (LHF), pulmonary complications would develop. Angina is the result of decreased supply of oxygen to meet the demands of increased workload of the heart. Rest decreases the workload, and therefore the oxygen supply is sufficient. This client could have had an anterior wall myocardial infarct of the left ventricle because of the location of the blockage in the picture. Because the left ventricle is the "power" of the heart, an adequate supply of oxygenated blood flow is needed at all times. Options 1, 2, and 3 are incorrect. Starling's law states that the more stretch of the muscles, the better the contraction force until the muscle is stretched out and can no longer contract sufficiently to move the blood through the circulation. Initially, this improves cardiac output. Option 1 is helpful in hypotension; option 2 explains contraction with each heartbeat; and option 4 is the pathophysiology behind hypertension. Afterload is the force or resistance that the left ventricle must pump against the impedance to the flow of the blood. By decreasing afterload in CHF, a pump that is already inefficient has to work less to be effective. Options 1, 3, and 4 are incorrect. A client who is just regaining his or her energy should be encouraged to do simple tasks, which will also promote the client’s self-esteem. Suicidal clients are most at danger when they are feeling better and regaining their energy. Introducing the client to wood carving (option 1) and making a belt from rope (option 3) place the client at risk for self-harm. The nurse should encourage the client to participate in the occupational therapy for self-expression (option 2). Congestive heart failure is the inability of the heart to pump adequate blood to meet the oxygen and nutritional needs of the tissue. Think of CHF as a "pooped-out" pump. The conditions described in options 1, 2, and 3 do not pertain to congestive heart failure. Both the calcium channel blocker and the beta blocker have the potential of lowering the BP and pulse (sometimes significantly). Most textbooks still list 60 bpm as the baseline pulse. Giving the medicine as usual could lower the vital signs even further. Even if vital signs are monitored, the drugs will be in the client's system and could result in harm. Holding the medicine until rounds is not usually an acceptable practice. Unless specific parameters are established on a unit, the nurse should cover herself with a written order for parameters. Renin is released to conserve water, thus increasing the systemic blood pressure. Options 2, 3, and 4 are incorrect because the mechanism results in decreased renal flow, decreased blood pressure, and decreased tubular sodium concentration. Prior to surgery, the client should be questioned concerning any family history or prior problems with hypertension (HTN) if anesthetics were used. Malignant HTN is a medical emergency that can occur after administration of anesthetics. Although problems with hypotension (option 1) and the normal BP range (option 4) are important, anesthetics are usually associated with concern for malignant HTN. Option 2 is not applicable here. This description is of labile hypertension. The disease of hypertension progresses slowly into the vessels, the heart, the kidney, and the brain. Essential hypertension is an elevated systemic arterial pressure (option 1). There is no known cause. Normotension is a client with a normal blood pressure (option 3). Secondary hypertension is an elevated blood pressure associated with several primary diseases (option 4). As hypertension progresses untreated, the fundi of the eye will demonstrate changes. These include (a) minimal vascular changes in the early stage; (b) irregular appearance of arterioles; (c) changes progressing to attenuation of retinal vessels with retinal hemorrhage; and (d) attenuation of retinal vessels with disc swelling in the late stage. Microaneurysms are seen in clients with diabetes mellitus (option 2). No red reflex is seen in clients with a completely opaque lens (option 3). Cupping of the optic disc is seen in a client with glaucoma (option 4). ACE inhibitors block the conversion of angiotensin I to angiotensin II or inhibit the effect of angiotensin II; therefore, the potent vasoconstrictor is not able to increase the blood pressure. Beta blockers and sympatholytics block the sympathetic nervous system, which stimulates renin (option 1 and 2); diuretics affect the absorption of sodium and water (option 3). Teaching about the antihypertensive drug management will include informing the client about situations that might cause lightheadedness and fainting. These situations would be standing motionless for a prolonged period of time, rising suddenly from a sitting position, or soaking in a hot bath. All of the answers are correct. However, if the drugs are properly administered, compliance is maintained (option 1 and 2) and the BP could be monitored on a monthly basis (option 3). MHR is determined by subtracting the client's age from 220. A target heart rate (THR) should be estimated based on the client's condition. However, the MHR is the upper limit the client can safely reach (if possible) and should not be exceeded. Options 1 and 3 are too low, and option 2 is too high for an MHR. The client with varicose veins must be monitored for the presence of constipation. If this is present, the client is encouraged to consume a high-fiber diet. Constipation increases the intra-abdominal pressure, thus promoting venous stasis in the lower extremities. Options 1, 2, and 3 are more commonly considered because these are likely problematic to the client already. Clients should be taught to avoid standing or sitting in one spot for a prolonged time period. Frequently, the healthcare provider will suggest wearing support hose, elastic stockings, or wrapping the legs from toes to upper thigh with elastic bandage. Knee-bending exercises are also suggested (option 1). Walking for the client with varicose veins is appropriate; however, the walking time should be about 1 mile per day, unless the client is already walking 3 miles (option 2). Encouraging the obese client to investigate a weight loss program is satisfactory; however, the key is to enroll and become actively involved with the weight loss program (option 3). Suicidal clients are at most risk when they begin to demonstrate improvement and have the energy to carry out suicide. A mute client who is not willing to share with others (option 1) is at risk for suicide but may be placed on constant observation. Being afraid to go home (option 2) may be a positive sign that the client is aware of the danger he may pose to himself. Vacation is a stressful time, and being left alone (option 3) would place the client at risk; however, it is well documented that clients are at greatest risk when showing signs of improvement. The client with Raynaud's disease will have altered peripheral tissue perfusion to the fingers and toes caused by spasms within the arterioles. This phenomenon may occur unilaterally or bilaterally as a result of a number of diseases, such as collagen vascular diseases, pulmonary hypertension, and many others. Raynaud's disease does not usually impair physical mobility (option 2). Anxiety is not a common finding; however, it may be present because Raynaud's disease is considered a chronic illness (option 3). Skin integrity may be decreased because of a diminished level of oxygen to the peripheral vessels. When this occurs, skin breakdown might occur and the risk of infection would increase (option 4). When monitoring fluid volume, the nurse needs to include the amount of blood loss from the client's system. Warning signs would be a decreasing blood pressure, restlessness, clammy skin, pallor, decreasing levels of consciousness, thirst, oliguria less than 30–50 mL/hr, and an increasing abdominal girth. Any changes indicating hypovolemia need to be reported to the surgical team immediately. Although options 1, 2, and 3 may be appropriate, notice that the question asks for the <i>highest</i> priority. Ischemia of the bowel may occur when the mesenteric vessels have been clamped and an ischemic colitis may follow (option 1). Altered tissue perfusion has probably occurred during the surgery. It is essential that pulses in each of the extremities be determined for presence or absence, and have the client report tingling or numbness anywhere in the body (option 2). Impaired gas exchange may occur because of the extent of the abdominal incision and the client's ability to cough and deep breathe (option 3). A client who is stable (without symptoms) and does not want to take medications or modify his or her lifestyle is likely to be noncompliant. Certain treatments for CHF are lifelong in order to prevent major complications, such as keeping blood pressure under control, modifying salt intake, exercising, maintaining a proper weight, and taking prescribed medication. Emphasis should be placed on the need to continue care even though there are no symptoms present. Hypertension is one of many potentially modifiable risk factors. All noted factors in options 1, 2, and 3 are not modifiable by the client. Other modifiable risk factors are smoking, high cholesterol, obesity, stress, and leading a sedentary lifestyle. Cholesterol is the substance carried by lipids that deposits along the arterial walls causing stiffening and narrowing of the vessel. These athrosclerotic plaques lead to coronary artery disease. The other answers are not applicable. Inverted T waves and a depressed ST segment are classic signs of ischemia. Elevated ST segment means damage. LVH would be noted by changes on a 12-lead ECG. Atrial fibrillation is accompanied by an irregular rhythm. The heart rate can be slow, within normal limits, or fast. The action of digoxin (Lanoxin) is to increase the force of contraction (positive inotropic) and decrease the heart rate (negative chronotropic). These actions will help in both congestive heart failure and atrial fibrillation. There is no need to monitor the vital signs every 15 minutes while on a telemetry monitor and in this situation. Normal cholesterol is less than 200 mg/dL. All the other options are nonmodifiable but are risk factors nevertheless. Emphasis should always be placed on modifiable risks. Intermittent chest discomfort relieved by rest is most likely angina pectoris. The pain of a myocardial infarction does not disappear until the damage has been done. Although the chest pain can mimic gastrointestinal distress or other illnesses, a thorough exam of the client should be made. A silent myocardial infarction can occur with no noticeable chest discomfort, and Q waves will appear on the ECG. The group at highest risk for successfully completing suicide attempts are European American males over the age of 50 (white, male, older adult). The clients in options 1, 3, and 4 are not in high-risk groups. Nitroglycerin is a vasodilator that dilates the coronary arteries and increases the blood flow to the myocardium, therefore relieving the pain. Morphine sulfate would be an example of option 2; options 1 and 4 are not related to angina. Increased heart rate decreases diastolic filling time, compromises coronary artery perfusion, and increases myocardial oxygen demand; the resulting ischemia leads to decreased cardiac output. The body's initial attempts are an effort to meet the supply and demand of the heart. Compensatory mechanisms, however, begin to work negatively later on. Shortness of breath, dyspnea on exertion, and crackles are classic signs and symptoms of left-sided heart failure. The fluid backs up into the lungs from the left side. Right-sided heart failure leads to backflow of blood to the peripheral circulation causing edema in the extremities, jugular vein distention, and possible ascites. Left heart failure produces increased pulmonary congestion and pink, frothy sputum; but exaggerated symptoms would be present for pulmonary edema to be diagnosed. Right-sided heart failure includes signs of peripheral edema. PND is a result of the fluid shift at night in the supine position, from the interstitial to the intravascular compartment, causing increased workload to the heart. Because of the increased volume, pulmonary congestion occurs. The client awakes with severe dyspnea. Elevated heart rates lead to decreased ventricular filling time and weaker pulse. Arrhythmias such as atrial tachycardia may increase the heart rate to 180 to 200 bpm. Monitor for signs of adequate cardiac output. Frequent monitoring of vital signs and hemodynamic monitoring allows for early detection of changes in condition and early intervention. Clients with heart failure can rapidly deteriorate; usually vital signs are the first indicator. Atrial dysrhythmias are frequently seen in heart failure. Atrial fibrillation is irregular, has no discernable P waves, and is often accompanied by a fast ventricular response. Sinus arrhythmia is a normal variant related to increased intrathoracic pressure (vagus stimulation) as seen with deep inspiration and expiration. It is a benign arrhythmia that requires no treatment. Athletic syndrome is common with very active individuals that have increased cardiac strength and force of contraction. The heart rate may be as low as in the 30s in extremely athletic individuals, especially runners. If the client is asymptomatic, no treatment is necessary. Voices telling a client to hurt himself or others are called command hallucinations. There is not enough data to support hopelessness (option 1), emotional pain (option 2), or delusions of grandeur (option 3). Junctional rhythm is a regular rhythm originating in the AV junction with a rate of 40 to 60 bpm, no discernable P wave or an inverted P wave before, during, or after the QRS complex. The QRS complex is less than 0.12 seconds in duration. The cause of the arrhythmia should be determined and treated or a pacemaker inserted. Second-degree heart block type II (also referred to as classical) has two or more P waves per QRS complex and has a constant PR interval. The ventricular rate is usually bradycardic. When examining a client with severe hypertension, the client may be demonstrating hypertensive encephalopathy. If this occurs, the client will have a change in the level of consciousness ranging from confusion to coma and possible seizures. The client experiencing severe hypertension may or may not demonstrate a headache (option 2). Unless pulmonary edema is present, the breath sounds will be clear bilaterally (option 3). Temperature is less critical than pulse (option 4). The PTT is used to monitor the level of heparin so that a therapeutic dose may be administered. GPT is a liver enzyme and will not be affected by heparin (option 1). The PT is used to monitor Coumadin therapy (option 2). The FBS is used to monitor the blood glucose levels (option 4). When reviewing the risk factors that are listed, both sodium consumption and the use of substances may be modified if the client desires to participate in a lifestyle change. Nonmodifiable risk factors are those that are not changeable, such as family history, gender, and ethnicity (option 1). Personal choice risk factors is not a commonly used phrase (option 2). Gender risk factors are a subgroup of the nonmodifiable risk factors (option 3). Triggers in Raynaud’s are cold, caffeine, smoking, and stress. Raynaud’s disease has the characteristic of the vessels that become vasospastic in nature, but inflammation does not occur (option 1). Smoking is considered a trigger because of the nicotine contained in the tobacco, but claudication is not usually found in clients with Raynaud’s disease (option 3). Smoking is the primary cause of Buerger’s disease (option 4). Raynaud’s is caused by genetics or autoimmune disorders. The primary treatment of a client with thrombi is to monitor the anticoagulant therapy. The therapy will prevent the formation or extension of thrombi by inhibiting the clotting factors or by quickening their inactivation. Options 1, 2, and 4 are correct, but are not the primary treatment. Clients need an analgesic for their discomfort. Warm packs may also be used to promote comfort (option 1). The client's bed is to be elevated 6 inches at the foot of the bed. This forces (via gravity) the blood to return and not to remain stagnant (option 2). Pulmonary emboli may occur and lung sounds should be auscultated (option 4). Hypertension is a major public health concern in the areas of prevention and early detection of new cases across the age continuum. Monitoring the existent hypertensive clients is a challenge and the focus is on the prevention of further complications of the disease and reducing the cardiovascular risks (option 2). The study of cardiovascular risks is a long-term goal. The population awareness and early detection are important within each community (option 3). The study of isolated systolic hypertension is narrowly focused and could be addressed in other initiatives (option 4). The diet of the client with hypertension needs to include the essential amounts of calcium found in milk for neuromuscular irritability, transmission of nerve impulses, skeletal muscle contraction, and clotting. Magnesium in the form of oranges is needed as an important intracellular enzyme system. Also, neither of these foods is high in sodium. Processed foods are generally high in sodium and should be avoided by the hypertensive client (option 1). Carbonated beverages contain either high levels of sodium or potassium (option 2). Nuts are high in phosphorus and sodium. Phosphorus and calcium are in an inverse relationship to each other (option 4). Drug distribution is determined by the adequacy of the plasma volume, the extracellular fluid volume, and the serum protein levels. Many of the drugs are processed through the liver or the kidney. Any impairment of either organ will potentially cause a problem of overdose (option 2). With a decrease of the total body water, the peripheral resistance will be increased to provide the body with an auto-transfusion (option 3). The elderly client has a slowing of the intestinal motility and absorption. This may adversely affect the therapeutic drug level (option 4). The client is communicating that he or she may not be around for the nurse to worry about. Creating a solution (option 2), expressing hope for the future and making plans (options 3), and decreasing frequency of voices (option 4) indicate that the client is experiencing a reduction in the risk for suicide. When the client has a diagnosis of fluid volume excess, monitoring all fluids is important. Failure to monitor the client places him or her at risk for further complications, such as pulmonary edema and congestive heart failure. Options 1, 3, and 4 are correct but are not the highest priority. Teaching the client about the treatment plan is important but is not the highest priority (option 1). The client needs to know about a low-sodium diet and appropriate food selection (option 3). Monitoring the client for signs of dependent edema is important (option 4), but intake and output of all fluids is higher. The kidneys will not excrete water and sodium unless there is an adequate pressure gradient. The mean arterial pressure rises between 40 and 60 percent in essential hypertension (option 1). Blood flow resistance rises between two- and four-fold in essential hypertension (option 2). The client with essential hypertension has a normal cardiac output (option 3). Raynaud’s disease occurs predominately in young women between the ages of 20 and 40. Causes are usually unknown or genetic (option 2). Raynaud’s disease is known as a progressive disease, which becomes worse over time (option 3). Intermittent claudication is not associated with Raynaud’s disease (option 4). The major therapeutic intervention that has the highest priority is to keep the client's hands and feet warm as well as free from injury. The hands and feet must be kept from exposure to cold temperature, which is a trigger stimulus. The client with Raynaud's disease does not have intermittent claudication (option 1). Opioids are usually not needed in Raynaud's (option 2). Stress management is considered important because anxiety may be a triggering stimuli (option 4). Buerger’s disease is a vascular disease of the small- and medium-sized peripheral arteries that become inflamed, thrombotic, and spastic. This disease is primarily found in the legs and feet. The exact cause of Buerger’s disease is unknown; however, it is possible that it is an autoimmune response. There is a high incidence of the disease in heavy smokers and it occurs in men under the age of 40 (option 2). Buerger’s disease has an intermittent course characterized by exacerbations and remissions. Over time, the severity and duration of the attacks become more severe (option 3). The hands of the client are rarely affected (option 4). When planning for the nursing management of a client with Buerger’s disease, managing the altered peripheral tissue perfusion is primary. Because the arterial circulation is thrombosed, inflamed, and spastic, there is limited ability to carry oxygen and nutrients to the tissues and return with the waste products of metabolism. All options are correct but the stem asks for the highest priority. The risk of injury to the tissue may be due to tissue hypoxia. The client must be encouraged to completely stop smoking (option 1). The client will probably be placed on bed rest because of the impaired activity and immobility during the exacerbations of symptoms (option 2). Pain is caused by the intermittent claudication. This, in turn, is caused by the vasoconstriction and vasospasm of the arteries following inflammation of the arteries (option 3). As the muscle hypertrophies in order to contract forcefully enough to overcome the high pressure and peripheral vascular resistance, this mechanism eventually requires more oxygenated blood to the heart. The increased workload will cause the heart to “tire out” and congestive heart failure can occur. What was a compensatory mechanism of the heart becomes a complication. The stiffened muscle cannot produce the necessary cardiac output and becomes congested. Options 1, 2, and 3 are not compensatory mechanisms. Anticoagulant therapy is started early to prevent the extension of the thrombus or the possible embolization of the thrombus. All options are correct but option 1 is the highest priority. Elevation of the client’s legs is a comfort measure, and the elastic bandages will provide support to the extremity. The client’s heel must be included in the wrap. These bandages are to be applied snuggly and rewrapped every 4 to 8 hours. They must be inspected frequently as they may become dislodged (option 2). The use of warm packs and an analgesic are appropriate but not as the first priority (option 3). The monitoring of the PTT or the INR will be done every 4 hours (option 4). The nurse will examine the lower extremities for swelling. Frequently, measurement of the midcalf is obtained every 8 hours. Homan’s sign is considered somewhat unreliable. It is reported that approximately 35 percent of clients with deep venous thrombosis will have a positive Homan’s sign (option 1). The extremity may be reddened in the area of the thrombosis if a superficial vein is involved. The client may or may not report calf tenderness (option 3). A pulse is usually palpable or audible by Doppler unless an arterial clot is present (option 4). Teach the client not to sit for prolonged periods of time (more than 30 minutes) or stand (more than 5 minutes) without changing positions. Instruct the client not to cross the legs when sitting and to elevate the legs periodically if prolonged standing is needed. Medication is usually not recommended with varicose veins (option 2). Protection from cold is needed in Raynaud’s and Buerger’s diseases, not for varicose veins (option 3). The management of the client’s pain may be of concern but should be controlled by over-the-counter medications and regulating activity. The pain is caused by the venous pooling of blood and the lack of nutrients and oxygen to the tissues. If the pain is worsening, the client’s condition needs further monitoring and possible modification of the treatment regimen (option 4). Releasing restraints at least every 2 hours is a standard of care to prevent physical harm. Every 15 minutes (option 1) or hour (option 2) may be too often, and every 4 hours (option 4) is too long and may cause the client injury. In addition to the intervention described, the client’s circulation should be checked every 30 minutes. Ensuring the client’s safety and well-being are a priority. The major pathophysiological factor in the development of varicose veins is the prolonged increased pressure within the venous structure. The process is compounded by the venous values becoming stretched and unable to close, creating a pooling of venous blood. Blood flow is compromised and is moving slower in the venous system of the lower extremities (option 1). Varicose veins involve the venous, not arterial, system (option 3). The intraabdominal pressure is constant and compresses the venous system of the lower extremities (option 4). The pulses with a venous insufficiency are normal or decreased; however, the pulses for an arterial ulcer are diminished or absent. Warmth usually indicates inflammation and possible thrombophlebitis (option 1). The skin appearance is brown with venous stasis and cyanotic when placed in a dependent position (option 2). The level of pain the client is reporting is usually a mild achy pain with venous insufficiency (option 3). When cardiac tamponade occurs, the restriction reduces stroke volume, cardiac output, and blood pressure. The right atrium is restricted causing JVD and increasing pressure during diastole. While the decreased stroke volume decreases the pressure during systole, the client compensates for decreased stroke volume and cardiac output by increasing heart rate. Because of decreased filling pressure, cardiac output drops and blood pumped from the right heart is reduced. Lung sounds are usually clear; heart sounds become more distant and muffled because they are heard through the fluid collection in the pericardium. Once a client is diagnosed with SBE, he or she is at risk for repeated episodes. Taking prophylactic antibiotics prior to dental care is an important activity to prevent further infections. There is no routine sodium restriction with SBE. Antibiotic treatment for SBE is given by the IV route for the entire course. Although stopping smoking will decrease his risk factor for coronary artery disease, it does not affect the SBE. Pulmonary edema in a client with heart failure is the accumulation of fluid in the alveoli characterized by increased rales; tachypnea; tachycardia; pink, frothy sputum; and decreased SO<sub>2</sub> and PO<sub>2</sub>. The client presents with acute restlessness and anxiety. Urine output is generally decreased in heart failure clients; increased urinary output is usually caused by diuretic therapy. The dye typically used for cardiac angiography is iodine based. The client with a known allergy to seafood is at risk for anaphylaxis and requires alternate media; atrial fibrillation and chronic renal failure are not contraindications to cardiac angiography; 5.0 mEq/L is a normal value for potassium. Daily weight is the most sensitive indicator of changes in fluid status. It is more accurate for a client at home than urine output. A fluid restriction may be recommended for a client with advanced heart failure, but it is not a method of monitoring fluid status. The client should never adjust the dose of his or her medications. Bed rest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. Explaining the rationale to the client is the best way to facilitate the client’s cooperation. Although the factual information in the other options may be true, it does not assist the client to understand the basis for care restrictions. Metoprolol (Lopressor) is a beta adrenergic blocker that slows the heart rate and decreases myocardial contractility (option 4). These actions reduce cardiac workload. Because of this, options 1 and 3 cannot be true. Nitroglycerine is a drug that dilates the coronary arteries (option 2). A prudent diet would be high in potassium because digoxin and furosemide can both deplete potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart failure. Chicken, potato, and cantaloupe are all potassium-rich foods and options 2, 3, and 4 are higher in sodium. Safety of the client is always a priority for clients who have recently attempted suicide. Options 1, 3, and 4 are all appropriate goals after safety has been assured. Although some clients may have fear, hopelessness, or knowledge deficit related to their disease progression, most clients with cardiomyopathy are likely to have decreased cardiac output and corresponding activity intolerance. More data would be needed to determine whether the other nursing diagnoses apply. A client who is in ventricular fibrillation requires immediate defibrillation; a client with atrial fibrillation may require synchronized cardioversion; a client with ventricular tachycardia may require defibrillation. The client with second-degree heart block is the client in this group that would most likely need a pacemaker. Blood pressure should be consistently below 140/90. Lifestyle modification must be used in all hypertensive clients with or without medication therapy. Pain of arterial occlusive disease is related to interrupted blood flow, which causes tissue hypoxia. An increase in blood supply, then, should reduce the client's ischemic pain. The other options list additional manifestations of peripheral arterial disease. Beta adrenergic blocking agents, such as propranolol, cause a decrease in heart rate and decreased contractility, which can result in bradycardia or heart failure. Constipation is a side effect of therapy with some of the calcium channel blockers, while hypokalemia increases risk of digitalis toxicity. The classic manifestations of a deep vein thrombosis are calf or groin pain, which may or may not be associated with leg swelling. The other options describe symptoms of arterial disease. Orange juice is an excellent source of potassium. Coffee will adversely elevate blood pressure. Milk is high in sodium. Cranberry juice is not as high in potassium as orange juice. The primary symptom of a dissecting aneurysm is sudden, severe pain. Abdominal dissections commonly cause back pain. The other responses do not address this emergency. Heparin dose concentration and number of units per milliliter per hour are ordered to maintain a therapeutic PTT. The other responses are incorrect. Intermittent claudication caused by muscle ischemia is a primary symptom of peripheral arterial disease. Pain occurs with activity but is relieved with rest. The other options are not associated with this disorder. The nurse should ensure that the interview be conducted in a quiet environment. Interruption should be kept to a minimum (option 2), but may not be possible to prevent. Intimidation of the client (options 3 and 4) is inappropriate. Clients with orthostatic hypotension are at risk for dizziness and syncope if they arise quickly. Option 3 is a correct action but does not relate directly to orthostatic hypotension. Blood pressure should also be taken while the client is sitting and standing (option 2). Option 4 is unrelated to the question. A common complication of hypertensive disease is target organ disease, including retinal damage to the eye. The appearance of the retina can provide important information about the severity of the hypertensive process. A side effect of digoxin and furosemide is that they promote the excretion of potassium and a U wave is a sign of hypokalemia. The other options are incorrect. The transducer must be at the same level as the right atrium in order to obtain an accurate measurement. It is the nurse’s responsibility to level the CVP transducer to this point at regular intervals according to policy and before each measurement. Vitamin K is not associated with the incidence of PVCs. There is no evidence in the question that this client has a potassium deficiency, or is at risk for one. It is recommended that clients having PVCs eliminate caffeine and nicotine. Atrial fibrillation is characterized by irregularly irregular QRS complexes and rhythm. There is no underlying regular rhythm with atrial fibrillation. Cerebrovascular accident (CVA) is a very serious complication of thrombolytic therapy. The most important intervention to detect this complication is frequent monitoring of neurological status. Testing for occult blood is important with these clients to detect GI or urinary tract bleeding, a less serious complication. PTT monitoring does not detect a specific area of bleeding. Teaching a client to use a soft toothbrush is important to prevent bleeding gums, a minor complication of this therapy. Prognosis is often poor with advanced cardiomyopathy and little can be done to increase the client's activity level. The symptoms usually become worse as the disease progresses. Irritability and withdrawal may be a sign of feelings of inadequacy or despair. Validating the difficulty of the client's experience is an intervention to create an environment of acceptance and empathy. Sudden onset of dyspnea, anxiety, and tachycardia are signs of pulmonary embolism, a serious complication of SBE. Chills and fever may be symptoms of SBE; bleeding gums and occult blood are not symptoms of a direct complication of SBE; the client with SBE usually has a normal WBC. In a client with heart failure, a weight gain of 3 to 5 pounds over a week is a significant indicator of an increase in retained fluid. It is not appropriate to provide false reassurance to a client. The fluid increase indicates that the therapeutic regime is not adequate for this client. It is important for the nurse to ascertain if the client has been taking his or her prescribed diuretics, and consult with the primary care provider before the client’s fluid overload becomes excessive. Diet alone is not adequate to treat this increase in fluids. Decreasing sensory input may decrease the anxiety or anger and help the client regain control. Seclusion should never be used for staffing ratios (option 2). Communication with others (option 3) is part of milieu therapy. Seclusion takes away the client’s responsibility temporarily (option 4). Pain is usually the first presenting sign of new or extended MI, which is a very serious complication for this client. Activity order for a client immediately post-MI is usually bed rest or commode privileges. Although an important client outcome is to be free from life-threatening dysrhythmias, clients frequently have benign dysrhythmias after an MI, and many are not in normal sinus rhythm. Maintaining a balanced intake and output is important, but not as critical as remaining pain-free. An adult who collapses after complaining of chest pain will require immediate defibrillation. This is a cardiac emergency and immediate defibrillation is the recommended response. Administration of nitroglycerine is recommended when the client is complaining of chest pain, but once the client collapses the next step is to apply the AED. Checking vital signs and calling the physician are appropriate once the emergency response system takes over client care. Pulses are monitored frequently to assure adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses may be absent for a short-term postoperatively due to vasospasm or hypothermia. Elevation of the extremities promotes venous return. Pulses are monitored to assure adequate circulation. Option 3 is unnecessary because the Unna boot is treating the ulcer and is changed every 1 to 2 weeks. Aspirin is an antiplatelet agent, and its properties will increase the risk of bleeding while the client is taking anticoagulant therapy. The medication does not place the client at risk for infection (option 2), nor does it directly affect blood pressure (options 1 and 3). During heparin therapy, the therapeutic PTT equals 1.5 to 2.0 times the control value. The other options do not reflect this ratio. In Raynaud’s disease, vasospasm causes the digits to initially turn blue and then white. As the vasospasm ends and circulation returns, the digits become very red and warm. The other disorders listed do not have these manifestations. A goal of venous ulcer care is for the client to experience no signs of inflammation or infection. This is the goal that is directly related to tissue integrity. The other options are good outcomes but do not relate directly to the question as stated. Both butter and margarine have 4 grams of fat, making the client’s statement incorrect and in need of further clarification. The responses in the other options are correct. Dry mouth is a common side effect of this centrally acting adrenergic blocker, which acts to reduce the flow of blood through the sympathetic nerves to the blood vessels and heart. Use of sugarless chewing gum, hard candy, and frequent sips of water will help relieve this side effect. Fidelity means to be faithful to agreements and promises. This nurse is acting on the client’s behalf to obtain needed information and report it back to the client. Nonmaleficence is duty to do no harm. Veracity refers to telling the truth—for example, not lying to a client about a serious prognosis. Beneficence means doing good, such as by implementing actions (keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium-restricted diet). The nurses must first assess current emergency department resources. No decisions can be made without a comprehensive assessment, such as outlined in option 1. The other options are not as encompassing, and a comprehensive assessment is needed with a possible impending disaster. Option 4 provides the client with information that the nurse is concerned about her, which may ease her emotional pain. Telling the client, “Of course people care” (option 1) is false reassurance. Telling the client not to talk about sad things (option 2) invalidates and ignores the client’s feelings. Option 3 may be seeking clarification but may also cause the client to feel she has to defend her position. Smoking is a major etiological factor for development of Buerger’s disease. Nicotine is a potent vasoconstrictor and will exacerbate peripheral vascular disorders. The other options do not address the issue of the question. Bed rest and immobility are risk factors for the development of deep vein thrombosis. Early ambulation assists venous return to the heart because of muscle movement against veins, and should be implemented as soon as possible in hospitalized clients. Nitroglycerine loses potency over time when exposed to light and heat. They should be kept cool, dry, and in a dark container. Clients should get a new bottle every 6 months, and store them in a cool place; tablets should be taken 5 minutes apart, taking more than one tablet at a time can actually decrease the effectiveness of the drug and may cause severe hypotension. ST elevations indicate immediate myocardial injury; ST depressions indicate myocardial ischemia; a Q wave forms several days after a myocardial infarction; a U wave is a sign of hypokalemia. ST depressions are a sign of ischemia. The physician should be notified immediately of any signs of ischemia after PTCA. This is the best first action, after which the nurse should continue to monitor the client for chest pain. Administration of nitroglycerine without an order is not an appropriate nursing action. There is no sign of bleeding at the site; therefore, there is no indication to apply pressure. St. Jude Medical is a mechanical valve. Lifelong anticoagulation therapy is required with this mechanical valve because there is a risk of thrombus formation. If a valve is replaced with a tissue valve, anticoagulation may be required during the immediate postoperative period but is not necessarily lifelong. It is recommended to take antibiotics prior to dental care. Vigorous coughing is discouraged for post-CABG clients because it may increase intrathoracic pressure and cause instability in the sternal area. Incentive spirometry and deep breathing are the preferred techniques for lung expansion with these clients. Premedication before ambulation will facilitate activity tolerance; auscultating lungs will detect adventitious lung sounds resulting from the ineffective breathing pattern, but it is not an action to encourage effective breathing patterns. A cholesterol level greater than 200 indicates elevated cholesterol; the ratio of HDL to total cholesterol of less than 1:5 indicates increased cardiovascular risk; triglycerides greater than 190 indicate increased risk (exception: triglycerides greater than 190 without elevated cholesterol do not indicate increased cardiac risk until they reach 250). Synchronized cardioversion is most effective with new-onset atrial fibrillation. Pacemakers are indicated for heart block, AICDs are used for ventricular dysrhythmias, and defibrillation is indicated for ventricular fibrillation and pulseless ventricular tachycardia. The client should have a light meal with no caffeine before a cardiac stress test. Options 1, 2, and 3 are incorrect because they do not follow this guideline. The client demonstrates effective coping by being able to discuss the incident without excessive distress and formulating a realistic plan to prevent recurrence, which will reduce anxiety (parking closer to buildings and enrolling in self-defense classes). If the client states she will never shop at the mall again, or will go shopping only when accompanied, this shows unresolved anxiety and a nonadaptive approach that is likely to interfere with her lifestyle. The best first action is to evaluate the client's level of consciousness and determine if the ventricular tachycardia is perfusing the body (BP, pulse). With pulseless ventricular tachycardia, immediate defibrillation is performed by an ACLS certified nurse. If the client has a good BP and pulse, is awake and alert, the physician may administer lidocaine and perform cardioversion using sedation. Anxiety and fear are common responses to a diagnosis of myocardial infarction because of the possibility of death. This prevents the client and family from absorbing the detailed explanations about the care being provided. Memory lapses are not a common symptom of myocardial infarction, and there is not adequate information to determine that this memory lapse is associated with Alzheimer's disease. Nurses in the emergency room are able to explain procedures well to their clients. Fifty percent of people over the age of 50 develop varicose veins, and a major risk factor is standing for long periods of time at work. The other responses do not address this concern. Primary hypertension is more common in African Americans than in people of other ethnic backgrounds. For this reason, this client should be carefully evaluated. Blanching of the nail bed for more than 3 seconds after release of pressure may indicate reduced arterial capillary perfusion, which may be an indication of decreased cardiac output. The other options are incorrect for the time frame indicated or do not apply. Elevating the legs increases venous return to the heart and will assist in raising the blood pressure. A semi-Fowler’s position could lower the blood pressure even further. A side-lying position will have no beneficial effect, and the Trendelenburg position could impair respirations by causing upward pressure on the diaphragm by gravity. Calcium channel blockers relax arterial smooth muscle, which lowers peripheral resistance through vasodilation. Dizziness is a common side effect because of orthostatic hypotension. Clients need to be taught to change position slowly to prevent falls. Spironolactone is a potassium-sparing diuretic. Hyperkalemia (potassium greater than 5.5 mEq/L) is a possible side effect. The other responses are incorrect. Anticoagulant therapy is used for deep vein thrombosis to prevent propagation of the clot, development of a new thrombus, and embolization. It does not dissolve the clot. It has no effect on infection and does not allow for immediate ambulation. Sclerotherapy, the injection of a sclerosing agent into a varicose vein followed by compression with a compression bandage for a period of time, is a common procedure for varicose veins. Peripheral circulation decreases and shifts to the vital organs. The vascular system collapses, causing decreasing pulse and blood pressure. The gag reflex is lost, and mucus accumulates in the back of the throat. Respirations decrease in rate, and the rhythm is irregular. Muscle rigidity typically occurs after death. Vision is blurred. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected. Because of the risk for inflammation or a blood clot, low doses of aspirin are recommended for all clients with peripheral vascular disease. Aspirin has antiplatelet activity; without platelet aggregation, a clot cannot form. Sensation in the feet may be diminished in clients with arterial occlusive disease. Teach the client to check the bathwater with the hands to prevent the risk of a burn injury. The client should stop and rest when pain is experienced (option 3). Options 1 and 2 are useful treatments for venous disease. Children with acyanotic heart defects may have a murmur without other symptoms. Dyspnea and tachycardia are early signs of pulmonary edema, which may lead to congestive heart failure. Pulmonary overload occurs prior to congestive heart failure. Crackles and frothy secretions are signs of moist respirations, a symptom of pulmonary overload. Fluid volume excess, secondary to ineffective cardiac function, leads to hepatomegaly and rapid weight gain. ASO titers indicate history of streptococcal infection, which is a precursor to rheumatic fever. The other symptoms are not related to this diagnosis. The streptococcus may or may not be present at the time of diagnosis, so the blood culture could be negative or positive and the WBC count normal or elevated. Blood pressure will be elevated in upper extremities and reduced in lower extremities with presence of coarctation of the aorta. The constriction of the aorta may be progressive. Vital sign monitoring provides data related to this progression and should be more frequent than once a day. The knee-chest position decreases venous return to the heart and thereby increases systemic vascular resistance, which leads to decreased cardiac output. Parents need to be prepared for emergencies. Crying for short periods is effective as a deep breathing exercise. Increased intracranial pressure is not associated with cardiac failure. Monitoring growth and development would not be the primary concern. Among the symptoms of rheumatic fever is migratory polyarthritis. The child will complain of aching joints. At the time of diagnosis, the child is not infectious. CPR is not a priority at this time because the child is hospitalized. Aspirin is ordered as an antipyretic and anticlotting agent, while immunoglobulins decrease fever and inflammation. Reducing symptoms of the disease will increase client comfort. The child’s lips are cracked, and soft foods and liquids are comforting. The child will be lethargic, and passive range-of-motion exercises are utilized to facilitate joint movement. Hospice specializes in end-of-life care. A rabbi is an important person during the end of life, but there is not an immediate need to make this call. An attorney or medical examiner is not necessary at this time. The child needs to take prescribed antibiotics indefinitely to prevent future infection and possible endocarditis from streptococcal infection. Complete bed rest is not required in the recovery period, but the child is maintained with limited activities. Complications of rheumatic fever are cardiac, not CNS. The patent ductus is a fetal structure that lies between the aorta and pulmonary artery. In fetal life, the ductus allows blood to bypass the lungs. After birth, because of the change in pressures, oxygenated blood will return to the lungs by the ductus. The pressure is greatest in the left ventricle because that heart chamber must supply blood throughout the body. The pressure in the other chambers is lower. The hemoglobin molecule carries oxygen. The oxyhemoglobin gives the skin the pink color. In the absence of oxyhemoglobin, the skin color darkens. Jones Criteria is a protocol to assist in identifying rheumatic fever. It consists of major symptoms, minor symptoms, and supporting evidence. Erythema, polyarthritis, and elevated ASO titer are among the major and minor symptoms and supporting evidence. Aspirin therapy is ordered 80 to 100 mg/kg/day until fever drops. Then aspirin is continued at 10 mg/kg/day until platelet count drops. Aspirin is used as an antipyretic and antiagglutination drug. Furosemide (Lasix) is a diuretic given to the client with congestive heart failure to assist the kidneys in reducing the fluid load in the body. An ineffective heartbeat tends to retain excess body water. Although a child requiring surgery for tetralogy of Fallot may have a need for additional services, such as supplemental oxygen at home, the child should be able to play and move about in the environment to meet both physiological and developmental needs. Direct pressure on the wound site helps to form a clot and reduce bleeding. Hemorrhage can be life threatening in the immediate postprocedure period. Food intake is a lesser concern than maintaining hemostasis. Infection would not be apparent immediately following the procedure. Signs of congestive heart failure could relate to the original disease process but are not a priority at this time; physiological needs take current priority. Furosemide is a diuretic, so measurements that most directly illustrate output and water loss would be evaluated. With this in mind, intake and output and daily weight would be key monitoring parameters, as they typically and accurately reflect fluid balance. Hemoglobin level measures the iron content of red blood cells. The pulse can be influenced by many variables. Partial pressure of oxygen is measured via arterial blood gases and is unrelated to the question. The body is to be handled with dignity at all times. Even though humor can alleviate stress, it is not appropriate at this time. Once the body is cleaned, all external tubes and drains are removed, the linen is freshened, the sheet is pulled to cover the client’s shoulders. While gloves should be worn during postmortem care, sterility is not an issue. State laws and policies differ regarding the nurse’s ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly and is not required prior to the family being allowed to view the client after death. Signs of digoxin toxicity include bradycardia, cardiac dysrhythmias, nausea, vomiting, anorexia, dizziness, headache, weakness, and fatigue. Because of activity intolerance and respiratory distress, the child may be unable to take in enough nutrients to meet the body’s need for growth. The child is not at risk for seizures or pain because of this health problem. There is no information in the question to support the diagnosis of diversional activity deficit. Cardiac involvement is the most serious complication. The other signs and symptoms are diagnostic indicators of Kawasaki disease. Older children with acyanotic congenital heart disease may be asymptomatic, or manifest exercise intolerance, chest pain, arrhythmias, syncope, or sudden death. Option 2 is false, and options 3 and 4 are both false and place inappropriate blame on the parents. Chronic hypoxemia in cyanotic heart disease leads to polycythemia, an above-normal increase in the number of red cells in the blood. This change increases the amount of hemoglobin available to carry oxygen. The other answers do not differentiate between the cyanotic and acyanotic forms of heart disease in the child. Aspirin is an antipyretic (option 5), an analgesic (option 1), and an antiinflammatory (option 1). It does not prevent complications, hasten recovery, or relate to the development of chorea. Infective endocarditis is the most common complication of the cardiac surgery. Children may need prophylactic antibiotic therapy for specific conditions as recommended by the American Heart Association. Clubbing of the fingers and toes occurs in cyanotic heart defects, such as transposition of the great vessels. Rheumatic fever is an inflammatory response of collagen tissue after experiencing a streptococcal infection. Some members of the family may be asymptomatic carriers. At this stage of grieving, the mother needs someone to listen and validate that her feelings are respected. Information will not be heard or remembered. The signs and symptoms listed indicate death will occur soon and the spouse is fearful to leave the room at this time. Obtaining a meal for the client’s spouse while she remains at the bedside and supporting her during the client’s imminent death demonstrate knowledge of the dying process in addition to compassion and concern for the client and spouse. In the child with a atrial septal defect, blood follows the normal pathway from right atrium to right ventricle to left atrium. At that point, some of the blood will flow through the atrial septal defect back to the right atrium. Prostaglandin E1 helps maintain a patent ductus arteriosus open and thereby allows for mixing of blood. If the ductus arteriosus closes, cyanosis will increase. The other options represent false statements. Although a ventilator is not required for injury below C3, the innervation of intercostal muscles is affected. Hemorrhage and cord swelling extends the level of injury making it likely that this client will need a ventilator. Keeping the head of the bed elevated to 30 degrees promotes venous drainage, which is important in decreasing ICP. Alignment of the head prevents obstruction of the jugular veins. Obstruction would impede venous drainage. Momentary loss of consciousness followed by a lucid period and rapid deterioration is a classic picture resulting from a torn cerebral artery, producing an epidural bleed. The period after the clonic phase of a seizure is the postictal period. Typically, the client slowly regains consciousness, moving from a relaxed, quiet state to confusion or disorientation on awakening. Protective pads or diapers should be used only after all other treatment modes have been tried. Early dependency on incontinence products may decrease motivation to seek evaluation and treatment. Clients with meningitis will be less able to protect themselves from both internal and external injury. Providing cognitive stimulation and increasing cardiac output are contraindicated with meningitis. Enhancing coping skills may be a focus if the client has residual effects from meningitis but is not a major focus. Presyndrome to Guillain-Barré syndrome is often a viral infection or immunization. Lower extremity weakness or paralysis that progresses upward is classic in Guillain-Barré. Fatigue is not usually seen, nor are tremors or seizures. The client should know the signs of crisis and should report them immediately. There is often more fatigue and weakness later in the day than in the morning, so the client should plan important activities for early in the day. It may be easier to eat three small meals with snacks because chewing may cause fatigue. Hospice care is provided to those clients who have 6 months or less to live. Hospice nurses are skilled in pain and symptom management as well as in emotional support to the dying clients and their families. Hospice care does not terminate once families learn to provide care (option 1), and a client in need of hospice services cannot be expected to resume self-care (option 3). The resting or nonintentional tremor may be controlled with purposeful movement, such as holding an object. Deep breathing, a warm bath, and diazepam will promote relaxation but are not specific interventions for the tremor. Always believe the client’s report and ranking of pain. The client tolerated the last full dose of medication, so he should be given a full dose now. The nurse would evaluate the client’s pain level within 30 minutes of administering pain medication depending on peak action time of the drug. The nurse will evaluate his vital signs in 30 minutes after administering another dose of medication, but it is not the priority action at this time. Stresses such as pregnancy can increase the chance of an exacerbation of MS. Signs of an exacerbation are spasticity, weakness, or visual changes. Option 1 indicates Guillain-Barré syndrome; option 2 indicates increased intracranial pressure or hematoma; option 3 indicates meningitis. When seizure activity becomes continuous and repetitive, respirations are affected and the progression of status epilepticus is life threatening. Nursing interventions address prevention of hypoxia, acidosis, hypoglycemia, hyperthermia, and exhaustion. A positive Kernig's sign, which is described in option 1, is common in intracranial hematomas. Option 2 is a negative Babinski; with a hematoma the nurse should expect a positive Babinski (fanning of the toes in an adult). Option 3 is common in many illnesses; option 4 is specific to Parkinson's disease. The spinal needle is inserted into the area below the spinal cord, eliminating the likelihood of paralysis. A misdirected needle may puncture a distended bladder. The client must maintain the knees-to-chest position until completion of the lumbar puncture. Because cerebrospinal fluid (CSF) has been removed during the lumbar puncture, time must be allowed for production and replacement of the CSF. Spinal cord injury at or above the level of T6 can experience an exaggerated sympathetic response, seen only after recovery from spinal shock. If untreated, autonomic dysreflexia is potentially fatal as bradycardia and severe hypertension progress. Corneal abrasion in the client with myasthenia gravis is caused by dryness of the cornea from inability to close the eyelids and blink. It can be prevented by application of artificial tears every 1 to 2 hours. Meningitis bacteria or viruses often gain entry into the cerebrospinal fluid secondary to an upper respiratory tract infection. Options 1, 3, and 4 are generally healthy practices for the elderly client but not specific health promotion for prevention of meningitis. Plasmapheresis is performed to remove autoantibodies that attack the myelin sheaths of motor and sensory nerves in Guillain-Barré and attack the acetylcholine receptors at the neuromuscular junction in myasthenia gravis. The other diseases have not been identified as benefiting from plasmapheresis. This client situation acknowledges that while the lack of nutrition and fluids will produce ketones and cause somnolence to decrease the client’s anxiety and promote overall comfort, the wife is more concerned about how dehydration might feel to her husband. Beneficence promotes doing good for the client, the focus of a quality death. Veracity and fairness are not considerations in this situation. The nurse should first encourage the client experiencing a loss to express his or her feelings. Option 1 acknowledges the client’s feelings, is open-ended, and promotes further discussion. The client’s pain is affective as well as sensory. Grieving his wife’s death is a normal response that does not necessarily require psychiatric consult. Options 1 and 2 address the sensory, not the affective, component of his pain. The first signs of increased intracranial pressure (IICP) are often subtle changes in level of consciousness. Other changes (including rising systolic BP, irregular respiratory rate, and bounding pulse) come later as intracranial pressure rises more. It is essential that the client recovering from meningitis take all of the prescribed antibiotic as directed. Failure to do so puts the client at risk for a relapse of symptoms and contributes to development of bacterial resistance to antibiotics. Options 2, 3, and 4 are important aspects of self-care during recuperation but not as essential as the completion of antimicrobial therapy. Chronic pain is multidimensional, often without an identifiable cause and not responsive to conventional treatment. By asking how/if the pain interferes with the client's daily activities, the nurse will obtain information about the impact the pain has on the person's quality of life. Urinary retention in the client with multiple sclerosis is a sequela of impaired conduction of nerves innervating the bladder. The client with multiple sclerosis will be encouraged to increase his fluid intake to prevent constipation. Urinary retention is incomplete emptying of the bladder. Neither running water nor caffeinated beverages would be useful. The nurse interviewing the client will promote client independence, communication, and self-esteem by talking directly to the client and patiently and carefully listening to him. While options 1, 2, and 4 are all appropriate interventions for the client with Parkinson’s disease, the essential approach to enhance and encourage self-care abilities will be an unhurried one that allows sufficient time for self-expression and for the client to do as much as possible for him or herself. A positive Babinski is an indicator of upper motor neuron disease of the pyramidal tract. The physician must be contacted immediately when a client’s reflex changes from a negative to a positive Babinski as this reflects increased intracranial pressure. Increasing intracranial pressure is aggravated by hypercarbia and suctioning should not be done for longer than 10 seconds. The other three options are not appropriate. People cope better when they accept what their life had to offer, have learned to cope with personal losses, have the time and ability to recover emotionally between multiple deaths, believe that death is a part of living, and have religious beliefs. Option 3 indicates the individual has planned for the future and believes that death is part of living. The client in option 1 is incorrect because this client has lost three people over a brief period of time (6 months). The client in option 2 is incorrect because he shows dependence, having never moved out of the home of his parents, who are both healthy. The client in option 4 is incorrect because individuals with religious beliefs are found to cope better. Keeping urine dilute helps to prevent urinary tract infections. There is no longer a need, as there may be immediately following a stroke, for a fluid restriction. A fluid intake of 2,000 cc per day will also improve bowel elimination. Mechanical ventilation would not be necessary with a thoracic injury at T8. Options 2, 3, and 4 are all applicable for a T8 injury. What the client describes is a classic ascending progression of Guillain-Barré syndrome. The muscular weakness may ascend to include the diaphragm. Total respiratory paralysis can occur, requiring ventilatory support. A Dilantin level would not be relevant to a stroke status. The nurse would want to avoid adding to the client’s volume status or contributing to increasing intracranial pressure (IICP) since a confirmed diagnosis has not been made. A more detailed examination is important in collecting data to meet client needs. The picture of multiple sclerosis may be unfolding. The nurse takes the time to be therapeutic, without providing false reassurance or limiting responses. Open-ended, nonjudgmental responses are ideal. Also known as absence seizures, petit mal seizures may be no more observable than brief staring instances. The parents should be instructed to note and report any change in the child’s behavior, no matter how small. After examining the pin sites for redness, edema, and drainage, a sterile applicator dipped in hydrogen peroxide is used around each pin site. This may be followed by normal saline and a topical antibiotic per hospital policy. Hemisection of the anterior and posterior portions of the spinal cord result in loss of position sense (proprioception) on the same side of the body as the trauma, below the level of injury. Option 3 is seen in anterior cord syndrome; option 1 is incorrect. The brain stem’s final effort to maintain cerebral perfusion is seen with an increased systolic blood pressure, bradycardia, and an irregular respiratory pattern know as Cushing’s response. To promote drainage, it is more effective to secure an airway by turning the client on the side. Inserting a tongue blade can cause trauma; the tongue blade may move during the seizure and obstruct the airway. Oxygen should be available but does not have to be applied. Clients go through multiple stages and tasks when they are dying. During bargaining, they “negotiate” to meet a life goal. The other stages are not consistent with the client’s statement. Denial would be refusal to accept the diagnosis of terminal cancer. Anger and depression are natural reactions to anticipated loss. Acceptance is shown when the client has come to terms with the diagnosis and anticipated death. Mosquitoes are the vectors that transport encephalitis. Meningitis can be attributed to overcrowded conditions, Parkinson’s has an unknown etiology, and the risk for MS includes genetic or family history. Guillain-Barré syndrome is an acute demyelinating disorder that presents with initial weakness in the cranial nerves that progresses downward. Impairment of cranial nerves IX and X will affect swallowing. When the muscles involved in chewing and swallowing as well as the diaphragm and intercostal muscles are weak, the client may aspirate or experience poor gas exchange; both increase the risk for pneumonia. Parkinson’s disease is a progressive degenerative neurological disease. The goal of care is to control symptoms so that the client can maintain as much independence and function as possible. The disease does not go into remission. Skin care and weight gain may be intermediate goals but are not the major goal. Vital signs (VS) should be watched for 30 minutes to an hour after a grand mal seizure. The respiratory rate, pulse, and blood pressure may be decreased but should slowly return to normal. An aura would precede the seizure. Electrolytes and remembrance of the event are not critical during the postictal stage. The gate control theory of pain postulates that large sensory fibers close the gates to pain in the dorsal form, blocking the transmission of small nociceptive fibers. Rhythmic breathing promotes relaxation, affecting the behavioral components of pain. Guided imagery affects the cognitive components of pain. Changes in level of consciousness; confusion; restlessness; lethargy; and disorientation to time, place, and then person are the most sensitive and earliest indicators of increased intracranial pressure (IICP) produced by an expanding lesion. Extremes of temperature may cause an exacerbation of myasthenia gravis. Alcohol and quinine water may increase weakness. Medications should be taken on time to maintain blood levels and thus muscle strength. The client should avoid energy activities that will cause excessive fatigue. The nurse needs to further determine the client’s respiratory status by first auscultating the lungs, checking tidal volume and oxygen saturation, and suctioning the nasopharynx if needed. Confusion may be caused by cerebral hypoxia. A stiff, sore neck is a sign of meningeal irritation and possible meningitis. The nurse may further inquire if flexion of the neck causes pain and also causes the hip and knee to flex (Brudzinski's sign), as well as how high the fever is. The other symptoms are typical of influenza. The infant must weigh at least 20 pounds in order to be safe in a forward-facing infant seat and must be 1 year or older. Option 4 does not treat the client with respect and sensitivity and therefore is an example of maleficence. Option 1 provides a rationale for a therapy that may be uncomfortable. Options 2 and 3 advocate for the client. Only the client is allowed to administer the medication. The PCA pump has preset dose limits. Both of these measures prevent overdose. The client is instructed to push the delivery button when the pain begins. Persons using opioids for acute pain have a very low prevalence of addiction. Less total medication is needed with use of a PCA. This position promotes venous drainage from the head and decreases venous return, reducing blood pressure. Alcohol is a drying agent and should not be used when performing mouth care (lemon-glycerin products should also be avoided). Use a small toothbrush to make cleaning easier. Place the client on the right or left side and avoid the supine position to reduce the risk of aspiration. Toothettes can be used on the gums, tongue, and mucous membranes to reduce drying and subsequent breakdown. Vital signs changes are late indicators of rising intracranial pressure. Trends include an increase in temperature and blood pressure, and a decrease in pulse and respirations. The level of consciousness would also deteriorate before these manifestations arise. Hyperventilation to achieve a PaCO<sub>2</sub> of 25 to 30 mm Hg causes cerebral vasoconstriction that will lead to reduced intracranial blood volume and reduced ICP. Option 1 is excessive, option 3 is normal, and option 4 indicates hypercarbia (excess carbon dioxide). Hemiparesis is a one-sided weakness that often occurs following stroke. The client will have maximum return of function and the least amount of frustration with relearning new tasks when objects are placed within easy reach on the unaffected side. This will also decrease the risk of client injury because the client will not have to reach for objects needed for self-care. Unilateral neglect is not a problem when the client has right-sided deficits, so objects do not need to be placed on the affected side. Clients who have a spinal cord injury above the level of T7 are at risk for autonomic dysreflexia, an exaggerated autonomic response to a noxious stimulus. This complication can be determined by noting the presence of severe, throbbing headache; flushed face and neck; bradycardia; and severe hypertension that is sudden in onset. Other signs to monitor for are nausea, sweating, nasal stuffiness, and blurred vision. Documentation about seizure activity includes the time the seizure began, changes in pupil size, eye deviation or nystagmus, body part(s) affected, utterance or sounds (epileptic cry), the type of movements and progression, client condition during the seizure, and postictal status. The other items listed are unnecessary. Clients with Parkinson’s disease have bradykinesia (slow movements that are hard to initiate), which can be offset to some degree by rocking back and forth to initiate movement. Activities should be interspersed with rest periods throughout the day to minimize fatigue. Chairs should be high and firm rather than soft and deep. Velcro fasteners and slide buckles will be of most use to a client who is trying to maintain independence with dressing and grooming. Nurses caring for clients who have Alzheimer’s disease should ensure that these clients are wearing an identification bracelet so they do not become lost if they wander. It is unnecessary to monitor LOC hourly, and restraints are also not indicated. It is not essential that the client be placed in a quiet, calm environment; rather, the client often prefers to be allowed to move about at will. Rando’s process of bereavement is to (1) recognize the loss and death, (2) react to experience and express the separation and pain, (3) reminisce, (4) relinquish old attachments, (5) readjust and adapt to the new role while maintaining memories and form a new identity, and (6) reinvest. The pain of trigeminal neuralgia is triggered by stimulation of the sensory fibers of the trigeminal nerve. Examples of pressure-related triggering events include shaving, toothbrushing, washing the face, and eating or drinking. Examples of temperature-related triggers include environmental changes and hot or cold food and drink. The other options listed do not initiate the pain of this disorder. Antidepressants, tranquilizers, and anticonvulsants are generally withheld for 24 to 48 hours before an EEG. The client does not have to be NPO, but should avoid stimulants such as coffee, tea, cola, alcohol, and cigarettes. Preprocedure care for EEG involves teaching that there is no discomfort, and shampooing the hair. Oral or gastrointestinal secretions can enter the client’s airway and cause aspiration. The onset of adventitious breath sounds indicates this risk clearly. The other options are incorrect because they do not relate to the client’s airway. Normal ICP readings extend up to 10 mm Hg pressure (options 1, 2, and 3). Sustained elevations above 15 mm Hg are of concern, as they are abnormally high. The client’s neurological status is probably deteriorating as well. As outlined in the options, the Glasgow Coma Scale is divided into three subsets. Each subset has a range of scores within it, and for the total scale the highest possible score is 15 while the lowest is 3. The higher the score, the more optimal should be the recovery. Scores in the "best eye-opening response" category range from spontaneously (4), to speech (3), to pain (2), no response (1). Scores in the "best motor response" category range from obeys verbal commands (6), localizes pain (5), flexion-withdrawal (4), flexion-abnormal (3), extension-abnormal (2), no response (1). Scores in the "best verbal response" category range from oriented (5), conversation-confused (4), speech-inappropriate (3), sounds-incomprehensible (2), and no response (1). A client who experienced a CVA may have involvement of the cranial nerve responsible for swallowing (XII), and generally undergoes a swallowing evaluation to determine whether a diet can be taken. The client with some residual dysphagia may be started on a diet once the gag and swallow reflexes have returned. In this instance, liquids should be thickened to avoid aspiration. The other options represent helpful actions for the client with dysphagia. Above the level of T6, clients with spinal cord injury are at risk for autonomic dysreflexia. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. This complication is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden, severe hypertension. A client may also exhibit nasal stuffiness, blurred vision, nausea, and sweating. It is highly controversial whether or not to use a bite stick when a client is experiencing seizure activity. The greatest risk is that teeth could be damaged if it is inserted during a seizure. The other pieces of equipment listed are useful in the care of the client and should be made ready at the bedside. The Parkinsonian gait is characterized by short, shuffling, accelerating steps. The head leans forward, the hips and knees flexed, and the client has difficulty starting (bradykinesia) and stopping. Options 1, 3, and 4 describe ataxic, dystrophic, and festinating gait, respectively. Since long-term memory is retained for a longer period of time than short-term memory, clients with Alzheimer’s disease will be able to recollect events from long ago. It is helpful to allow clients to reminisce. The other options represent nontherapeutic techniques for this client as described. The definition for the ethical principle of justice is “fairness.” Option 2 reflects anger on the part of the family, while option 3 reflects anger on the part of the client. Option 4 demonstrates a concern that the client will suffer an injustice by enduring unnecessary tests. The optic nerve, which governs vision, is cranial nerve II. For this client it would be most helpful to clear the area of objects that may not be perceived by the client but that could lead to falls. The actions described in the other options are unnecessary. Prednisone is often used to treat Bell’s palsy. The drug is a steroid, which will reduce inflammation and edema and thereby allow the return of normal circulation in the area of the nerve. It can help preserve a significant amount of function, and is effective against pain, when given early in the course of treatment. The client should move the entire torso to scan the visual field because the client cannot turn the head. The client should use straws to prevent spills with liquids. The client should avoid bending because the device has a high center of gravity, which could lead to falls. The device is not removed at bedtime. The zero level for ICP monitoring is 1 inch above the ear, which is at the height of the foramen of Munro. Each time an ICP reading is done, it should be done with the client’s head in the same position. Basilar skull fracture can lead to leakage of CSF from the ears or nose. CSF is noticeable in that the drainage will separate into bloody or yellow concentric rings on the dressing material, which is called halo sign. The fluid also will test positive for glucose. Scanning the environment can help to overcome homonymous hemianopsia, loss of one-half of the visual field. The other items listed will not be of help to the client who has this type of visual deficit. During spinal shock, there is loss of voluntary control of skeletal muscles and autonomic reflexes below the level of the injury. These lead to flaccid paralysis, loss of spinal reflex arcs, and bowel and bladder retention. The other responses are either partially or totally incorrect. Generalized seizures are seizures without a focal point of onset and that are bilaterally symmetric. There are seven subtypes, including tonic-clonic, tonic, clonic, absence, atonic, myoclonic, and infantile spasms. The tonic-clonic pattern is as described in the stem. Partial seizures begin locally and are divided into three subtypes, including simple partial seizures (without impaired LOC), complex partial seizures (with impaired LOC), and partial seizures secondarily generalized. Parkinson’s disease is characterized by depletion of dopamine levels in the substantia nigra, leading to the onset of symptoms of Parkinson's disease. Option 1 describes Guillain-Barré syndrome. Option 2 is nonspecific. Option 3 describes myasthenia gravis. The plaque that characterizes Alzheimer’s disease is a cluster of degenerating nerve terminals, both dendritic and axonal, which contain amyloid protein. The other responses are incorrect statements. Anger is a common element to all the theories of grief and stages of dying. It is important to acknowledge the client’s anger, help him or her identify the source of the anger, and offer choices or control when possible. It is important to be nonconfrontational (option 2), not to take the anger personally (option 1), and not to ignore the client’s issue (option 3). Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth. This may be done to detect small changes in muscle strength that might not otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance in gait. While all other choices are important to monitor, the priority in monitoring any critically ill child follows the ABC rule—airway, breathing, and circulation. This position opens the intervertebral spaces and allows easier access to the spinal canal. The position does not decrease pain or help to restrain the child. All lumbar punctures are done below L4 (the level of the spinal nerves), so injury to the spinal cord is always avoided. It is important to never forcibly restrain a child during a seizure or insert a padded tongue blade; both are more likely to add trauma than prevent it. Oxygen via mask is of little benefit. Overall, the child must be protected from injury from the environment. Viral meningitis does not require antibiotics. Treatment is aimed at reducing the symptoms. The child should be allowed to assume a position of comfort; the room should be kept dim and stimulation reduced. Seizures can occur, although the disease is usually self-limiting. Measuring the head circumference is of no benefit because the sutures are fused. This therapy involves an implanted pump that must be accessed through the skin to refill the pump. Parents are not taught to refill the pump. Baclofen does inhibit the neurotransmitter GABA; however, this is not the essential data to be shared with the parents. Promising the parents that the child will be able to run with normal gait offers false hopes. The implanted pump’s dosage cannot be changed without special equipment. Guillain-Barré syndrome is an ascending paralysis. While the child will have increasingly less muscle tone in extremities, the hoarseness could indicate involvement in the muscles of respiration. Serious concern is raised when the respiratory muscles are affected. Sometimes mechanical ventilation is indicated. Tingling is a common sign of Guillain-Barré and not related to respiratory distress. Discharge instructions will include the necessity of waking the child to check neurological status throughout the night. Vomiting could be a sign of increasing intracranial pressure and should be reported. Narcotics are not given after a head injury. Amnesia for the events surrounding the injury may be permanent. It is not a sign of increasing intracranial pressure. No eye opening, no verbal response, and no motor response are the lowest criteria on the scale. Confusion is a criterion applicable only for the older child and adult but is comparable to “irritable and cries” for the infant (which is a 4 out of 5 on the verbal response subscale). “Eyes open only to pain” is the next to the lowest level on the eye-opening category. Open communication with concrete evidence of emotional attachments assists in coping at the end of life. Option 4 provides concrete assurance in the presence of the loved ones. Relaxation tapes help with stress reduction but do not help with resolution of problems experienced by the family. Staffing needs do not permit a nurse to be with one client continually, and families require privacy as well. Assurance that the past no longer matters is an assurance lacking concrete properties. The Moro or startle, tongue extrusion, and tonic neck reflexes are all neonatal reflexes that should have disappeared by this child’s age. Lack of head lag indicates good motor development. A developmental delay or the presence of a neonatal reflex are some of the earliest clues to cerebral palsy. All of the above are symptoms of increased ICP or hydrocephalus. Head enlargement and bulging fontanels would not be seen in the child after closure of the sutures (12 to 18 months). Shrill, high-pitched cry is a late-stage symptom of children. Headache and vomiting on arising would be an early symptom in an older child. While work or industry is the primary developmental task of children this age, emphasis should not be placed exclusively on school. Recreational activities are an integral part of growing up, and all efforts should be made to provide access to such programs. Scouting programs provide recognition of individual successes and strengths and can do much to enhance a child’s self-esteem. All families deal with stresses, and the family with a child with a chronic health problem is no exception. Chronic sorrow is the emotional experience many families experience of grieving for the loss of the perfect child. This grief is intensified at times of developmental crisis and each time in the child’s development at traditional milestones such as “first steps” when the parents are reminded of what their child will not be able to do. The teacher is most aware of the varied reactions of the classmates and together the parents and teacher can plan strategies to promote acceptance of this child. A Medic Alert bracelet is appropriate but will not improve self-esteem. A psychiatrist might be consulted if the child shows symptoms of altered self-esteem, but this is not required now. Prior to surgical repair of the meningocele, leaking cerebrospinal fluid usually reduces the intracranial pressure. The priority concern preoperatively is maintaining the meningocele sac and preventing infection. It is not a priority to measure head circumference daily, use semi-Fowler’s position, or monitor for irritability and vomiting (signs of increased intracranial pressure). The prognosis for children receiving shunts depends on brain damage that has already occurred. The shunt will need to be revised as the child grows. Usually an extended length of tubing is placed with ventriculoperitoneal shunts to allow for some growth, but eventually a revision is necessary. Most brain damage is not reversible. Research studies have shown a significant decrease in incidence of spina bifida in infants born to mothers who took folic acid supplements prior to pregnancy and during the first trimester. Spina bifida is not related to rubella or rubeola. No relationship has been seen between maternal age and the development of spina bifida, nor is there a genetic trait that can be linked to spina bifida. Common side effects with antiepileptic medications include ataxia and rashes, which disappear when dosage is adjusted. Some drugs such as phenobarbital can adversely affect cognitive function, school performance, and behavior. Carbamazepine is considered relatively free of the sedativelike side effects but does have the side effects of blurred vision, diplopia, drowsiness, vertigo, headache, and rarely a rash (Stevens-Johnson syndrome). A serious complication after the insertion of a shunt would be infection, most likely meningitis. It is not common to see decreased intracranial pressure, but too-rapid decrease can result in a subdural hematoma. Symptoms of shunt malfunction would include all signs of increased intracranial pressure. Symptoms of infection such as meningitis in the young infant include fever, poor feeding, vomiting, marked irritability, restlessness, seizures, and a high-pitched cry. A living will is written by the client and includes desires for use of different types of treatment in case of a life-threatening illness. A durable power of attorney is a legal document designating an individual to make legal decisions if the client is unable to make choices independently. The best answer is to do further data collection of the child’s abilities. At 8 months, most infants can sit without support; however, a remarkable piece of history for this child is her prematurity. Up until 2 years of age, it is important to remember to adjust for the weeks premature to have more realistic milestones for this individual child. Additional examination of motor skills is important to determine developmental progress while accounting for prematurity. Motor impairments associated with voluntary control are not usually apparent until after 2 to 4 months at the earliest so that motor dysfunction (and subsequent diagnosis of cerebral palsy) may not be confirmed until the second half of the first year. It is not unusual for the disorder to be overlooked in mildly affected infants until they exhibit a delay in some advanced motor skill such as walking. Since it may take up to a month for the brain to heal after a concussion and subsequent injuries can compound the original injury, the child should not engage in contact sports for a month. Postconcussion syndrome in adolescents includes headache, dizziness, irritability, and impaired concentration. It can be helpful for teachers to understand any possible changes in behavior or school performance during this period. Vomiting should be reported and is a serious symptom of increasing intracranial pressure; but it is not treated with antiemetic. While monitoring the child on a regular basis for 24 to 28 hours postinjury is recommended, having him bend his head to his chest (Brudzinski's sign) would be a good indicator of meningitis but will not provide helpful information about complications of brain injury. Brudzinski’s sign indicates meningeal irritation. As the head and neck are flexed toward the chest, the legs flex at both the hips and the knees in response. Brudzinski’s sign may be seen in the other options because of the meningeal irritation. Increased intracranial pressure in infants is characterized by lethargy, irritability, bradycardia, tachycardia, apnea, bulging fontanels, setting-sun eyes, vomiting, and hypertension. Myelomeningocele refers to a neural tube defect, which is obvious on the back. Skull fractures indicate injury to the head and may be asymptomatic or may be accompanied by other pathology that could lead to increased intracranial pressure. Hypertension does not display symptoms of setting-sun eyes. The most common mechanisms for the development of hydrocephalus include decreased reabsorption (communicating hydrocephalus) and obstruction to the flow of CSF (noncommunicating). Obstruction may result from congenital anomalies, inflammation, external blockage, and other causes. Most children with spina bifida cystica (myelomeningocele included) have the level of their defect at a point that does affect the innervation to both the colon and anal sphincter. The result is constipation and incontinence. Any lack of mobility increases the risk for constipation, and all children need a pattern of regular bowel movements. Clients are considered contagious until the causative organism is determined and antibiotic therapy has been initiated. Children are usually placed in respiratory or droplet isolation. Twenty-four hours of antibiotic therapy usually eliminates the necessity of isolation. The child with meningitis will hyperextend the neck and head in an arching position referred to as opisthotonic. The child does this to relieve discomfort from the meningeal irritation. Decerebrate posturing is a symptom of dysfunction at the level of the midbrain and is characterized by rigid extension and pronation of arms and legs. Decorticate posturing is a symptom of a dysfunction of the cerebral cortex and is characterized by adduction of the arms at the shoulders, the arms flexed on the chest with hands in fists and wrists flexed, and lower extremities extended and adducted. Jacksonian seizure is a simple motor seizure characterized by clonic movements that begin in a foot, hand, or face and then spread to sometimes include the entire body. Turning the head to one side can occlude the flow of CSF, increasing the ICP. Oxygen can serve as a vasodilator, decreasing the ICP. Keeping the head of the bed slightly elevated also promotes flow of CSF. Diuretics are often part of the medical treatment to decrease ICP. Vigorous range of motion and forcing oral fluids would not be appropriate. Epidural hematomas are characterized by arterial bleeding. Onset of symptoms occurs within minutes to hours. Other types of bleeding are often venous, which has a slower onset of symptoms. The nurse needs to consider the client’s wishes while also acting within the law. Euthanasia constitutes illegal nursing practice in the United States at this time. To act ethically, the nurse should provide care to clients according to need, regardless of belief systems. Clients who are diagnosed with terminal illness may or may not be ready for do-not-resuscitate orders, depending on anticipated life expectancy, quality of current life, and psychosocial variables. Obtunded indicates a diminished level of consciousness with limited response to the environment. The child will fall asleep unless given verbal or tactile stimulation. Stupor is a diminished level of consciousness with response only to vigorous stimulation. Semicomatose is when a child only responds to painful stimuli; lethargy is when a child sleeps if left undisturbed and has sluggish speech and movement. The most common form of cerebral palsy involves spasticity of muscles. Because of the excessive energy expended, these children often need more calories than other children their age and size. Feeding difficulties are often a component of cerebral palsy, but whether a child needs assistance with feedings is dependent upon the muscle groups affected. Epispadias and bilateral inguinal hernias are frequent anomalies associated with exstrophy of the bladder. The other conditions listed are not. Edema is the major clinical symptom of nephrosis. The child may gain twice his or her normal weight in severe cases. Diapers are weighed on a gram scale before using them and after removal (1 g = 1 mL). The weight of the dry diaper is then subtracted from the weight of the wet diaper to determine urine output. Bubble baths are irritating to the meatus and increase the incidence of urinary tract infections. An acidic urine is desirable in preventing urinary tract infections. Although children with acute glomerulonephritis may feel well, they are confined to bed until hematuria resolves. This can lead to boredom, making it important for the nurse to provide activities that are fun for the child to help pass the time. Urinalysis allows for early diagnosis and treatment of acute glomerulonephritis, which is a serious complication that can follow group A beta-hemolytic streptococcal infection. The open bladder allows bacteria to enter the urinary system, and urinary tract infections are common. At this age, sexual dysfunction would not be an appropriate diagnosis. The unformed bladder does not hold urine, so urinary retention would not be an appropriate diagnosis. Disorganized behavior does not apply. The ASO titer indicates a preceding infection with group A beta-hemolytic streptococcus. The urinalysis would show hematuria, but this alone would not be diagnostic of acute glomerulonephritis. Blood cultures may be negative as the infection preceded the illness by 1 to 3 weeks. The focus of hospice is improving the quality of life and preserving dignity for the client in death. Hospice care may be provided by nurses, volunteers, or other members of the health care team in a variety of settings. It is available to any client who has a terminal illness with a life expectancy of 6 months or less. Clean-catch urine specimens are not reliable urine samples; therefore, catheterization is necessary. The urine does need to be obtained at the time of voiding. With the inability to secrete urine, electrolytes will build up in the blood, including sodium and potassium. The child should be on a low-sodium, low-potassium diet with restricted fluids and proteins. Urinary tract infections are ascending in nature; an untreated UTI can lead to acute pyelonephritis with resulting kidney scarring and damage. Early diagnosis and prompt antimicrobial therapy will prevent or minimize permanent renal damage. Proteinuria (presence of protein in urine) is a prime manifestation of acute glomerulonephritis. The other options are inconsistent with this diagnosis. Prednisone is a synthetic corticosteroid that depresses the immune response and increases susceptibility to infection. Steroids mask infection; therefore, the child must be monitored for subtle signs and symptoms of illness. Specimens collected utilizing proper technique will minimize contamination of the urine sample, ensuring accurate urinalysis results. It is unnecessary to force fluids prior to specimen collection. The specimen container is not cleansed, although the urinary meatus is. The specimen should be sent to the lab immediately after collection to prevent urine degradation. With infectious or inflammatory processes of the upper urinary tract, the kidneys’ ability to filter and reabsorb salt and water is altered, resulting in edema. Weights can be an easy and effective measure to determine fluid loads. Gentamicin is an aminoglycoside antibiotic that is nephrotoxic. Nephrotoxic drugs should be avoided in a child with acute renal failure. The other options do not represent drug groups that are particularly nephrotoxic. HCG is given to induce the descent of testes if testes have not descended during the first year of life. The other reasons listed are incorrect rationales. Nephrotic syndrome is an inflammatory reaction in the kidneys. Urinary tract infections and obstructions are also associated with the development of acute renal failure. The other diseases pose minimal risk of developing acute renal failure. Grief resolution requires letting go of the past and looking forward to the future. The client needs to be able to put the loss in perspective and engage fully and effectively in daily life as an independent person. In option 2, the client has not let go of the past because decisions are made in the present only through memories of preferences of the deceased. Options 1, 3, and 4 all indicate healthy grief resolution. The parents must understand the need for compliance with medical orders to promote the child’s health. Relaxation should be accomplished without harming the child. The additional fluids will increase urinary output, causing greater urine volume and more frequent voiding, thus flushing the dye from the urinary system. The other options do not describe the correct rationale for this intervention. Dietary intake is often inadequate in children with renal failure related to anorexia and dietary restrictions. Calories and nutrition are needed to optimize growth and to prevent growth retardation. Depending on the degree of renal failure, sodium, potassium, and phosphorus may be restricted. Fluids are monitored closely for balance and may be restricted if oliguria is present. The kidney normally excretes potassium. Hyperkalemia occurs with decreased kidney function resulting in cardiac arrhythmias, which can be life threatening. Peritoneal dialysis is an invasive procedure that places the child at risk for infection. Hypervolemia is secondary to poor kidney function and does not cause altered renal tissue perfusion. The child is anorexic and the child is not at risk for fluid volume deficit. The child’s condition is chronic and routine health maintenance will need to be integrated with chronic disease management. Dehydration results in hypovolemia, which can precipitate acute renal failure in infants and children. The other responses are incorrect because they don't directly impact renal perfusion. Azotemia and oliguria are characteristics associated with renal failure in children. The BUN would be elevated. Renal failure is characterized by inadequate glomerular filtration. Although there is fluid retention as a result of oliguria, this does not hamper the renal tissue perfusion. The weight gain is a result of fluid retention, not overeating. The child will be lethargic but not in acute pain. This condition is repaired surgically. Preoperative teaching can relieve parental anxiety regarding body image disturbances. The other options are unrelated to care needed for the client with hypospadias. The prepuce, or foreskin, may be needed in the reconstruction of the penis. The mother can sign permission for her son without needing the father’s permission as long as she is fully alert. The risk of infection is no greater for this child than for others. Hope instillation is often an effective intervention in dealing with anticipatory grieving. Option 3 deals with the symptom and not the actual problem. Options 2 and 4 are not appropriate because there is no evidence in the stem of the question to support their need. Premature males are often born with undescended testicles. The testes normally descend during the last few weeks of gestation or shortly after birth. This would not be a concern at this time. If surgery should be needed, it will be done prior to age 2. Undescended testicles do not affect urine formation. A double-diapering technique will help to protect a urinary stent following repair of hypospadias or epispadias. The inner diaper collects the infant's stool, while the outer one collects urine. Pyelonephritis is an upper urinary tract infection, involving the kidney tissue. Lower urinary tract infections include urethritis, prostatitis, and cystitis. The most common upper urinary tract infection is pyelonephritis. <i>E. coli</i> is the infective organism in over 90 percent of first-time infections. The nurse should check that the organism is sensitive to the antibiotic or notify the health care professional. Due to the anatomic structure of the male urethra and bacteriostatic effect of prostatic fluid, all urinary tract infections in the male client should be considered complicated. Urine may have a foul odor and appear cloudy because of mucous and excess white cells present, which is common in cystitis. Casts and proteins are never normal in urine. The greatest risk factor for stone formation is a prior personal or family history of urinary calculi. The other answers are important information to know but do not contribute greatly as risk factors. Red blood cell casts are not present in the normal urinalysis but are present in glomerular diseases. Iatrogenic causes result from treatment from a physician or other care provider. Examples include nephrotoxic medications, radiologic contrast dye, and shock after surgery. In end-stage renal failure, 90 percent or more of the nephrons are destroyed; glomerular filtration rate is < 20 percent normal with increased creatinine and BUN. Option 4 is correct because the faucet is considered contaminated. The hands are considered to be more contaminated than the elbows. Therefore, water should flow from least contaminated to most contaminated, eliminating option 1. Option 2 can result in burns to the nurse. Warm water removes less of the protective oils in the skin. Option 3 describes a surgical scrub. The Hindu and Buddhist religions require that believers are alert and mindful as they leave the life on earth and transcend to their next life. This requirement is not found in Islam or Catholicism. The blood urea nitrogen is primarily used as an indicator of kidney function because most renal diseases interfere with its excretion and cause blood levels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass, and is excreted entirely by the kidneys, making it a good indicator of renal function. In the second stage of chronic renal failure, renal insufficiency, there is at least 75 percent of functional renal parenchyma destroyed. Balanitis, or inflammation of the foreskin and prepuce, would cause edema and pain of the penile glans, leading to dysuria. Option 1 is inappropriate for balanitis; a urethral discharge (option 3) may occur in gonorrhea; back pain (option 4) could indicate many diseases, but not balanitis. Prostatitis creates pain in the tissues surrounding the prostate gland. Option 1 indicates a gonococcal infection; option 2 herpes virus; and option 3 syphilis (secondary stage). Secondary syphilis begins with the healing of the chancre, and ends when the rash disappears, which can take up to 6 months from time of infection. The latent stage of syphilis then starts, which can last for years. VDRL and RPR would need to be positive for syphilis (option 2); option 3 could indicate TB or HIV; option 4 is signs and symptoms of nongonococcal infections in females. Hypospadias repair is undertaken using the foreskin to create a channel through the penis to the tip of the glans so that he will deposit his sperm near his partner’s cervix. Although option 1 may also be an appropriate answer, it is not the best answer to demonstrate effective teaching. Options 2 and 4 are incorrect. DUB most commonly results from a progesterone deficiency that causes a fragile endometrium that fails to mature from proliferative stage to secretory. This causes irregular menstrual bleeding. Treatment is aimed at correcting the cause, thus progesterone supplementation is prescribed. Douching should be avoided in order to prevent bacteria present in the lower reproductive tract from being forced upwards into the uterus, potentially causing PID. Chemotherapy and radiation used in the treatment of testicular cancer often cause a radically decreased sperm count. If the client desires children, he should consider sperm banking prior to beginning treatment. Caffeine can precipitate or worsen fibrocystic breast disease. No other dietary factors have been identified. Knowledge of response to pain offers accurate and careful assessment of pain with earlier and more complete pain relief. It should include physical and emotional behaviors. Doxycycline (Vibra-Tabs) is a commonly utilized treatment for chlamydia infections, and like all antibiotics, must be taken until the medication is gone. Use of condoms with every sexual encounter decreases the transmission of sexually transmitted diseases. Sexual contacts should be notified of the infection so that appropriate testing can be obtained. This is especially important with Chlamydia because it is so often asymptomatic in women, and early detection can prevent complications such as pelvic inflammatory disease. Testicular self-exam is screening for testicular cancer, not diagnosing. Primary dysmenorrhea begins at menarche and is usually a lifelong condition. Options 1, 2, and 4 can occur with secondary dysmenorrhea or endometriosis. Hematuria, either gross or microscopic, is generally present in clients with urinary calculi. Leukocytes and protein may be common with other urinary disorders. Adult polycystic kidney disease is an autosomal dominant disorder. In children, it is caused by an autosomal recessive trait. Acute pyelonephritis is a bacterial infection of the kidney. Chronic pyelonephritis is associated with nonbacterial infections and noninfectious processes that may be metabolic, chemical, or immunological. Hypertension may develop as renal tissue is destroyed. Infection of the pharynx or skin with <i>group A beta-Hemolytic streptococcus</i> is the common precipitating factor for acute glomerulonephritis. Risk factors of urinary tract infections include female, older clients, urinary obstruction or calculi, strictures, chronic disease, prostatic hypertrophy and prostatitis, diaphragm use, instrumentation, and impaired immune system. Although children and teenagers can contract a UTI, incontinence and disease conditions in the elderly make them a higher risk population. Glomerular cells proliferate along with macrophages to form crescent-shaped lesions obliterating Bowman’s space, resulting in a rapid decline in glomerular filtration rate (GFR), which leads to many of the complications. Sulfonamides are considered to be the drug of choice for acute, recurrent, or chronic urinary tract infections when there is no evidence of obstruction or bacteremia. The diet before competition should be high in complex carbohydrates and low in fat and protein. Option 2 reflects the best selection to meet this dietary balance. All of the other options are high in fat and/or protein and would not be beneficial in terms of supporting athletic performance. Vitamin C helps to maintain a pH of 5 or less, thereby inhibiting bacterial growth. The other vitamins have no proven use in preventing urinary tract infections. Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increasing the signs and symptoms of a urinary tract infection (UTI). Fluids should be taken, and douches will not help a UTI. All antibiotics should be taken completely to prevent resistant strains of organisms. The primary genital herpes infection involves systemic viremia, and encephalitis is a possible complication. Headache and stiff neck may indicate encephalitis, and requires further investigation. Breast cancer detection begins with monthly self-breast exams. Mammograms should be performed yearly after age 40. Birth control pills do not increase nor decrease breast cancer risk, but the longer a woman is on estrogen replacement therapy, the greater her risk for developing the disease. Continuous bladder irrigation serves to flush out the blood that will be oozing from the raw edges of the TURP site before the blood can clot. Clots in the bladder would obstruct the urine flow through the catheter. Lupron is a synthetic analog of luteinizing hormone-releasing hormone, and acts as an estrogen antagonist, causing the endometriosis deposits to shrink in size, thus decreasing the pain and infertility associated with endometriosis. Hot flashes and night sweats are common side effects while on the medication, and resolve upon discontinuation of the medication. Balanitis, inflammation of the foreskin, occurs due to poor hygiene, and occurs after the foreskin becomes retractable (at about age 3). Options 2 and 4 are incorrect because of the circumcision. Early childbearing with breastfeeding for a total of 2 years or more decreases a woman’s lifetime risk of developing breast cancer. BRCA1 or BRCA2 gene mutations increase risk. Hodgkin’s disease treatment usually involves chest radiation, which increases breast cancer risk and breast cancer mortality. Aging is another factor: The older a woman becomes, the more likely she is to develop breast cancer. Chlamydia, although often silent and asymptomatic, will eventually present symptoms including new occurrence of dyspareunia, dysmenorrhea, and low abdominal and pelvic pain, with yellow or yellow-green vaginal discharge. HSV1 does not survive more than a few minutes on inanimate objects, and although it is often a genital tract infection, it does occur orally. Sexual contact is the most likely method of transmission, and persons with intact immune systems can easily be infected. One characteristic of Hispanic diets is the high-fat preparation method used in cooking. Suggesting a new preparation method for a familiar food item would best help the client to begin changing cooking habits. Option 1 is incorrect—complex carbohydrates should not be eliminated because they are components of a healthy diet. Option 3 is incorrect—the Hispanic client would probably be unwilling to relinquish beans and nuts in the diet because these are considered staple food products. Option 4 is incorrect because stewing is considered a high-fat method of cooking because the fat from the meat does not drain off. BPH clients may be asymptomatic until large alcohol intake, which relaxes the bladder sphincter, making it impossible to empty the bladder. Subserosal uterine myomas are located on the outer surface of the uterus and tend to cause fewer menstrual disorders than submucosal or intramural myomas. However, they do cause mechanical pressure on the pelvic contents from their size and weight, including bladder pressure that results in urinary frequency and urgency. Older clients may not exhibit the classic symptoms of UTI but present with nonspecific complaints such as nocturia, incontinence, confusion, behavior change, lethargy, anorexia, or just not feeling right. Urinalysis would be a first-line diagnostic test. Prerenal causes of acute renal failure include those affecting renal blood flow and perfusion. Hemorrhage, an extracellular fluid loss, can lead to renal ischemia due to decreased renal perfusion, decreased glomerular filtration rate, and azotemia. The most common cause of urologic obstruction is urolithiasis, stones within the urinary tract. The symptoms in option 3 are the typical signs and symptoms of stones. Option 1 is associated with bladder cancer, option 2 with UTI, and option 3 with glomerulonephritis. Painless hematuria is the presenting sign in 75 percent of urinary tract tumors, along with flank pain and an abdominal mass. Hematuria may be gross or microscopic. Males are more likely to develop nephrolithiasis than females. Option 1 would be more common in females, option 3 in African-Americans, and option 4 does not apply. The majority of kidney stones are comprised of calcium oxalate or calcium phosphate. Sturvite stones (15 to 20 percent), uric acid (5 to 10 percent), and cystine stones are uncommon. A low-purine diet is required for clients with uric acid stones. High-purine foods such as sardines and organ meats are eliminated. Moderate-level purine foods such as red and white meats and some seafoods are limited. Proteins are restricted in renal failure. Oliguria is a urine output of less than 400 mL/24 hrs. It may result in decreased glomerular filtration rate. Option 2 is of concern and should be monitored closely. Egg yolks are high in cholesterol and should be limited to 2 to 3 per week. Dietary fiber, fish, and soybean products have been shown to lower blood lipids. Dietary fiber is necessary in the body to promote regulation of elimination patterns and to help lower blood lipids. Soybean products are a source of phytoestrogens and have been shown to be cardioprotective. Tuna is an excellent source of omega-3 fatty acids, which are helpful in protecting cardiac function and decreasing clot formation. The decreased glomerular filtration rate caused by the inflammation of the glomerular membrane causes activation of the renin angiotensin-aldosterone system and can lead to hypertension. Hypertension can also be caused from fluid retention and disruption of the renin-angiotensin system, a key regulator of blood pressure. Option 1 is common with urinary tract infections, option 2 with kidney stones, and option 3 with polycycstic kidney disease. The urine of acute glomerulonephritis is often cocoa- or coffee-colored. Hematuria is associated with the other disorders and may be gross or microscopic. This question draws on your knowledge of pharmacology as well as acute renal failure. Tobramycin can be nephrotoxic to the kidneys and a blood urea nitrogen/creatinine should be monitored during administration, especially if high doses are given. Even in a client with normal, healthy kidneys, the nephrotoxic effects can occur. This question draws on your knowledge of pharmacology as well as ARF. The classic triad of symptoms, gross hematuria, flank pain, and a palpable abdominal mass occur in only about 10 percent of people with renal cell carcinoma. Painless hematuria is the most consistent symptom. Renal ultrasound often provides the first diagnostic evidence of a kidney tumor. It is particularly beneficial in differentiating cystic kidney disease from renal neoplasms. CT is used to provide information about the tumor. Radical nephrectomy is the treatment of choice for tumors of the kidney. The adrenal gland, perirenal fat, upper ureter, and fascia surrounding the kidney are removed. Radiation and chemotherapy are treatment options for metastatic kidney tumors. Dialysis is used for end-stage renal disease. Obstructive causes of acute renal failure are classified as postrenal. BPH is the most frequent precipitating factor and a form of obstruction. Other causes may include renal and urinary calculi and tumors. Salt and water retention lead to edema and put the client at risk for congestive heart failure and pulmonary edema. The immune function is impaired, leading to infectious complications. Increased urine volume occurs at the end of the maintenance phase, diuretic period. Nephrotoxins are associated with the initiation phase of ischemia. Conditions causing chronic renal failure typically involve diffuse, bilateral disease of the kidneys leading to progressive destruction and scarring of the nephron. Diabetic nephropathy causes glomerulosclerosis and thickening of the glomerular basement membrane. Cardiovascular disease is a common cause of death in clients with end-stage renal disease resulting from accelerated atherosclerosis. Hypertension, hyperlipidemia, and glucose intolerance all contribute to the process. All other disorders may be present throughout the uremic stage but are less likely to cause death. Foods that decrease lower esophageal sphincter (LES) pressure should be avoided to reduce reflux symptoms; these include caffeine, alcohol, and chocolate. Clients should also avoid eating large meals, drinking fluids with meals, and eating at bedtime; they should remain upright for 1 to 2 hours after eating. Weight is the most critical index of fluid status. Although options 1 and 3 suggest fluid problems, weight is used as a measure for how much fluid is retained. If overhydrated, the hematocrit would be low. Normal serum creatinine for an adult female is 0.5 to 1.1 mg/dL and 0.5 to 1.2 mg/dL for an adult male. Levels greater than 4.0 mg/dL indicate serious impairment of renal function. Although options 2 and 4 are high, with chronic renal failure, levels greater than 4.0 should be expected. Urinary retention may result when a client with benign prostatic hypertrophy ingests large amounts of alcohol or takes a medication with B-sympathomimetic side effects. The bladder sphincter becomes relaxed and does not open, and the bladder is unable to generate enough force to get urine past the enlarged prostate gland. A modified radical mastectomy requires Jackson-Pratt drains, which would still be in place 6 days postoperative, and is therefore at greater risk for infection than the other clients. In addition, this client faces significant psychosocial issues related to the cancer diagnosis and removal of the breast, which will affect her body image. Physiologic and psychosocial data collection should be performed. Secondary dysmenorrhea develops after menses have become ovulatory and regular, following menarche. Obstruction is the most common cause and can result from uterine fibroids or scarring of the uterine cavity. Uterine fibroids or myomas are solid tissue tumors that are not precancerous. Pedunculated fibroids are on a stalk or stem and can extend either into the uterine cavity or outward into the pelvic cavity. Gonococcal ophthalmia neonatorum is the eye infection in newborns caused by Neisseria gonorrhoeae. This infection can cause blindness within a few hours after birth if not treated with antibiotic eye medication. Antiviral medications like acyclovir (Zovirax) and valcyclovir (Valtrex) are used to treat primary infections and recurrences and will shorten the duration of the outbreak. As suppressive therapy, they help prevent recurrences. No cure exists for HSV1 infections; the virus will live on the nerve root until the next outbreak. Radiation treatments cause nausea and vomiting; fluid status should be monitored to determine if the client is dehydrated. Phimosis is a tight foreskin that is unable to be retracted by an age when retraction should take place. A 2-gram sodium-restricted diet requires use of no salt in cooking, no salt added at the table, avoiding high sodium foods, and limiting milk to 2 cups per day. Option 1 is incorrect—no salt can be added in this restricted diet. Options 2 and 4 are incorrect—1 cup of milk per day and the use of salt-free butter are requirements of a 1-gram sodium restricted diet. Benign prostatic hyperplasia (BPH) is seen in elderly men in all ethnic groups and races and is thought to result from decreasing testosterone levels that begin in middle-age. BPH is neither cancerous nor precancerous. Caffeine and smoking both increase the incidence of benign cysts of the breast. Breast cysts (fibrocystic breast disease) are neither a precursor to nor a risk factor for developing breast cancer. The small incision will usually not affect lactation. Small tumors that are localized are often treated with lumpectomy. Recurrence rates and survival rates are not improved in these cases with more radical surgery. Cryptorchidism is the single greatest predictor of testicular cancer, even when the condition is corrected in early childhood. Varicocele does not increase the risk of the disease, nor does a second-degree relative with the disease. No activity has been associated with testicular cancer. Condoms used consistently will decrease the transmission of sexually transmitted infections and protect sexual partners. Latent syphilis usually has no symptoms. The latent phase begins when the rash of secondary syphilis clears, and may last for decades without further symptoms. Giving away personal possessions is a sign of depression and suicidal ideation. Although the diagnosis of cancer may result in depression, indications of suicidal tendencies must be addressed. Impotence after prostatectomy is common, and sometimes responds to oral or injectable medications. Chemotherapy often causes nausea, and medication to control the nausea should be used. Normal incisional healing involves some itching, and because the subcutaneous nerves are severed during surgery, numbness around the area may result. Nerve-sparing surgical techniques can sometimes be utilized, but impotence and incontinence are still common side effects. First-degree relative with the disease is a strong risk factor for developing prostate cancer. In elderly men the cancer is slow growing, but the younger the man is at time of diagnosis, the more aggressive the cancer is likely to be. Uterine fibroids or myomas will cause heavy menses with large clots. The presence of intramural or submucosal myomas can cause early pregnancy loss or infertility. Ultrasound examination will detect the presence of myomas. Congenital syphilis can occur when a mother is in any stage of syphilis infection during the pregnancy, including if she becomes infected during this pregnancy. All sexual partners should be treated. Penicillin is the antibiotic used for treating syphilis. Because syphilis is blood-borne, gowning and gloving when having contact with the dead infant's skin is all that would be required. Diagnostic work-up may include lumbar puncture. The DASH diet increases daily servings of vegetables and fruits, and recommends low-fat dairy foods and reduced intake of saturated fats and cholesterol. Option 1 reflects increased fats; option 3 represents increased fat, cholesterol, and sugar; option 4 reflects increased sodium content. Endometriosis causes infertility both in the presence of blockage of the fallopian tubes from endometrial implants as well as without blockages for unknown reasons. Pregnancy is often extremely difficult if not impossible unless medical or surgical intervention is initiated. Herpes simplex virus (HSV) infections of the genital tract are exquisitely painful, start as blisters that become craterlike lesions, and are often accompanied by enlarged groin nodes. People living in heavily industrialized states experience higher rates of urinary tract cancers than those living in agricultural states. People living in northern regions have a higher risk than those living in southern regions. Midstream urine is considered to be less likely to be contaminated from the external genitalia. Analysis for disorders as serious as ARF requires a good specimen if not a cath specimen. Cranberry juice helps the acidity of the urine to inhibit bacterial growth. The juice should not account for the presence or absence of glucose or protein. The specific gravity is affected by fluid balance. Phenazopyridine (Pyridium) is a urinary analgesic that stains the urine/semen orange. Antibiotics can be used (option 1); options 3 and 4 are incorrect. Fluids should always be encouraged. An increase in fluid intake of 2,500 to 3,000 mL/day is a prevention measure for further urolithiasis. A client with CHF, however, will probably not tolerate this amount of fluid without complications. Restricting dietary protein early in chronic renal failure may slow the disease progression and also reduce nausea and vomiting due to anorexia associated with uremia. Protein intake of 0.6 g/kg body weight or approximately 40 g/day is usually adequate. Carbohydrates should be high to compensate for energy needs. Early management of the client with chronic renal failure focuses on elimination factors that may further the decrease of renal failure and measures to slow the progression of the disease to end-stage renal disease. If conservative treatment fails, dialysis or transplantation is the treatment option. Limiting Vitamin D inhibits absorption of calcium from the GI tract. Acid-ash foods promote acidity of the urine, whereas alkaline-ash foods promote calcium stones. The client with burns needs increased amounts of protein and Vitamins C and D until the wounds are completely healed. Option 1 reflects high-protein sources, an antioxidant source, and fortified milk that includes Vitamin D and calcium. The other options do not reflect the necessary protein, vitamins, and mineral sources needed for the care of clients recovering from burns. Creatinine is solely indicative of renal function and represents damage to a large number of nephrons. BUN can be affected by the amount of protein in the diet. Bilirubin indicates liver problems and electrolytes can be altered for many reasons. Vesicoureteral reflux is a condition in which urine moves from the bladder back toward the kidney. Diet, swimming, and circumcision should not cause an infection of the kidneys. The indwelling urinary catheter is left in place about 2 weeks after a TURP procedure. The urine should progressively become clearer and less pink, and clots are to be reported to the physician immediately. Low abdominal pain of new onset can be a symptom of cystitis, and should be reported. Nonsteroidal antiinflammatory drugs are to be avoided because of the potential for increased bleeding. Adequate fluid intake is important to keep the catheter draining well, but caffeine and alcohol are both bladder irritants and may cause bladder spasm as well as dehydration. The highest incidence of syphilis infections is among black men in urban areas, particularly in the southeastern United States. This client has two risk factors, because syphilis is spread through both sexual contact as well as being blood borne. Epispadias is a rare defect that develops very early in fetal development. No known risk factors have been identified, and parents should be assured it wasn't caused by anything they did or didn't do. <i>Chlamydia trachomatis</i> is the most common bacterial cause of pelvic inflammatory disease. The bacteria ascend from the cervix into the uterus and fallopian tubes, where infection worsens. Testicular cancer occurs most often between the ages of 15 and 34, and presents with a lump or thickening of one testicle, pain in the testicle and lower abdomen, lower back, or rectum. Neurosyphilis can occur during any stage of syphilis but most commonly occurs during the tertiary stage. Central nervous system involvement causing dementia, paralysis, gradual blindness, and numbness characterizes neurosyphilis. Syphilis is blood borne and sexually transmitted, so all sexual contacts should be tested. Treatment is based on lumbar puncture results and estimated length of time of the syphilis infection. Bleeding calendars are utilized to quantify the amount and frequency of bleeding. The client should document each day that she has bleeding, how much bleeding she has, the color of the flow, and when she has clots (including the size of the clots). All information must be obtained in order to make an accurate diagnosis. Endometriosis is small areas of growing endometrium in the pelvic and/or abdominal cavity, which increase in size during the secretory phase of the menstrual cycle. Because there is nowhere for the endometrium to be shed, scarring occurs. Simple sugars and carbohydrates, including honey and jelly, increase the osmolality of the gastric contents and enhance movement of food out of the stomach. Therefore, these should be avoided by the client at risk for dumping syndrome. Six small meals per day, not taking fluids with meals, and lying down for 30 to 60 minutes after meals will help reduce the risk of dumping syndrome. Primary dysmenorrhea results from the overproduction of prostaglandins by the myometrium. Nonsteroidal antiinflammatory medications (like Naprosyn) have antiprostaglandin activity and thus decrease the dysmenorrhea. Ibuprofen is a nonsteroidal antiinflammatory drug, and has antiplatelet aggregation properties. It must be discontinued 10 days prior to surgery to prevent excessive blood loss. Uremia is a syndrome, or group of symptoms, associated with end-stage renal disease. The normal function of the kidney is altered, resulting in various metabolic and systemic effects including fluid and electrolyte disturbances. Pyelonephritis (inflammation of the kidney and renal pelvis) and cystitis (inflammation of the urinary bladder) do not lead to uremia. Polycystic kidney disease is a hereditary disease characterized by kidney enlargement and cyst formation. If outflow drainage is less than inflow, the nurse should change the client’s position to shift abdominal fluid, and hopefully move the catheter into contact with the fluid in the abdomen. Although vital signs are monitored, the blood pressure is not a concern at this time (option 1). The catheter does not need to be irrigated (option 3). A direct nursing intervention is needed, while continuing to monitor is data collection and does not correct the current problem (option 4). A client with glomerulonephritis should eat a diet that is high in calories but low in protein to inhibit protein catabolism, and allow the kidneys to rest by diet (since they have fewer nitrogenous wastes to clear). It is important to protect the kidneys while they are recovering their function. The other responses are incorrect. Acute renal failure is a condition that may be caused by nephrotoxic drugs such as aminoglycoside antibiotics. Acute renal failure has a rapid onset and is potentially reversible. The condition usually responds to treatment if diagnosed early. Chronic renal failure develops insidiously and requires dialysis or transplantation. Serum creatinine measures the amount of creatinine in the blood. Creatinine is the end product of creatine phosphate, used in skeletal muscle contraction. Blood urea nitrogen (BUN), another common laboratory test, measures the nitrogen portion of urea and helps detect dehydration. These tests are often ordered together when monitoring renal function. An acid-ash diet lowers urine pH, which may reduce bacterial growth. An acid-ash diet includes the following foods: meat; fish; shellfish; poultry; cheese; eggs; cranberries; prunes; plums; corn; lentils; grains; and foods high in chlorine, phosphorus, and sulfur. Foods to be avoided include: milk and milk products; all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and foods containing high amounts of sodium, potassium, calcium, and magnesium. Peritonitis is the major complication of PD. The nurse should use strict aseptic technique and should teach the client to use it whenever accessing the catheter. The client does not need postvoid residuals (option 1). Heparin is added to dialysate as ordered, but it would be added to each bag, not to one bag per day randomly; the catheter site dressing is changed daily (options 3 and 4). Renal colic is an acute, severe pain in the flank and upper abdominal quadrant on the affected side, generally associated with renal calculi that obstruct a ureter. Clients experiencing renal colic describe it as sudden in onset and may be accompanied by nausea, diaphoresis, and vomiting. Washing the skin with the combination of soap and water will remove the blood through mechanical friction. While alcohol can kill bacteria, it cannot kill viruses and fungi (option 1). Tissues would not adequately remove the blood (option 2). Hot water can burn the nurse, and water alone is inadequate in removing the blood (option 3). Increased dietary protein can lead to increased uric acid formation, which in turn lowers urinary pH and causes precipitation of uric acid stones. Clients should not exceed protein intake of 100 grams per day and should monitor purine content of foods. Option 1 is incorrect—factors other than dietary intake can cause stone formation, specifically alterations in urinary pH and the presence of metabolic disease. Option 2 is incorrect—there is no clinical evidence to suggest that decreasing calcium intake will prevent the formation of renal calculi; rather, research is showing that a high-calcium diet offers protection against stone formation. Even though most renal calculi are composed of calcium oxalate, it is the oxalate component that appears to cause the formation of stones. Option 4 is incorrect because increasing intake of complex carbohydrates is recommended to prevent renal calculi formation. Painful urination, frequency, and urgency are common signs of cystitis, or bladder infection. In addition, the urine may have a foul odor and appear cloudy. Bacteria, virus, parasites, or fungi may cause the condition, with GI tract bacteria being the most common cause. Pain is the most common sign of UTI and is usually the most distressing symptom for the client. The pain may be caused by inability to void or by bladder spasms. The client may have manifestations of the other nursing diagnoses as well, but pain is the highest priority. Various relationships between BPH and diet, obesity, sexual activity, and racial origins have been explored; however, none of these provide insight into its etiology. Priapism is considered a medical emergency, because continued erection may lead to tissue fibrosis and impotence. Immediate treatment involves ice packs, not warm soaks. Options 2 and 4 do not apply. Propranolol, a beta adrenergic blocker, and many other antihypertensive medications can contribute to erectile dysfunction. Other examples include clonidine (Catapres) and benazepril (Lotensin). The other medications listed in options 2, 3, and 4 aren't known to have this effect. Because painless vaginal bleeding is often the only symptom of cervical or uterine cancer, this client should be tested for cancer. Options 1 and 4 are not probable given the client's age. Hormonal imbalances (option 3) may cause bleeding but are less urgent than the threat of cancer. NPTR monitoring helps differentiate between psychogenic and organic causes of erectile dysfunction. The other options are not monitored using NPTR monitoring. Third-degree uterine prolapse is visible outside the body as the uterus inverts the vaginal canal. Rectocele is prolapse of the rectum. Cystocele is prolapse of the urethra. A vaginal infection would not cause tissue protrusion from the vagina, although the vaginal tissues would be reddened and/or edematous. The Pap smear test is used to screen women for cervical cancer, determine hormonal status, and identify the presence of sexually transmitted diseases, such as HPV infection. Infertility and AIDS are not diagnosed with the Pap test. Sterility is a male reproductive problem. Early menstruation, before the age of 12, is a risk factor for breast cancer. Use of foam contraceptives is not a factor. Late menopause increases the risk for breast cancer, but not early menopause. A first birth after the age of 30 is a risk factor, but first birth before age 20 is not. Clients with COPD who overeat, in addition to consuming excess carbohydrates, have increasing difficulty with breathing because of excessive CO<sub>2</sub> levels that place additional stress on the lungs. The client should eat a proper diet and correct percentages of macronutrients to maintain adequate weight. In addition, chronic COPD is associated with PEM (protein-energy malnutrition), infection, and unintentional weight loss. Option 1 is incorrect—increased calories alone can lead to increased work of breathing. The percentage of fat in the diet may also pose a problem if the client is experiencing contributory disease or malabsorption. Option 2 is incorrect—merely providing medication therapy to stimulate weight gain does not address the problem of the obvious excess of calories that the client is consuming or that the client is experiencing difficulty breathing. Option 4 is incorrect because an increase in high-quality proteins will not help to correct the clinical symptoms. Breast examinations should be done monthly, at the same time each month to aid in remembering to do it regularly. A postmenopausal woman would select the same date each month, while premenopausal women should do BSE at completion of the menstrual cycle. Breast examination during menstrual flow is not the best time, because of hormonal influences on the breasts. Syphilis is transmitted from open lesions during any sexual contact: genital, oral-genital, or anal-genital. Kissing, sharing eating utensils, and shaking hands do not transmit the disease. With end-stage renal disease the kidneys have difficulty excreting protein, and the buildup of toxins in the system causes systemic problems. Clients must usually restrict dietary protein while increasing carbohydrate intake to meet energy needs and prevent tissue breakdown. Potassium and sodium are restricted in clients with end-stage renal failure. Protein-rich foods are also high in phosphorus, which is restricted to avoid osteodystrophy. Magnesium is not specifically restricted. The pain experienced with cystitis usually resolves as antibiotic therapy becomes effective. However, clients may be treated for urinary tract pain with phenazopyridine, which is a urinary analgesic. Bethanechol chloride is a cholinergic agent used with neurogenic bladder or urinary retention. Oxybutynin and propantheline bromide are antispasmodics used to treat bladder spasm. Clients who have urinary stones of the uric-acid type should avoid foods containing high amounts of purines, including the following: organ meats (liver, brain, heart, kidney, and sweetbreads), herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages. Benign prostatic hyperplasia (BPH) is a common cause of urinary retention when the enlarged prostate gland obstructs urinary flow. The other answers may also cause retention, but are less common than BPH. This type of incontinence is called urge incontinence, caused by a hypertonic or overactive detrussor muscle that leads to increased pressure within the bladder. Stress incontinence is loss of urine with abdominal pressure. Reflex incontinence refers to loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Functional incontinence is an involuntary, unpredictable passage of urine. Clients with excess fluid volume need to have restrictions in sodium intake because of the relationship of water and sodium. Elevated serum sodium will cause water to be retained. The client should be instructed to avoid foods that are high in sodium such as cured meats, preserved foods, and canned goods. In addition, developing a schedule for oral intake and offering limited ice chips and frequent mouth care helps in the water restriction necessary for these clients. The other options are not appropriate interventions for the nurse to implement specific for the nursing diagnosis excess fluid volume. Cranberry juice reduces bacteria by acidifying urine and making it more difficult for bacteria to remain attached to the bladder wall. Citrus fruits should not be used because they make the urine alkaline. Drinks containing caffeine, including sodas, may irritate the bladder and worsen the urinary frequency. Peristomal skin should be cleansed with each appliance change using a gentle soap and water, and then should be rinsed and dried thoroughly. The client should change the appliance early in the morning, when urine production is slowest from lack of fluid intake during sleep. The opening of the appliance should be cut no larger than 3 mm greater than the opening of the stoma; an opening smaller than the stoma would prevent proper application. Fluids are encouraged to dilute the urine and decrease the odor. A client who has stomatitis will have pain upon ingestion of food caused by the inflammatory process. Cool foods are often tolerated better than hot foods, as are soft, creamy products. Option 1 is incorrect—peanut butter is a thick, dense food that may irritate the mouth by sticking on mucous membranes and requiring more effort to swallow. Option 2 is incorrect—pretzels are high in salt, which may cause further irritation to the oral cavity. Option 3 is incorrect because tomatoes are high in ascorbic acid; even though they are in the form of a soup, they may cause irritation. Nephrotoxicity can be caused by aminoglycoside antibiotics. This type of drug accumulates in tubular cells, eventually killing them. Options 2 and 3 are ototoxic, while option 4 is avoided in renal disease. A Kock pouch is a continent internal ileal reservoir, eliminating the need for an external pouch. The nurse needs to instruct the client about the technique for catheterizing the pouch to empty the urine. Antibiotics are not required unless an infection is present and dietary restrictions are unnecessary. The spirochete <i>Treponema pallidum</i> causes syphilis. The other responses are incorrect. The client’s symptoms are consistent with secondary syphilis, which occurs 2 weeks to 6 months after the initial chancre disappears. Latent syphilis produces no symptoms, and tertiary syphilis is the final stage of the illness. Tertiary syphilis is characterized by the development of infiltrating tumors and involvement of the central nervous and cardiovascular systems. Herpetic lesions are very painful, so the first priority is to provide comfort measures for the client. The other diagnoses do not address the client’s most immediate concern. A painless, hard nodule is the classic presenting symptom of testicular cancer. Testicular self-examination can help detect this sign. Testicular cancer is the most common cancer in men between the ages of 15 and 35, and is the third-leading cause of cancer death in young men. Testicular torsion, or twisting of the testes and spermatic cord, is a potential emergency, because compromised blood flow to the testicle may lead to ischemia and necrosis. The other conditions usually don’t require emergency intervention. Hydrocele is a fluid-filled mass within the scrotum. Option 2 describes spermatocele. Option 3 describes varicocele. Option 4 describes testicular torsion. Sildenafil is an oral medication used to treat erectile dysfunction in men. The other medications may worsen the client's condition. Clients who take nitrates may experience severe hypotension when using sildenafil. Taking the drug after a high-fat meal will delay its onset. The drug should not be combined with other treatments for erectile dysfunction, and should not be taken more often than once daily. A client who is lactose intolerant has a difficulty handling milk and dairy products because of deficient lactase enzyme. Full liquid diets are based on milk and dairy products. If a client is known to be lactose intolerant, the diet will have to be adjusted to reflect lactose-reduced or lactose-free products in order to prevent GI irritation. Option 1 is incorrect—it does not reflect the added clinical condition of lactose intolerance but merely refers to progression of diet. Option 2 is incorrect because lactose intolerance does have an impact on diet patterns. Option 3 is incorrect because diet progression does not rely merely on the return of a bowel movement pattern. Chlamydial infection may be present for months or years without producing symptoms in women. The disease may invade the uterus, resulting in devastating complications. It is caused by <i>Chlamydia trachomatis</i>, a bacterium that behaves like a virus. Young women using oral contraceptives have the highest risk. When diagnosed early and confined to the prostate gland, prostate cancer is curable and the 5-year survival rate is 100 percent. Men under the age of 40 rarely have prostate cancer. African-American men have a higher incidence of prostate cancer and a higher mortality rate. Positioning the client in semi-Fowler’s position allows optimal lung expansion. Positioning the client on the operative side helps to splint the incision and improves lung expansion. The combination of these two positions provides the best positions to prevent respiratory depression in a postnephrectomy client. Dehydration and immobility predispose the client to the formation of renal calculi. Prolonged immobilization leads to loss of bone calcium and hypercalciuria, which predisposes an individual to the development of calcium oxalate stones. Adequate hydration prevents urinary stasis and stone formation. Option 3 does not have a direct link to the development of renal calculi. While infection of the urinary system can lead to development of renal stones, it is not the most likely cause. A client with impaired renal function requires close monitoring of intake and output. The serum creatinine value of 7 (normal 0.8 to 1.2 mg/dL for males; 0.6 to 0.9 for females) provides evidence of an estimated decrease in the glomerular filtration rate. Although peripheral edema, weight increase, and skin changes may occur in renal impairment, measurement of intake and output is vital in monitoring fluid balance. Forcing fluids helps prevent urinary retention and flushes bacteria from the bladder. Citrus juices along with caffeine and alcohol should be avoided because they cause bladder irritation. The use of a heating pad and sitz baths may ease the discomfort associated with the infection, but increasing the fluid intake is a more important action. Urinary incontinence is not a normal part of aging. The causes of urinary incontinence include anything that may interfere with bladder or sphincter control. Option 1 refers to Kegel exercises, which can contribute to regaining continence. Voiding schedules and prompted voiding help, too in regaining continence. Application of pressure over the bladder area, also known as the Crede maneuver, helps in successful urination. The first specimen contains urine that was in the bladder before the test began, so it should be discarded. The test begins with the next voided specimen. Infection is a significant risk for CAPD clients, because organisms can enter the body through the peritoneal catheter and through the dialysate solutions. The other diagnoses are either inappropriate or have lower priority because the problems are less threatening. Corticosteroids, such as prednisone, help control rejection of the new kidney. Rejection is a common cause of graft loss in individuals with renal transplants. The other medications are not routinely ordered for the client. A client who is receiving enteral feedings via nasogastric tube can be at risk for dehydration caused by inadequate fluid intake. It is therefore important to irrigate the tube with water as ordered (before and after feedings or medication administration) and include these irrigations in the client’s total I&O measurements. Option 1 is incorrect because although inspection of the skin surrounding the tube is necessary, it does not relate specifically to fluid balance. Option 2 is incorrect because clients are often weighed daily. Option 3 is incorrect because feeding tubes are not flushed only once a day. Erythropoietin, a hormone synthesized in the kidneys, stimulates the bone marrow to produce red blood cells. The production of this hormone is in response to low oxygen levels in the kidney cells. When there is decrease in functioning renal mass, erythropoietin synthesis is also decreased. With deficient erythropoietin, anemia develops in the client with renal disease. The figure shows that a portion of the ileum is formed into a tubular pouch with the open end brought to the surface of the skin and the ureters inserted into the pouch. An ileal conduit is the most common urinary diversion. A colon conduit (option 1) is similar to the ileal conduit but utilizes a portion of the sigmoid colon rather than the small intestine. Option 2 (Indiana continent reservoir), describes a surgical diversion whereby the reservoir is formed from the colon and cecum. A Kock pouch (option 4) is similar to the ileal conduit, but nipple valves are formed, which prevents leakage and reflux. The seminiferous tubules within the testes produce sperm, while Leydig’s cells (interstitial cells) within the testes manufacture testosterone. The other options are incorrect. Because the statement in option 1 is incorrect, the client needs more teaching. He will be able to have intercourse and will remain fertile without his prostate gland. Semen volume will decrease, because the prostate secretions make up one-third of the volume. The vagina, ovaries, fallopian tubes, and uterus are parts of the internal organs of the female reproductive system. The other organs listed are external. The definitive diagnosis for chlamydia is tissue culture of the endocervix or the urethra. This is an expensive test and therefore a careful analysis of the history and physical findings are relied upon. VDRL, RPR, and FTA-ABS are diagnostic tests for syphilis. Option 1 is the most sensitive way to inquire about erectile function. Interview questions are less threatening if they are asked in a way that gives the client the option to report behaviors and symptoms. Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. Testicular cancer is the most common cancer in men between the ages of 15 and 35. Testicular torsion occurs at any age and gonorrhea is highest in occurrence during the sexually active years. Among women, 15- to 19-year-olds and men 20 to 24 years old have the highest rate. The statements in the first three options correctly describe signs of BPH. Option 4 indicates the need for further teaching, because the client should increase his fluid intake (unless contraindicated) to prevent urinary tract infections and lessen dysuria. A retropubic prostatectomy is used to remove massive prostatic tissue. It involves having a low midline abdominal incision but the bladder is not incised. A suprapubic prostatectomy involves an abdominal incision but cuts through the bladder to access the anterior aspect of the prostate. TURP is a surgical approach that involves insertion of a resectoscope into the urethra. In the perineal resection approach, the incision is made between the anus and the scrotum. Perineal resection is used more commonly in cancer of the prostate. A client with a significant cardiac history on a fat-restricted diet should not use additional fat during the cooking or preparation process. Option 1 is incorrect—a client with a significant cardiac history will require some form of fat control or restriction as part of a dietary pattern for the rest of his or her life. Option 2 is incorrect—fat is a necessary nutrient for the body. To deprive a client of all fat sources can lead to a clinical deficiency of essential fatty acids that can cause further problems for the client. Option 4 is incorrect because ice cream is considered a high-fat product. The client could have low-fat ice cream, yogurt, or sherbet to satisfy dietary needs. The healing period after prostate surgery is 4 to 8 weeks, and the client should avoid strenuous activity during this period. Blood in the urine is fairly common after surgery. The client should not drive for 2 weeks, except for short rides. With prostatodynia, the client experiences symptoms of prostatitis, but shows no signs of inflammation or infection. Positive cultures, chills and fever, and purulent secretions are symptoms of infection. Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is diagnostic for appendicitis. Examination for rebound tenderness would also assist in the diagnosis. Options 2 and 3 are common with ulcers; option 4 may suggest ulcerative colitis or diverticulitis. Fever indicates an infection, ruling out options 3 and 4. Appendicitis typically causes pain in the umbilical area or right lower quadrant and is not usually accompanied by diarrhea. Fever and diarrhea accompany diverticulitis. <i>H. pylori</i> causes release of toxins and enzymes that promote inflammation and ulceration. It is not spread from one person to another. Contributing factors are those that increase secretion of acid and pepsin. Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake or spicy foods, not restricting the client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition. Red blood in the stool is more characteristic of left-sided cancer of the colon. If blood occurs in the stool at all in right-sided cancer of the colon or gastric ulcers, it will be black or tarry. There is no blood in the stool of a client with gallbladder disease. Remember, bright red blood can also occur with hemorrhoids, but this choice was not available. Aspirin is one of the nonsteroidal antiinflammatory drugs (NSAIDs). These drugs are predisposing or contributing factors in the development of an ulcer, because of the effect on prostaglandins. Many of the medications used for arthritis may also irritate an ulcer; therefore, a physician should be consulted. These are all signs of perforation. If the client is going into shock, it is important to establish IV access before the veins collapse. The doctor will probably schedule emergency surgery. If the client has a possible perforation, she should be in low Fowler’s position (option 1) to contain the secretions in the abdomen. Walking (option 2) is not recommended, and food allergies (option 3) are not as likely to be the problem. This description of pain is consistent with ulcer pain. The pain is epigastric, is worse when the stomach is empty, and is relieved by food. These symptoms are not common with cholelithiasis. Ordinary indigestion does not present with this clinical scenario. Allergy I and II diets are used in sequence to identify and eliminate potential food allergens. Option 1 is incorrect—even though this diet pattern is used over a short time period, this response does not address why it is necessary to follow the diet pattern. Option 2 is incorrect because it provides false and inaccurate information. Option 4 is incorrect—referral to an immunologist for allergy testing is not a required accompaniment to this dietary pattern. Referral to an immunologist for allergy testing may eventually be indicated if the client is found to have a multiple allergy profile. One form of intestinal obstruction is paralysis, caused by decreased movement of the intestinal contents by normal peristalsis. The client in option 1 is at high risk for Crohn’s disease and ulcerative colitis. Option 3 enhances the risk of cancer of the colon and diverticular disease; option 4 is consistent with peritonitis. Gastroesophageal reflux disease causes epigastric pain that is usually described as burning; it is accompanied by belching with a sour taste, pain after eating, increased salivation, and flatulence. The symptoms of a sliding hiatal hernia are similar to GERD, but not to those of a rolling hernia. Symptoms of PUD are more pronounced and reflective of a full or empty stomach. Ulcerative colitis symptoms are related to pain and bowel movements. A fatty liver is one of the main effects of alcohol consumption, known as Laënnec's cirrhosis. Other factors such as dietary intake of fat, body stores of fat, and hormonal status can also contribute to fatty liver. Hepatitis A has an acute onset, and accounts for about 25 percent of hepatitis cases in the United States. The usual incubation period is 15 to 40 days. The disease is spread where there is fecal contamination of water supplies and from oral contamination (such as in day care). Portal hypertension and liver cell failure contribute to the late manifestations of cirrhosis. Cholelithiasis and cholecystitis will be accompanied by pain, food intolerances, and/or vomiting. Pancreatitis presents with pain radiating to the back, mild cardiovascular changes, and hypocalcemia. The onset of action for meperidine is 10 to 15 minutes, and the onset for morphine is 20 to 60 minutes. Both drugs are equal in the potential for addiction. Demerol is less sedating than morphine. The most important difference is that the meperidine causes fewer spasms of the sphincter of Oddi, which contributes to the goal of giving the pancreas a rest. The client is at increased risk for a return of the encephalopathy because of the diagnosis of pneumonia and dehydration. She has volume depletion and the potential for electrolyte imbalance, both of which can contribute to the development of encephalopathy. Dietary protein intake must be controlled (or eliminated) in order to minimize the ammonia levels in the bloodstream. In the cirrhotic liver, fibrous tissue develops among the parenchymal cells preventing the production of adequate plasma proteins. The consequence of low plasma proteins leads to a decrease in colloid osmotic pressure and generalized edema. When combined with high portal capillary pressures, large amounts of fluid and protein form in the abdominal cavity, which is called ascites. Gravity causes the fluid to sink and gas-filled loops of the bowel rise, creating the shifting dullness and tympany during examination. The cancer cells alter enzyme secretion and flow to the duodenum in addition to causing fat and protein malabsorption. These changes result in weight loss and nausea, which are common signs and symptoms of cancer of the pancreas regardless of location. When bile production is reduced, the body has reduced ability to absorb fat-soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts. Foods that contain gluten (wheat, oats, rye, and barley) are restricted for a client with celiac disease because of an inability to handle gluten protein. All of the other choices reflect items that cannot be used in a gluten-restricted diet. The posticteric phase follows jaundice. Symptoms decrease and the serum enzymes begin to return to normal. Hepatitis B is transmitted by parenteral, sexual, or perinatal routes. Hepatitis A is transmitted by the fecal-oral route. Hepatitis D has a rapid onset. Chronulac is a synthetic, nonabsorbable disaccharide metabolized to organic acids by enteric bacteria and causes osmotic catharsis while reducing the growth of ammonia-forming bacteria. Chronulac also lowers the pH of the colon, which converts ammonia to a nonabsorbable form, allowing expulsion through the laxative action of the drug. The dose required is 15 to 30 mL orally every 4 to 6 hours and may be titrated to a lower dose if diarrhea occurs. Lying on the side with legs flexed, pain over McBurney’s point, and rebound tenderness are characteristic symptoms of appendicitis. Vomiting frequently accompanies the pain. The client definitely should not have an enema if appendicitis is suspected. If surgery is needed for appendicitis, the client needs to be NPO. Zollinger-Ellison syndrome is a condition usually caused by a gastrin-secreting tumor of the pancreas, stomach, or intestines that leads to the increased secretion of pepsin and hydrochloric acid. This often leads to peptic ulcer disease. Option 1 explains one of the pathologic reasons for peptic ulcer disease; option 3 explains a volvulus obstruction, and another name for Crohn’s disease is regional enteritis. Dumping syndrome is the rapid influx of stomach contents into the duodenum or jejunum causing increased peristalsis and dilation of the intestines. Although this occurs primarily after a gastrectomy, the condition can cause an ulcer. The bacteria <i>H. pylori</i> has been discovered to be the leading cause of many ulcers and can be treated with success by antibiotics. Options 1, 2, and 4 are unrealistic answers for the action of antibiotics. Caffeine stimulates the acid secretion and can interfere with the function of the lower esophageal sphincter. Chocolate contains caffeine and should be limited along with other drinks and foods with caffeine. Spicy or hot foods, smoking, and alcohol should also be avoided. The bowel wall becomes congested, thickens, and sometimes develops fistulas, which can become infected. This leads to malabsorption and deficiency in absorption of folic acid, calcium, and Vitamin D. The anorexia can play a role in weight loss, but most clients eat and cannot explain why they have weight loss. Elderly clients often eat less food with less roughage and fiber and therefore do not obtain the proper nutrients from their diet, which can aid in the development of the disease. Most often chronic constipation, not diarrhea, is a cause. Clients with Crohn’s disease are at risk of developing cancer of the GI tract. A noncompliant client increases that risk and should be educated that Crohn's can be successfully kept under control. A client taking MAO inhibitors has to avoid foods that are high in tyramine because tyramine can lead to significant complications resulting in hypertensive crisis. Cottage cheese is an unfermented cheese that 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. A client with any GI disorder, especially a peptic ulcer, should never receive any aspirin product. Many pain medications contain aspirin and are combinations of an opioid analgesic and a nonopioid analgesic such as aspirin. The nurse administering the pain medication should know what ingredients are in it. Hydrocodone is a schedule III opioid analgesic in agents such as Lortab. Inserting an NG tube will decompress the bowel, which will relieve the vomiting and pain and hopefully prevent the client from going into shock. This may be a measure to institute only until surgery can be performed. All of the interventions are appropriate, but vomiting fecal matter can be dangerous (as well as unpleasant) because of the possibility of aspiration, especially with a decreasing level of consciousness. Causes of pancreatitis include alcohol abuse of excessive intake of liquor or wine for 6 years or more, high triglyceride levels, and hypercalcemia. Stones lodged in the pancreatic duct can cause obstruction and lead to inflammation of the pancreas. Options 1, 2, and 3 are worded incorrectly. When the pancreas is injured and/or has an impaired or disrupted function, the pancreatic enzymes (phospholipase A, lipase, and elastase) leak into the pancreatic tissue and initiate autodigestion. Options 3 and 4 can be causes of pancreatitis. Option 1 is incorrect to this situation. In pancreatitis, the lipase, amylase, glucose, and white blood count (WBC) are all elevated. The calcium is low for 7 to 10 days and is a sign of severe pancreatitis. Bleeding is a complication of pancreatitis and is usually identified through a positive Turner’s sign (flank bruising) or Cullen’s sign (umbilical bruising). Options 1 and 3 are correct in pancreatitis, but do not answer the question. Read the stem carefully when taking the test. Option 2 is incorrect; remember the pain may be relieved by flexing the left leg or by walking. Although option 4 is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options 1 and 3 are incorrect, fluid accumulation is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged. Clients with cirrhosis have used their clotting factors, and the liver is unable to provide enough clotting factors. A prothrombin time is an indication of the time needed for blood to clot. If clotting factors aren’t present, bleeding is more likely. Although hepatitis is associated with cholestasis (option 2), the most likely candidate would be someone with a viral infection. A classic example is someone with varicella zoster. Options 1 and 3 are not related to hepatitis. Other causes include alcohol, toxins, and severe hepatocellular damage. Hepatitis A is transmitted by fecal-oral route. The virus is excreted in oropharyngeal secretions (nose and throat) and transmitted by direct contact of person-to-person, or by fecal contamination of food or water. A worker at the pub could have hepatitis A and transfer it to the food that is being prepared. Options 1, 2, and 4 are classic of hepatitis B, C, and D. The perception of being in a state of “always dieting” can be problematic in terms of compliance and goal attainment because it can be viewed either as a restriction or as a form of punishment. Option 1 is not true: Wanting to lose weight is not the only factor to consider; many other variables affect weight loss. While it is important to find out the type of the diet the client is on (or has been on), this knowledge doesn’t address the main concern of the client regarding “always dieting” and the yo-yo effect (weight cycling). The symptoms in preicteric hepatitis are vague and more flulike as described above. The physician usually needs laboratory work to verify a diagnosis. In this case, the presence of the antigen HBsAg concludes that the client has an active form of the disease since hepatitis B surface antigen is present. Although an abdominal ultrasound, x-ray, and CT scan are useful in the diagnosis of cancer of the liver, the alpha-fetoprotein serum markers are specific to detecting primary hepatocellular carcinoma. Eating at bedtime may cause increased secretion of pepsin and gastric acid, which will cause pain later when the stomach is empty. Sleeping pills should be the last resort, and stress can aggravate the circumstance, but it would not be just at night. When the appendix ruptures, there is a decrease in pain because the appendix is no longer distended. The problem is worse, not better. There is no indication in the question that the child has had a change in level of consciousness. A high-fiber diet increases stool bulk and decreases intraluminal pressure, decreasing development of diverticula. The other responses will not necessarily be effective or they are incorrect. Clients with rectal and intestinal polyps have a higher incidence of colon and rectal cancer. Early diagnosis facilitates more effective treatment. Caloric and fat content should not be increased. The inflammatory process is the pathology in the development of Crohn’s disease. Inflammation results in ulcers and fissures or fistulas as well as fibrosis. The other options are not related to Crohn’s disease. Presence of a mass demands immediate attention. The other symptoms are characteristic of cancer of the liver. These symptoms could represent stomach cancer also. Annual guaiac testing is recommended by the American Cancer Society as a means of detecting colon cancer. The other options are not. Ranitidine (Zantac) is an H2-receptor antagonist; the action is to block the secretion of HCl by depressing the histamine receptors. It does not coat the lining. The object is not to increase gastric acid or make histamine receptors more sensitive. Standard precautions are used with all clients, regardless of the medical diagnosis. Clients with AIDS are not contagious, and family members are not required to wear protective equipment in a casual interaction. Diets that are rich in fruits and vegetables have been proven to be effective in decreasing the risk of developing cancer because these foods contain phytochemicals. None of the other food groupings have been shown to decrease the risk of cancer. These symptoms are characteristic of dumping syndrome and occur because of hypertonic food entering the jejunum with no sphincter. The other options result in a different set of symptoms. These studies require the client to take strong laxatives and enemas and to be NPO as preparation for the procedure. The client may become dehydrated. Increasing fiber provides bulk and keeps the stools soft and easy to expel. Fluid intake affects the consistency of the stool. An obstruction takes more than 1 day to form. Colon cancer is more likely to develop in clients who have had inflammatory bowel disease. It is not infectious and there is no effective cure. Symptomatic control is possible. Caffeine increases acidity in the stomach and can affect the lower esophageal sphincter, which could account for the symptoms that are consistent with gastritis. Stresses to the body such as burns, trauma, and surgery can cause stress ulcers even in individuals who did not have an ulcer before the event. Option 2 is not supported by the scenario and options 1 and 4 are incorrect. A pH probe test is done to determine both the number of drops in pH of the stomach and the length of each of the drops. Even though the level did not remain low, 100 drops in 24 hours is excessive. Dyspepsia is a symptom (option 2). The scenario does not support options 1 and 4. Crohn’s disease has a characteristic skip lesion on visualization of the intestinal wall. Option 2 occurs with ulcerative colitis; options 3 and 4 are not suggestive of Crohn’s disease. Elderly people have a lack of adequate blood supply because of the aging process and often consume less of the nutrients necessary in the diet to maintain adequate peristalsis and normal bowel function. Options 1 and 2 can be general causes; option 3 does not apply. Intestinal obstructions are mechanical (options 1, 2, 4) or paralytic, in which neurogenic or muscular impairment hinders peristalsis. Early ambulation after surgery usually helps to prevent this. When an athletic client is considering utilizing any ergonomic aid or supplement, trainers and/or nutritional specialists can monitor the client closely to establish a client baseline, provide education, and prevent potential complications related to therapy. Option 1 is incorrect because a nurse should not suggest an alternative ergonomic aid. The client needs a proper referral to an expert in the field. Option 2 is incorrect because it does not address the priority need—to make the referral. Although it is important to note what type of exercise the client practices, it is still more important to refer the client to the proper specialist who can assist in supervising an athletic treatment regimen. Middle school and high school age students are high users of tobacco by smoking, dipping, and chewing. Teenagers do not feel anything can harm them; therefore, they think they will probably never have cancer. Options 2 and 3 are less likely to apply to their age and teenagers are constantly altering their weight and appetite. Option 4 is false; lesions should be reported. Although the client’s symptoms could suggest option 4, they are highly suggestive of colorectal cancer. Options 2 and 3 are incorrect. Biliary obstruction caused by a stone in the pancreatic duct is one cause of pancreatitis. This type of pancreatitis may result in mild jaundice depending on the degree of obstruction. It is not an indication of a terminal stage. The decision to give oral feedings is based on degree of pain and presence of bowel sounds or laboratory data, which are an indication of improvement of the client and moving from an acute to chronic stage. Hepatitis B vaccine provides protection against hepatitis B or possibly hepatitis D only. Hepatitis A may also be contracted from contaminated food, water, or direct contact. The process of cirrhosis involves fibrotic changes in the liver in which fibrous bands form nodules, which gives the liver a cobblestone appearance. Liver failure is a secondary condition. The process in hepatitis is more necrosis, hyperplasia, and inflammation. Liver cancer is the development of tumor cells. In portal hypertension, decreased protein synthesis results in a decrease in albumin, which causes edema and ascites. Hypoglycemia occurs as a result of increased insulin production. Esophageal bleeding can occur in portal hypertension, which can result in hypovolemic shock, but neither is a direct result of decreased serum albumin. The incidence of cancer of the pancreas is twice as high in smokers as nonsmokers. Other risk factors are high-fat diet and pancreatitis. Correlation has not been shown to obesity, fiber, or alcohol. Bile reflux causes activation of pancreatic enzymes, which cause autodigestion of the pancreatic tissue. There is a definite relationship between these two conditions. Pancreatitis is not always directly caused by alcohol intake. Replacement of pancreatic tissue by fibrous changes causes exocrine and endocrine changes with loss of pancreatic enzymes for digestion and loss of function of islets of Langerhans, which secrete insulin, resulting in diabetes mellitus. As a chronic condition, there is very limited recovery. There is a direct correlation between alcohol abuse and chronic pancreatitis. Obstruction of the common bile duct interferes with movement of the bile so that it cannot be excreted. A clear liquid diet is recommended for short-term use (1–2 days). Therefore, the maximum is 2 days. It can be used both before and after surgery or diagnostic procedures, during acute stages of illness, or as an initial diet after a significant period of GI inactivity or bowel rest. The client’s ability to determine activities that would not cause excess fatigue allow for self-direction and participation. Bed rest is encouraged and activities are progressed slowly; however, strict bed rest is not common. Planned rest periods are highly recommended. Increased ammonia occurs because the liver is unable to convert ammonia to urea. Calcium is probably decreased because of bed rest. Serum creatinine is probably increased because of impaired renal function; RBCs are probably decreased because of decreased production in the bone marrow. Low albumin in the blood causes a decrease in plasma colloidal osmotic pressure, causing fluid to escape into the extravascular compartment. In hepatic encephalopathy, the level of ammonia is increased with high levels of protein in the intestine. Calories are needed to promote healing. Potassium levels are usually increased because of impaired kidney function, therefore the intake should not be increased. Sodium is restricted because of ascites. Portal hypertension develops as a result of development of fibrous bands, which develop following necrosis and regeneration of lung tissue. The other conditions are due to other changes in the liver as well as bleeding. Esophageal bleeding occurs as a result of portal hypertension, not just the opposite. Esophageal varices occur as a complication of portal hypertension and cirrhosis. They result in vomiting of blood. The angiomas are another indication of bleeding tendencies common with cirrhosis. Obese, middle-aged or older women are more likely to develop cholelithiasis. It is also seen in Native Americans. All of the other options contain fat. Fat generally is not appetizing to clients with hepatitis. If there are no complications, it is better to give high-calorie and high-protein early in the morning before developing nausea. Increased amount of gastrointestinal bleeding results in the formation of increased amount of ammonia because of intestinal bacteria metabolizing the blood cells. The lactulose creates an acid environment, which causes the ammonia to leave the circulatory system and to be expelled through the colon. Medications such as acetaminophen (Tylenol) are highly metabolized by the liver and should be avoided. Other such drugs are barbiturates and sedatives. Options 1 and 2 are ordered to decrease the ammonia level, and option 3 may be ordered for pain. Age above 65 is a risk factor for cataracts. Double vision, increased intraocular pressure, and blurry vision are signs of glaucoma. Pain usually does not accompany ruptured varices. The increased venous pressure and gastric acid causes the rupture, which is usually followed by bleeding. Hypertension, melena, and high ammonia levels are all expected. A condition developing 6 to 8 weeks after initial symptoms in a client with hepatitis is fulminant hepatitis where there is necrosis and shrinking of the liver with possible liver damage. The symptoms are classic and the condition often leads to coma, possibly death. Elevating the chest and head may reduce gastric reflux, which is causing the pain. The other positions do not accomplish this. Position change is preferable to medication for sleep. The action of this drug is to promote healing by promoting mucous and bicarbonate production. It promotes healing because it is a prostaglandin. NSAIDs decrease prostaglandins and promote ulcer formation. It does not affect the proton pump, esophageal sphincter pressure, or the speed of gastric emptying. Peritonitis follows gastric perforation with spilling of stomach contents into the peritoneal cavity. Increased white blood cell count, abdominal rigidity, and severe pain occur, accompanied by fever. Dysuria is not seen. Although tarry stools may be seen with gastric bleeding, they are not characteristic of peritonitis. Potassium has a tendency to be irritating to the lining of the esophagus or stomach and may cause nausea and vomiting. Giving it with meals will decrease this tendency. Options 2 and 4 would be irritating because the client has an empty stomach. It is appropriate to give this drug at the same time other medications are given. Crohn’s disease is characterized by lesions anywhere in the gastrointestinal system. The diarrhea is more liquid and harder to control. The excessive diarrhea frequently causes fluid and electrolyte imbalance. It is often accompanied by fistulas between the colon and other organs or other segments of the bowel. The fibrotic changes cause the colon to be inflexible and thick. Curling’s ulcers, which occur after a major burn, are characterized by multiple superficial ulcers caused by ischemia from vasoconstriction. They are not caused by excessive gastric acid. They are painless and may or may not involve massive bleeding. They are not related to <i>H. pylori</i>. An ulcer below the pyloric valve is a duodenal ulcer, and the pain is more common when the stomach is empty; food helps stops the pain for awhile. Option 1 is common with gastric ulcers. Options 3 and 4 are not applicable to PUD. Severe and stress conditions such as burns, hypoxia, and shock decrease mucous production, which leaves the mucosal cells unprotected from the high-acid environment of the stomach. Options 1 and 2 are causes of PUD but not as a secondary condition of shock. Option 4 indicates the pathophysiology of shock, not PUD. Hearing loss, especially of upper-range tones, is common in the elderly. Speaking to the client slowly and in a lower-pitched voice while facing the client is the best means of communication. Options 1 and 4 are not helpful, and option 2 is unnecessary. Antacids should be separated from other medications by at least 1 to 2 hours and after meals by at least 1 hour. Therefore, if medications are scheduled for 9:00 a.m. and 9:00 p.m., the antacid could be given an hour after (10:00 a.m./p.m.). When diarrhea occurs for an extended time in a client with Crohn’s disease, dehydration is a complication. Signs and symptoms are excess thirst, fatigue, sunken eyeballs, and decreased skin turgor. Although the client may be experiencing malabsorption (option 1) and electrolyte imbalance (option 2), the scenario did not give symptoms consistent with these complications. These foods are all high in fat and are usually not tolerated with a client with cholecystitis. Clients should continue to ambulate and be as active as usual. Protein does not necessarily have to be increased. The elevated amylase and lipase are key lab tests for pancreatitis. The glucose is elevated because of the role of the pancreas in controlling glucose values. The calcium is decreased because the calcium is deposited in the fatty necrotic tissue of the pancreas. In this type of question, try to think of the rationale for the decrease or elevation, instead of memorizing. An ultrasound of the gallbladder will detect the presence of stones. A barium swallow, as well as endoscopy, is for upper gastrointestinal disorders. A CT scan is not usually the first choice if the stones are visible on the ultrasound. Hepatic encephalopathy is a complication of cirrhosis and is manifested by changes in consciousness, mentation, and motor function. Asterixis (or liver flap) is the flapping tremor of the hands when extending the arms. The cause of bleeding in a client with esophageal varices is usually rupture, which is a medical emergency. The hemorrhage that occurs is usually frank bleeding such as vomiting of copious amounts of dark-colored blood. The nurse should be able to recognize signs of hemorrhage (tachycardia, hypotension, low platelets, and hematocrit and hemoglobin [H & H]). Alcoholism in high school age students is common, and this population usually feels invulnerable to illnesses such as cirrhosis. Although biliary cirrhosis may occur because of drug abuse, alcoholism is more prevalent in teenagers in the United States today. The bilirubin will be elevated in cholelithiasis and cholecystitis. When the indirect bilirubin is elevated, liver damage is suspected. The elevated direct bilirubin indicates involvement of the biliary ducts. The amylase should be normal and the alkaline phosphatase confirms the diagnosis. Bleeding is a primary complication of a liver biopsy or invasive procedures involving the liver, because the liver disorder has more than likely altered the clotting factors. In order to prevent a massive hemorrhage or complications, the coagulation studies should be evaluated prior to the procedure. Providing the client with a clock and calendar helps the client to be oriented to time and date. These would be meaningful stimuli for the client and decrease the chance for sensory deprivation. It may not be realistic in an ICU to remove equipment from the room. Explaining all procedures and routines would increase the risk of overload. Giving the client prolonged rest periods would only increase the risk for deprivation. High fat content in the diet as well as hyperlipidemia are risk factors for cholelithiasis. In addition, this client has a family history, which is another risk factor. Obesity is certainly a concern, but the stem does not indicate that as a problem (don't read into the question). In cirrhosis, the liver is usually not functioning properly and cannot metabolize medications as well as it normally would if healthy due to the scarring of the tissue. Certain medications are metabolized primarily by the liver, while other medications are metabolized by other organs. Consideration should be made for each medicine ordered to avoid overburdening the liver. The liver produces between 700 and 1,000 mL of bile a day. The gallbladder stores and concentrates bile and then releases it when stimulated, but is not an essential structure. Hyperbilirubinemia (total serum bilirubin greater than 2.5 mg/dL) manifests in jaundice, a yellow discoloration of the body tissues. Ascites (option 1) may accompany liver disease in later stages, but there is no evidence in the question to indicate this. Options 2 and 4 are unrelated to the question as stated. Clay-colored stools indicate that no bile is reaching the intestine and suggests obstructive jaundice. Options 1 and 3 are unrelated to the question. Option 4 could be present due to cardiovascular disease or as an indirect consequence of portal hypertension with impaired venous return, but there is insufficient information in the question to support this option. Jaundice frequently causes pruritis. Comfort measures include keeping the air temperature cool (68 to 70° F) and the humidity at 30 to 40 percent. Tepid baths (not hot) with colloidal agents decrease itching (option 2). Use of an emollient lotion is also helpful, but anything drying should be avoided (option 4). Hot beverages (option 1) are of no benefit as a comfort measure for pruritus due to jaundice. The incubation period for hepatitis A is 4 to 6 weeks in length with viral shedding highest 10 to 14 days before the onset of symptoms and during the first week of symptoms. The other options do not fall within this time frame. The liver is responsible for the production of albumin, which in turn is responsible for maintaining colloidal osmotic pressure. With less production of albumin, osmotic pressure decreases and edema develops. Options 2, 3, and 4 are false statements that do not explain the relationship between cirrhosis and edema. Complications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should monitor for signs of hemorrhage (increased pulse, decreased blood pressure) every 30 minutes for the first few hours and then hourly for 24 hours. The client should be monitored for fever every 4 hours and remain on bed rest for 24 hours. Lactulose (Cephulac) is a disaccharide laxative used to decrease the absorption of ammonia in the intestines, thereby lowering the serum ammonia and resulting in improvement in hepatic encephalopathy. To prevent vascular impairment, proper application of elastic bandages is required. Wrapping distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly while stretching it ensures that there will be even tension applied to the extremity. Wrapping it loosely will not secure the bandage in place. Excessive pressure would cause circulation to be compromised. Factors that increase the risk of gallstone formation include female gender, aging, use of oral contraceptives, pregnancy, rapid weight loss, high cholesterol level, and diseases of the ileum. Pancrelipase (Lipancreatin) aids in the digestion of starches and fats and should be taken with meals. It should not be crushed since hydrochloric acid destroys the drug, and it should not be mixed with alkaline foods (milk, ice cream). The posterior pharynx is anesthetized for easy passage of the endoscope into the esophagus. The return of the gag reflex indicates that normal function is returning and the client is able to swallow. Thick secretions and particulate matter may obstruct the tube, causing drainage to cease; the client may experience nausea and vomiting. The tube should be gently flushed to ensure patency and rule out obstruction as the cause of the client’s symptoms. Dumping syndrome is the rapid dumping of food into the jejunum without proper mixing and digestion. Interventions that help to minimize dumping syndrome are lying down after eating, eating a diet high in fat and protein and low in carbohydrates, and no fluids with meals. BMI is an estimation of total body fat in relation to height and weight. An optimal BMI is 20 to 25, increasing to 24 to 27 in the elderly. The client with GERD is encouraged to eat smaller, more frequent, low-fat meals and to avoid lying down after eating. Clients are instructed not to eat for at least 2 hours before bedtime and to avoid foods that decrease lower esophageal sphincter pressure such as anything containing caffeine (coffee, tea, cola, chocolate). Gastric ulcers are usually a result of a disruption of the protective mechanism of the gastric epithelium. Substances that reduce prostaglandin secretion in the gastric mucosa (aspirin, NSAIDs, alcohol) are responsible for gastric ulcers. Although certain foods and fluids may aggravate an existing ulcer, they do not cause them. Famotidine (Pepcid) is a histamine-2 receptor antagonist and reduces the secretion of gastric acid. This class of drugs does not have a direct effect on reflux, LES tone, or GI motility. Hemorrhage and bleeding is a common feature of ulcerative colitis, and over time this can lead to significant loss of RBCs. The client should be monitored for possible anemia. A closed fracture has no break in the skin. A cat bite, a laceration, and a stab wound all impair skin integrity, which could lead to infection. Diverticular disease is virtually unknown in cultures where highly refined foods are not available (e.g., Africa, Asia) and was unknown in the United States prior to 1900. The other statements are false. Early in a bowel obstruction, the bowel attempts to move the contents past the obstruction, and this is heard as high-pitched, tinkling bowel sounds. As the obstruction progresses, bowel sounds will diminish and may finally become absent. In cirrhosis, the liver becomes fibrotic, which obstructs the venous blood flow through the liver. This increases the vascular pressure in the portal system, and causes congestion in the spleen and development of varicosities in the esophagus. Bleeding esophageal varices are a complication of portal hypertension and result in vomiting of blood and possible hemorrhage and death. Any medication that is metabolized by the liver should be avoided, such as acetaminophen, sedatives, and barbiturates. Ranitidine is a histamine-2 reception antagonist, psyllium is a laxative, and ascorbic acid is Vitamin C. A low-sodium diet is recommended for clients that have cirrhosis and ascites. Potato chips are high in sodium. Cookies and hard candy are high in sugar, while bread is high in complex carbohydrates. The liver synthesizes clotting factors I, II, VII, IX, and X as well as prothrombin and fibrinogen. These substances are needed for adequate clotting, so their reduction leads to increased risk of bleeding. The other responses do not address this concern. HBsAg is hepatitis surface antigen and is usually present before symptoms manifest. It indicates acute disease. The other options are incorrect conclusions regarding this test result. Vasopressin causes vasoconstriction and may precipitate an acute anginal attack or myocardial infarction, especially in those with known cardiovascular disease. The other options are unrelated to the question. After the extracorporeal shock wave lithotripsy, the nurse should monitor for biliary colic and nausea. The colicky pain is caused by passage of stone fragments through the biliary tree into the small intestine. Headache, diarrhea, and hiccoughs are unrelated manifestations. With the advent of laparoscopic surgical technique, the only absolute contraindication for surgery is acute infection. The other options do not address this concern. Disuse syndrome is a result of prolonged immobility. Stating “the client remains free of contractures” describes in active terms the desired outcome for the client. The last two options describe nursing activities to meet the stated client goal. The nurse has no control over option 1. Pancreatitis is associated with alcoholism in men and gallstones in women. The disorders in options 1 and 3 are not associated with increased risk of pancreatitis, while option 4 promotes health. The client with chronic pancreatitis may require pancreatic enzyme supplements such as pancrelipase (Pancrease). These will promote proper digestion of foods. The other medications do not address this need. Keeping the client in a high Fowler’s position minimizes the risk of aspiration. The other options do not address this priority issue of care. Activity, including position changes and ambulation, stimulates intestinal peristalsis and assists in the forward movement of the tube. Scissors should be kept at the bedside of all clients with an esophagogastric tube and the tube should be cut if the client experiences respiratory compromise. Maintaining the client's airway is the first priority of care. A healthy stoma is red to reddish-pink, moist, and shiny. A stoma that appears dark red, bluish, or black indicates ischemia or necrosis. This finding must be reported immediately because the viability of the tissue is at risk. Options 3 and 4 are of no concern immediately postop. Symptoms of dumping syndrome can occur within 5 minutes to 3 hours after eating and include nausea, vomiting, tachycardia, diaphoresis, abdominal pain, diarrhea, syncope, and hyperactive bowel sounds. Undernutrition affects many systems, causing decreases in metabolic function and cell-mediated and humoral immunity, thereby increasing the susceptibility to infection. The other responses are incorrect. Conservative treatment for hiatal hernia consists of lifestyle changes including remaining upright after eating; avoiding straining, tight clothing, and vigorous exercise; and eating small, frequent, low-fat meals. Many common substances contribute to decreased LES pressure including fatty foods, caffeinated beverages, nicotine, beta-adrenergic blocking agents, calcium channel blockers, nitrates, theophylline, peppermint, alcohol, high levels of estrogen and progesterone, and anticholinergic drugs. Weight-bearing exercise is the best approach to preventing disuse syndrome. Disuse syndrome occurs because the stresses of weight bearing are absent and the bone releases calcium. The other options list general nursing interventions that are not specific to weight-bearing. There is no known cause of IBS, and diagnosis is made by excluding all the other diseases that cause the symptoms. There is no inflammation of the bowel. Some factors exacerbate the symptoms, including anxiety, fear, stress, depression, and some foods and drugs, but these do not cause the disease. Sulfasalazine is a GI antiinflammatory medication that exerts its action by decreasing prostaglandin production in the bowel. It does not have the other effects listed. Many clotting factors are produced in the liver including fibrinogen (factor I), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The prothrombin time will evaluate blood clotting ability while the others will not. Manifestations of chronic pancreatitis include nausea, vomiting, weight loss, flatulence, constipation, and steatorrhea that result from a decrease in pancreatic enzyme secretion. Weight gain (option 1) is the opposite of what occurs with this disorder, while options 2 and 4 are unrelated. Hemolytic jaundice is caused by excessive breakdown of red blood cells and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Unconjugated bilirubin is insoluble in water and is not found in the urine. Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice. Alkaline phosphatase increases with biliary obstruction but not cholesterol. Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin (option 4). Options 1 and 3 are unrelated. The T-tube may drain 500 mL in the first 24 hours and decreases steadily thereafter. If there is excessive drainage, the physician should be notified immediately. Option 1 would be contraindicated while options 2 and 4 are of no help. When T-tube drainage subsides and stools return to a normal brown color, the tube can be clamped 1 to 2 hours before and after meals in preparation for tube removal. If the client tolerates clamping, the tube will then be removed. Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels, predominantly in the paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Option 2 is an action aimed at interrupting the portal of entry link in the chain of infection. By using sterile technique, the nurse reduces the risk of introducing pathogens into the client’s wound via the drain. Option 1 is an action that breaks the chain of infection at the reservoir link. Options 3 and 4 control the mode of transmission. Options 1 and 2 indicate nursing activities aimed at promoting healing. Option 3 refers to other areas of the body. Option 4 refers to the wound itself and is the best indication of the wound’s current status. Spironolactone (Aldactone) is used in clients with ascites that show no improvement with bed rest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes potassium retention by inhibiting aldosterone. Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. The loss of parietal cells that secrete intrinsic factor results in vitamin B<sub>12</sub> deficiency post-gastrectomy. For this reason, clients require vitamin B<sub>12</sub> injections for life. A side effect of Gastrografin is diarrhea. It does not cause the other signs and symptoms listed. Bowel perforation is a possible result of colonoscopy, if the colonoscope accidentally pierces the bowel wall. The other options are incorrect. Use of the high Fowler's position utilizes gravity to protect against aspiration and is the position of choice for NG tube insertion. Option 2 provides minimal protection against aspiration, while options 3 and 4 provide none. The tube should be clamped to prevent air from entering the stomach; air causes cramping and bloating. Next, the tube should be flushed with water (30 - 60 mL). The client should remain in a high Fowler's position or an elevated side-lying position for 30 to 60 minutes to reduce the risk of aspiration. Intestinal tubes are used to treat bowel obstruction, a symptom of which is a fecal taste in the mouth. Frequent mouth care including hard candy, ice chips, and throat lozenges is essential to reduce the experience of fecal taste. The client is encouraged to move in bed and ambulate to assist in the advancement of the tube. A client with an ileostomy has no control over bowel movements and must always wear a collection device. The drainage tends to be liquid, but becomes paste-like with intake of specific foods. Dumping syndrome can occur following gastrectomy, in which gastric contents rapidly enter the bowel. Dietary fats and proteins are increased, and carbohydrates, especially simple carbohydrates such as fruits, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms. After immobilization, unexercised muscles will atrophy. The muscles would not be flexible or hardened. Hypertrophy is the opposite of atrophy. The individual is considered obese at 20 percent over ideal body weight and morbidly obese when over 100 percent above the ideal body weight. The pain of a gastric ulcer is dull and aching and occurs after eating and is not relieved by food as is the pain from duodenal ulcer. Chronic aspirin use is irritating to the stomach (option 2). The manifestations in options 3 and 4 are unrelated. During the immediate postoperative period, protecting the operative site is a priority in the nursing care of this child. A toothbrush should be a familiar object to an 18-month-old child. Deciduous (primary) teeth are still present at this age and are replaced by permanent (secondary) teeth around 6 years of age. Oral care will be performed according to the physicians’ orders but usually consists of cleansing the area with sterile water. The goal after pyloromyotomy is to slowly increase the volume of feeding while preventing vomiting. Burping is essential after feed. Rocking is avoided as this might increase vomiting. Antiemetics are not helpful as the vomiting is not associated with nausea. Omphaloceles are congenital malformations in which abdominal contents protrude through the umbilical cord. The protrusion is covered by a translucent sac; immediately after birth, the sac requires priority attention. The sac is covered with sterile gauze soaked in normal saline solution to prevent drying and injury. Infants with Hirschsprung’s disease usually display failure to thrive, poor weight gain, and delayed growth. Vomiting is usually bile stained. The child will demonstrate alternating constipation and diarrhea, but the stools are not bloody. Decreased urine output and intermittent sharp pain are nonspecific symptoms that can be associated with many different diseases and disorders. Small, frequent feedings followed by placing the infant at a 30- to 45-degree angle has been shown to be beneficial in treating gastroesophageal reflux. Diluting the formula would not be recommended because the infant needs the calories from the full-strength formula. It may be recommended to thicken the formula with rice cereal. It is recommended to burp frequently; to delay burping would only increase the occurrences of reflux. Gastroesophageal reflux is not related to milk intolerance so changing the formula would not help the child. An ice bag may help relieve his pain. A rectal tube is contraindicated because it stimulates bowel motility, which would increase the pain. A heating pad is contraindicated because it increases the flow of blood to the appendix and may lead to rupture. An antispasmodic agent would not be beneficial for the pain associated with appendicitis. Antispasmodic agents are typically used to inhibit smooth muscle contractions. Discharge planning focuses on educating the parents in maintaining a gluten-free diet for the child. Dietary modifications are life-long and should not be discontinued when the child is symptom-free. Symptoms will return if dietary restrictions are not maintained. Measuring the abdominal girth frequently aids in early detection of necrotizing enterocolitis, which, in turn, minimizes loss of bowel. Measurement of gastric pH is not done. Frequent monitoring of the neurologic status is not specific to this disease. Rectal temperatures are contraindicated because of the increased risk of perforation. Passive range of motion is most appropriate because the client is unable to move that side of the body on her own. The other exercises require resistance on the part of the muscles on the left side, and the client is unable to do that. Hepatitis A is highly contagious and is transmitted primarily through the fecal-oral route. The virus is transmitted by direct person-to-person contact or through ingestion of contaminated food or water, especially shellfish growing in contaminated water. The remaining answers are related to other infectious diseases. Mucous membranes typically appear dry when moderate dehydration is observed. Other typical findings associated with moderate dehydration include restlessness with periods of irritability (especially infants and young children), rapid pulse, poor skin turgor, delayed capillary refill, and decreased urine output. Both anterior and posterior fontanels are closed on a preschool-age child. The skin is usually dry with decreased elasticity, not diaphoretic. Urine specific gravity increases with decreased urine output associated with dehydration. Elbow restraints are used to keep hands away from the mouth after cleft palate surgery. This precaution will be maintained at home until the palate is healed, usually 4 to 6 weeks. They are not used to protect the IV site, maintain NPO status, or maintain body alignment. In pyloric stenosis, bile is unable to enter the stomach from the duodenum because the pylorus muscle is hypertrophied, which causes the obstruction. Most children who remain on a gluten-free diet remain healthy and free of symptoms and complications. Gluten is a protein found in wheat, barley, rye, and oats. For this reason, appropriate foods need to be free of these grains. HBV vaccine provides active immunity, and current recommendations include immunizations for all newborns, as well as for several high-risk groups. Hepatitis B is spread by blood and body fluids, including sexual contact, not the fecal-oral route. The disease can exist in a carrier state. The nurse would expect an increased desire to drink fluids and a higher specific gravity caused by the concentration of urine. The heart rate would be elevated, and the fontanels sunken. The degree of dehydration is based on the percent of weight loss, so a weight gain would not be likely. Diminished urine output with elevated specific gravity is an expected normal finding in dehydration. Capillary refill is slowed, especially in children less than 2 years of age. Clinical findings will vary in infants born with congenital diaphragmatic hernias, but the first indications are of respiratory distress. Further examination will reveal bowel sounds auscultated over the chest, cardiac sounds on the right of the chest, and a sunken abdomen with a barrel-shaped chest. Celiac disease is characterized by intolerance for gluten. Gluten is found in wheat, barley, rye, and oats. This includes bread, cake, doughnuts, cookies, and crackers, as well as processed foods that contain gluten as filler. The corrective surgery for Hirschsprung’s disease requires pulling the end of the normal bowel through the muscular sleeve of the rectum. With this type of procedure, rectal temperatures and any invasive procedure would be avoided to allow proper healing to occur. The weight of the body should be borne on the arms, not the axillae. When clients allow the axillae to bear the weight of the body, they are at risk of developing crutch palsy, a nerve damage. The other options represent correct information about use of crutches, and therefore no further information is needed on those points. Infants with GER should be given small, frequent feedings. After a feeding the infant should be placed in a prone position with the head of the bed elevated. A harness can be used to help maintain this position. Infant seats should be avoided because of the increased intrabdominal pressure this position creates. Signs and symptoms of a ruptured appendix include fever, sudden relief from abdominal pain, guarding, abdominal distention, rapid shallow breathing, pallor, chills, and irritability. It is a common finding that when the infant with an umbilical hernia cries, it will protrude. It is not going to rupture, despite its appearance. The family should be instructed not to apply tape, straps, or coins to the umbilicus to reduce the hernia, because these could increase the risk of pressure and possible strangulation. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression. The child is kept NPO until bowel function returns. Appropriate pain management is an ethical nursing obligation; a pain rating scale recognizes the child's right to be in control. Kasai procedure is palliative, and prognosis is best if performed before 10 weeks of age. Its purpose is to achieve biliary drainage and avoid liver failure. A liver transplant is required in 80 to 90 percent of cases. The infant will continue to need medication, vitamins and special formula to counteract the ineffective function of the liver. Urine specific gravity is a measurement of the concentration of urine and provides information regarding hydration. Urine specific gravity is elevated in dehydration. Careful measurement of intake and output, level of consciousness, skin turgor and mucous membrane moisture will also indicate the child’s status. Sending a stool for ova and parasites evaluation could be indicated if this was suspected as a cause of diarrhea, but the stem of the question does not state that the child has diarrhea. Upper GI series and stool evaluation for fecal fat would help to diagnose GI disorders. In severe diarrhea, excess bicarbonate is lost. There is also carbohydrate malabsorption and depletion of glycogen stores, resulting in fat metabolism. Ketoacids are the byproducts of fat metabolism. For both of these reasons, the client can develop acidosis. The nature of the problem is metabolic rather than respiratory. ESSR feeding technique for cleft lip or palate: Enlarge nipple; Stimulate suck reflex; Swallow fluid; Rest after each swallow. It has nothing to do with a suture maintenance tool, the surgical procedure, or a method of positioning the infant. It is important that any signs of infection be reported at once. After Soave procedure, the colostomy is usually closed and normal bowel function is expected. Acute episodes are characterized by large quantities of fat in the stools (steatorrhea), bulky, frothy stools, anorexia, and irritability. The other options contain data that is inconsistent with the status of a child with a flare-up of celiac disease. Primary intention healing occurs when the wound edges are well approximated; wounds that heal by secondary intention have edges that cannot be approximated. Scarring is greater for wounds that heal by secondary intention and those that become infected. The location of a wound has little to do with scarring. Parents often react to a child's illness with feelings of guilt for not recognizing the severity of the condition sooner. Emotional support and reduction of parental anxiety encourages parents to feel confident in their abilities as caregiver. Non-organic failure to thrive is not due to metabolic or organic problems or the absence of food availability. Children with this form of malnutrition often display other non-specific symptoms related to the emotional illness. The thyroidectomy is the third alternative treatment used when medication and iodine-based radiation therapy are unsuccessful. There is a great concern of causing hypothyroidism in the client, which would necessitate lifelong hormone replacement therapy. The other answers are incorrect statements of fact. A complication of a thyroidectomy is thyroid storm, which can be fatal. Other primary concerns would be observing for hemorrhaging, respiratory obstruction, and laryngeal nerve damage. These would be the priority nursing activities. The premature secretion of testosterone promotes the closure of the epiphyseal growth plates. Many of these children appear very tall in sixth grade, but their friends "catch up" and surpass them in linear growth. The child is expressing concern about her appearance as compared to others, making body image disturbance the best diagnosis. There is no evidence in the stem regarding social isolation or personal identity disturbance. The cause of the precocious position would have been discussed earlier. The only form of insulin given IV is regular. Physicians often order D5½ NS with insulin added providing the child the glucose to meet the body's needs while providing the insulin in the same infusion. Antibiotics would be appropriate to treat the underlying infection. The blood glucose should be monitored on a regular basis. Lispro insulin peaks at one hour after administration. A food source should be available at the bedside to prevent the possibility of hypoglycemia shortly after administration. All of the other choices are incorrect. The exchange diet plan is suggested for clients with diabetes mellitus. Even young children can learn to trade foods in the same exchange category to maintain control. All basic food groups should be included. Diet sodas are allowed. A high fiber diet is recommended for improved control of blood glucose. Exophthalmos (bulging eyes) and an enlarged thyroid are evidence of hyperthyroidism. Other symptoms would include weight loss, tremors, tachycardia, and elevated basal body temperature. Some children may display behavior problems and have sleeping difficulties. The other symptoms are not associated with hyperthyroidism. Activities that are likely to lead to dehiscence include vomiting and coughing because they increase intraabdominal pressure. In addition, clients who are obese and those with poor nutrition are candidates for dehiscence. Since the client is already postoperative, encouraging weight loss at this time would not affect risk for dehiscence. Women with PKU should maintain good control prior to becoming pregnant. The fetus may have complications if the mother's phenylalanine levels are high. She should also avoid diet drinks because of the aspartame, which is high in phenylalanine. PKU follows the autosomal recessive inheritance, and her baby could be affected if the father is a carrier Symptoms of excessive fatigue may indicate inadequate medication. Symptoms of overdose would include a rapid pulse rate, diarrhea, and weight loss. The other answers indicate correct understanding of the management of hypothyroidism. Congenital hypothyroidism in infants is diagnosed due to hypotonicity and hypoactivity. The infants are often described as a “good baby” because they rarely cry. Prolonged jaundice, constipation, and umbilical hernia are common findings in hypothyroidism. Tests done 24 to 48 hours after delivery may be interpreted as high because of the rise in TSH that occurs immediately after birth. Sore throat and enlarged cervical nodes are common side effects of the medication. A dosage reduction or withdrawal of the drug should be considered. If a child exhibits signs of hypoglycemia, a source of sugar like orange juice can elevate glucose levels and prevent further signs of hypoglycemia. A 10-year-old must remember to only take one serving and wait ten minutes for symptoms to be alleviated. The peak action of NPH or Lente insulin is 6 to 12 hours after administration subcutaneously. During peak times, the client may need a snack to offset potential hypoglycemia. Since hypothyroidism is a lifelong condition, the levothyroxine will need to be taken indefinitely. It is important that the infant takes the medication in a small amount of food or liquid and not placed in the bottle since he/she may not receive the full dose if the entire bottle is not consumed. In each pregnancy, there is a 25% chance of the child having the disease, a 50% chance that the child will be a carrier of the gene, and a 25% chance that the child will be unaffected. PKU affects both sexes equally. Decreased levels of tyrosine cause a deficiency of the pigment melanin, causing most children with PKU to have blond hair, blue eyes, and fair skin that is prone to eczema. Vascular changes, such as atherosclerosis and atrophy of capillaries, impair blood flow to the wound. The other statements are false. Older adults are not necessarily overweight, although weight gain does tend to occur with increasing age. Decreased activity levels with aging does not diminish local blood supply to a healing wound. Keloid formation is an abnormal type of healing of a wound. Foods with low phenylalanine levels include vegetables, fruits, juices, and some cereals and breads. The amount of protein in the diet is restricted based on phenylalanine blood levels. Keeping the levels of phenylalanine at a low level in children with PKU and daily administration of levothyroxine in children with congenital hypothyroidism will decrease the incidence of mental retardation by allowing normal brain growth. Children with Type 1 diabetes mellitus must take insulin because they have a total absence of secretion of insulin from their pancreas. Type 2 diabetes mellitus, which does not make the client dependent on insulin, may be associated with some insulin production so the client can take the oral antidiabetic agents. Checking the blood glucose at least twice a day prevents sustained levels of either high or low glucose readings. The glycosolated hemoglobin measures long-term control and is a very important value. Long-term effects of Type 1 DM include retinopathy, heart disease, renal failure, and peripheral vascular disease. These complications can affect children and adults. The longer the child lives with diabetes, the greater the likelihood of complications. Exercise increases the utilization of glucose, thus an afternoon snack would be very important. Milkshakes would be concentrated carbohydrates that should be avoided. The toddler needs to feel some control. Cleaning off his fingers with alcohol, with supervision, will allow some control. Another way to promote control would be for the toddler to choose food selections from options offered. It is inappropriate to allow the toddler to assist with injections and it is unnecessary to test glucose every time the toddler goes out to play. Most babies with congenital hypothyroidism exhibit bradycardia, protruding tongue, and hypotonia. Open fontanels are normal for a 2-month-old infant. Exercise makes the body more sensitive to insulin, thus metabolizing the glucose faster. While hospitalized, the child was less active. Now that the child has returned to normal activity, it is possible that the insulin dose is too high or more glucose is required in the diet. The other options are inaccurate Lethargy may indicate an overdose of the drug, causing the child to exhibit signs of hypothyroidism. The other signs indicate signs of hyperthyroidism. An adolescent client with delayed puberty may need to talk about issues of low self-esteem. If he has a constitutional delay, puberty will usually follow with time. Hormone therapy is not given until after the age of 14. Protein and Vitamin C are necessary for building and maintaining tissues. A deficiency of Vitamin C would prolong wound healing. The other options have nothing to do with Vitamin C. Propranalol, a beta-adrenergic blocking agent, provides relief from adrenergic hyperresponsiveness. It is usually needed for 2 to 3 weeks along with antithyroid hormone therapy. The screening is done only after an adequate amount of protein has been ingested. Breast milk and formula meet the requirements. The testing is usually done at 48 hours of age. Hyperthyroidism is an excess of thyroid hormone (TH), which places the body in a hypermetabolic state manifested by increases in appetite, body temperature, and oxygen consumption. Hypothyroidism manifestations are the opposite of those seen in hyperthyroidism. The manifestations of parathyroidism are related to disturbances in calcium levels. Though fluid volume status, neurological status, and pain are all important data collections, the immediate priority for postoperative thyroidectomy is airway management. Respiratory distress may result from hemorrhage, edema, laryngeal damage, or tetany. Monitoring respiratory status should include rate, depth, rhythm, and effort. For best absorption, thyroid medications should be taken 1 hour before meals or 2 hours after meals. Lifelong treatment of hypothyroidism is necessary. Foods that inhibit thyroid hormone (TH) synthesis, such as cabbage, spinach, and carrots, should not be consumed in excessive amounts. Thyroid medications should be taken in the morning to reduce the possibility of insomnia. Hypercalcemia is the primary complication of hyperparathyroidism, and the manifestations of the disorder are directly related to the effects of hypercalcemia. Administering large amounts of intravenous saline promotes renal excretion of calcium. Calcium gluconate would increase serum calcium levels, and tetany is a symptom of hypocalcemia. The normal serum calcium level is 8.8 to 10 mg/dL. The therapeutic response of supplemental calcium is demonstrated by normal calcium levels. Cushing's syndrome is manifested by sodium retention, which leads to edema and hypertension. Fluid volume excess is the appropriate diagnosis. Treatment is aimed at restoring normal body fluid balance. Anxiety and knowledge deficit should be addressed following fluid volume excess. Hypertension and hypokalemia are the most common signs and symptoms of hyperaldosteronism. Surgical removal of the adrenal gland(s) is the treatment of choice; however, if that is not possible, the client is treated with Aldactone, a potassium-sparing diuretic, to treat the hypertension and correct the hypokalemia. Weight must be monitored <i>daily</i>; any increase indicates fluid retention and should be reported immediately. Corticosteroids are immunosuppressants; therefore, careful monitoring for infection is necessary. Additionally, an increase in the medication may be required for stressors such as infection. A Medic-Alert bracelet is recommended to inform healthcare providers of Addison's disease and cortisol treatment. Safety measures are encouraged to prevent injuries. The client has bilateral weakness of the lower extremities, and the proper assistive device is one that will provide bilateral support. In this case, a walker provides the most support. Additionally, a four-wheeled walker does not require the client to lift the walker as steps are taken. SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume excess. Type 1, or insulin-dependent diabetes, requires lifelong replacement of insulin, because no insulin is produced from the beta cells of the pancreas. Options 2, 3, and 4 are incorrect for Type 1 diabetes. Exophthalmos occurs as a result of accumulation of fat deposits and by-products in the retro-orbital tissues. Even with treatment of Graves' disease, these changes are not reversible. The client should receive instructions on proper eye care. Myxedema coma is a life-threatening crisis manifested by hypothermia, hyponatremia, hypoglycemia, lactic acidosis, cardiovascular collapse, and coma. Maintaining airway and circulation are the priority interventions. The treatment for primary hyperparathyroidism is a parathyroidectomy (surgical removal of parathyroid glands). Options 2, 3, and 4 are incorrect treatments for primary hyperparathyroidism. Risk for injury related to hypocalcemia is the priority diagnosis as injury may occur as a result of low calcium levels and tetany. The client is at risk for fluid volume deficit, not excess, and anxiety and knowledge deficit would not take priority over injury. The therapeutic effects of mitotane are the results of direct suppression of activity of the adrenal cortex. Modrastane blocks the synthesis of glucocorticoids (option 1), octreotide suppresses ACTH (option 2), and radiation destroys the pituitary gland (option 4). Since the client will have a bilateral adrenalectomy, lifetime corticosteroid replacement is necessary. After the adrenalectomy, the client's aldosterone levels should return to normal; therefore, no dietary restrictions will be necessary. Hydrocortisone is given to replace cortisol in the client with adrenal insufficiency. Abrupt withdrawal of the hormone can precipitate Addisonian crisis. Florinef is given to replace mineralcorticoids. Hyponatremia is caused by aldosterone deficiency, which affects the renal tubules ability to conserve sodium; therefore adding salt to the diet is recommended. Insulin-dependent diabetes is a complication of Addison's disease; however, there is no indication that diabetes precipitated the crisis. Because of a deficiency in antidiuretic hormone, diabetes insipidus results in massive diuresis and dehydration. Vasopressin (antidiuretic hormone) is administered to promote fluid retention and achieve fluid balance. Oral fluids are encouraged, and hypotonic fluids are administered. To provide maximum support and appropriate body alignment while walking, the cane is held in the hand on the stronger side. The tip of the cane should have rubber to prevent slipping. Hypertension with systolic blood pressures reaching up to 300 mmHg is possible with pheochromocytoma, making this disorder a life-threatening event. Monitoring blood pressure is a priority. Urine output and neurological status would follow blood pressure, and there is no indication to monitor glucose levels. Treatment of choice for this disorder is an adrenalectomy. The client should inform the healthcare provider of illness, and then should follow "sick-day rules" as prescribed by healthcare provider, which include taking insulin as prescribed, or increasing insulin as prescribed, consuming extra fluids, resting, and monitoring glucose every 2 to 4 hours. Options 1, 2, and 3 are all correct responses by the client. Iodine reduces the size and vascularity of the thyroid, reducing the risk of hemorrhage, which is a potential complication of thyroidectomy. Antithyroid medications, not iodine, are given to reduce hormone comprehension levels. The treatment for cancer of the thyroid is a total thyroidectomy. Hyperthyroidism causes a hypermetabolic state, resulting in increased body temperature causing the client to have heat intolerance, and sensitivity to noise and loud sounds. A cool, quiet environment is recommended. Clients with hyperthyroidism require an increased, not a decreased, caloric consumption. The thyroid gland is highly vascular, therefore there is a potential risk of postoperative hemorrhage. The client should be thoroughly monitored for hemorrhage behind the dressing, as blood may drain and run back and under the client. Options 1, 2, and 4 are correct data collection for hemorrhage. Muscle twitching when pressure is applied in taking a BP is called a positive Trousseau's sign, which indicates tetany in a client with hypoparathyroidism. Metabolic acidosis is the alteration in acid-base balance with DKA. This question draws on your knowledge of ABG values. The results show uncompensated metabolic acidosis because the question asked about the initial admission. Partially compensated (option 1) or fully compensated (option 3) values would be expected later. Option 4 indicates respiratory acidosis. Constipation is a potential complication of hypothyroidism as a result of decreased gastric motility. Instructing client to consume at least 2,000 mL of fluid a day, unless contraindicated, increase fiber intake, a maintain a well-balanced diet will help promote bowel elimination. Options 1, 3, and 4 are appropriate responses. The normal values for T3 (triiodothyronine) are 80 to 200 ng/dL, and the normal values for T4 (thyronine) are 5 to 12 & µg/dL. Both of these values are decreased in hypothyroidism. With treatment of thyroid medications resulting in therapeutic effects, the thyroid levels should be normal. The other values are too low and do not indicate therapeutic effects have been achieved. The most common cause of hypoparathyroidism and the resulting hypocalcemia is damage to the parathyroid glands during a thyroidectomy. Hyperactive reflexes, tetany, positive Chvostek's and Trousseau's signs are all manifestations of hypocalcemia. Options 2 and 4 are core principles of surgical asepsis. Options 1 and 3 are core principles of medical asepsis. Option 5 is an incorrect principle of surgical asepsis. The outer 1 inch of a sterile field is considered contaminated. Unless the skin loss is extensive, the skin will continue to absorb Vitamin D and prevent the loss of heat from the body. Tactile stimulation can still occur with a wound. However, a loss of skin integrity places the client at risk for bacterial invasion and subsequent infection. Increased serum cortisol levels are diagnostic for Cushing's syndrome. Options 2, 3, and 4 are the opposite of the expected abnormalities seen in Cushing's syndrome. Hyperaldosteronism leads to sodium retention, which increases fluid volume and blood pressure. Hypertension and hypokalemia are the most common signs of this disorder. Hyperaldosteronism leads to sodium retention (hypernatremia), potassium depletion (hypokalemia), and, as a result, metabolic alkalosis. To decrease incidence of gastric ulcers, cortisol replacements (prednisone) should be taken with food or milk. Clients should weigh self daily and report changes, and increase fluid intake to be up to 3,000 ml a day unless contraindicated. Abruptly discontinuing cortisol replacements can result in Addisonian crisis. A deficiency in cortisol leads to fluid volume depletion and sodium depletion. Added salt is recommended to replace sodium loss. Options 1, 3, and 4 are incorrect. SIADH results in fluid retention and hyponatremia. Intravenous hypertonic saline solution is administered in addition to diuretics. Maintaining oral fluid restriction is necessary to correct fluid imbalance. Chronic SIADH may be life-threatening if a medical emergency arises and the client is unable to inform healthcare providers. Chronic SIADH requires lifelong treatment. The client should weigh daily and report any changes, and there is no indication to consume more than the normal requirements of fluids once a fluid balance has been obtained. Excretion of massive volumes of urine leads to fluid volume deficit, which is the priority concern. Care and treatment is aimed at restoring fluid and electrolyte balance. Risk for injury and knowledge deficit are important diagnoses and should follow fluid volume deficit. Hypertension and tachycardia are the most common manifestations of this life-threatening disorder. Careful monitoring of blood pressure is required as blood pressure elevation can reach dangerously high levels. Stressors such as illness or surgery increase blood glucose levels. Temporary requirements for exogenous insulin may be necessary to adequately control glucose levels. The client should be informed of this temporary need. Options 1 and 3 are incorrect, and option 4 does not recognize the client's need for information or address the psychosocial needs as evidenced by the expression of concern. Evisceration occurs when internal viscera protrude from an incision that is dehiscing. In this situation, the nurse notes changes in wound appearance such as increased serosanguineous drainage, edges lacking approximation, and the protruding viscera. Diabetic clients often learn how to compensate and even be noncompliant without affecting their glucose levels excessively. A well-balanced diet with three meals is usually required to maintain the glucose at the appropriate level, especially since insulin is probably given in the morning. Options 1, 3, and 4 are all correct. Signs of Hypoglycemia include shakiness, coldness, sweating, nervousness, and palpitations. A fast-acting carbohydrate such as juice, crackers, or milk should be taken. If a glucometer is readily available, the glucose should be confirmed. Glucose levels should be monitored as instructed (option 3) and a glucose level of 100 indicates a therapeutic response to insulin (option 4). Since antithyroid drugs inhibit thyroid hormone (TH) production, they do not affect the hormones already formed. Therapeutic effects may not be noticed for several weeks, possibly up to 12 weeks. The client should be informed of this and encouraged to continue medications as prescribed. Weight gain, not loss, may be a sign of hypothyroidism, which is a potential effect of treatment with antithyroid drugs. Side effects include rash, pruritis, and elevated temperature. To decrease strain on the suture line, the client should support the head and neck with both hands behind the neck while moving in bed, coughing, or any other activity that could increase strain on sutures. The client should be encouraged to deep-breathe and cough, and pain medication will promote comfort. Hypotension, bradycardia, and dysrhythmias result from decreased cardiac output related to hypothyroidism. Options 1, 3, and 4 are all appropriate data collection for clients with hypothyroidism; however, they should follow the cardiovascular examination. Maintaining integrity of suture line is essential following a parathyroidectomy. Nursing care is essentially the same as for a thyroidectomy. The head should be supported with both hands behind neck when moving, sitting up in bed, or coughing. Restricting fluids is contraindicated, as is calcium, since hypercalcemia is a complication of hyperparathyroidism. Antithyroid medications are given to treat hyperthyroidism. The primary complication of hypoparathyroidism is hypocalcemia, which is a result of failure to release parathyroid hormone. Manifestations are directly related to decreased calcium levels. Options 2, 3, and 4 are manifestations of hyperparathyroidism. Adrenalectomy results in adrenal insufficiency, causing fluid imbalance (loss) manifested by hypotension. The lack of mineralcorticoids will result in hyponatemia and hyperkalemia (options 1 and 2), and the lack of glucocorticoids will result in hyperglycemia (option 4). Severe hypotension, circulatory collapse, shock, then coma are the complications of Addisonian crisis. Immediate intravenous replacement of glucocorticoids and fluids are indicated to prevent death. Options 2, 3, and 4 are recommended treatments for Cushing's syndrome, the opposite of Addison's disease. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) results in fluid retention and hyponatremia. Treatment is aimed at correcting fluid and electrolyte imbalance, which includes intravenous administration of hypertonic saline solution and oral fluid restriction. Edema is usually not a complication because fluid is retained between the intracellular and extracellular spaces. Lifetime treatment of this disorder is not necessary for an acute occurrence because the manifestations usually resolve within 3 days. The nurse should position herself or himself within the client’s line of vision to enable the client to read lips during the conversation. It is good to decrease background noises that interfere with the client’s ability to hear the nurse. It is also helpful to speak at a moderate rate and use the same voice tone throughout each sentence, not dropping the tone at the end of a sentence. The lighting should not be dimmed because doing so would interfere with the client’s ability to read lips. Words should not be overarticulated; exaggerated, unnatural movement of the lips can distort words for the client who relies on lip reading to compensate for hearing loss. The primary side effect of insulin is hypoglycemia. The client should be aware of the signs and symptoms, and should always have a source of sugar available. Options 2, 3, and 4 are incorrect and these responses would require further instruction. The nurse should watch for hypoglycemia during the peak time of both the regular insulin and NPH, which differ. The peak for regular is 2 to 4 hours; NPH 8 to 12 hours. Clients receiving doses of I-131 that are greater than 30 mCi may not have visitors for 24 or more hours based on radiation dose. For dose of 30 mCi or less, visitors must remain several feet away from client and client may not hold/cuddle children or sleep in same room as another person for 8 days (to protect them from radiation exposure). Clients who are allergic to shellfish are also allergic to iodine but egg allergy is irrelevant (option 1). Options 3 and 4 are unrelated to this medication. The parathyroid glands, located near the thyroid gland, may have been injured or accidentally removed, resulting in hypocalcemia. Hypocalcemia is life-threatening; thus it is important to identify early signs. Numbness and/or tingling of the mouth, face, or extremities are early symptoms of low serum calcium. Reduced thyroid hormone levels are expected results of surgery (option 1). Option 2 should refer to the pituitary gland. Option 4 is possible, but could be detected by hoarseness or weak voice. Iodine intake is needed for the thyroid gland to produce thyroid hormone. Insufficient iodine intake leads to low thyroid hormone production and symptoms of hypothyroidism, which includes constipation, weight gain, and muscle stiffness, among others. The other options are incorrect. Clients with Addison disease should be monitored for signs of Addisonian crisis following a stressful event such as surgery. Signs of Addisonian crisis include decreased urine output, decreased blood pressure, dry skin, and altered level of consciousness. Options 1, 3, and 4 do not apply to the necessary priority data collection related to Addisonian crisis, although they are good general post operative examinations. Research by the National Institute of Health and the American Diabetes Association demonstrates a strong correlation between chronic hyperglycemia and complications of retinopathy, nephropathy, and neuropathy. Thus, there is damage to the eyes, kidneys, and peripheral nerves, respectively. Lactic acidosis occurs with diabetic ketoacidosis (option 2). Option 3 is a false rationale for the client in the question. Insulin is needed to carry glucose across the cell membrane into the cell, not to be transported in the blood (option 4). In SIADH there is excess secretion of ADH that causes fluid retention, dilutes the plasma causing suppression of aldosterone, and increases renal excretion of sodium. Water then moves into the cells from the plasma and interstitial spaces causing cellular edema. The treatment is fluid restriction and hypertonic saline infusion. Options 1 and 3 are the opposite of standard treatment and are therefore incorrect. Option 2 is unrelated to this client. Diabetes insipidus (DI) can develop with head injury, tumors, and other conditions cause increased intracranial pressure. Excessive urine output of 350 ml/hr or more is a classic early symptom of DI. The specific gravity provides valuable information about renal function and response to ADH. Using critical inquiry to analyze the urine output, specific gravity and other characteristics of the urine, the nurse monitors for classic signs of DI that can occur following a head injury. Options 1 and 4 are false. Option 2 would be insufficient fluid replacement. Option 4 addresses the lifelong hormone replacement of thyroid, glucocorticoids, and gonadotropin needed when the entire pituitary gland is removed. Options 1 and 3 are incorrect. Option 2 relates to the immediate postoperative time while the client's comments relate to long-term outcome. The status of the client’s airway and breathing is of highest concern. Once the nurse has observed the airway and breathing, then the amount of oxygen and dressing status can be monitored. Finally, the time lapse since any analgesic medication can be determined. DKA is associated with excessive urine output, dehydration, and hypokalemia, placing the client at risk for decreased cardiac output and cardiac dysrhythmias. Option 1 is false regarding output and does not address the metabolic problem. Options 3 and 4 may apply to the client but are not the priority needs, in addition, option 3 will resolve as the DKA is treated. Daily total baths remove the protective sebum from the skin, placing the client at risk for altered skin integrity. Since the client's level of participation in the bath or other self-care activity is not presented, the other 3 options are inappropriate. In addition, options 2 and 3 are not specific and measurable enough to meet criteria for an outcome statement. Early signs of edema of the larynx leading to airway obstruction are tight-fitting dressing, stridor, stertor, and weak or harsh voice. Numbness or tingling or the extremities, lips or mouth are signs of hypocalcemia that can lead to respiratory distress due to tetany. The data in the other options are important routine postoperative evaluations, but they do not relate to the client's airway. HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness and hyperthermia. Ketones are not present in HHNK; thus, monitoring for ketones is inappropriate (option 3). Options 2 and 4 do not address the primary problems that occur with HHNK. The signs of hypoglycemia include hunger, shakiness, sweating, pale cool skin, and irritability. These signs may be manifestations of impaired cerebral function from the hypoglycemia. The other options are all signs of hyperglycemia. Glycosylated hemoglobin reflects the average blood glucose over the life of the RBC, usually 4 months. This test is not a ratio of hemoglobin to glucose content (option 3) nor is it helpful in diagnosing anemia (option 1). The time frame in option 4 is too long. The danger of hemorrhage is greatest during the first 24 hours following thyroid surgery. The tendency is for blood to flow down at the sides and posteriorly if hemorrhage occurs in the area of the neck. Inspecting the front of the dressings for signs of hemorrhage may not reveal bleeding (option 1). Changing dressings immediately after surgery is not appropriate (option 2). A drop in hemoglobin may be a clue to bleeding but is not the best initial action (option 3). Starvation-induced ketosis can be prevented by drinking juices that equal the prescribed carbohydrate meal pattern. Fluids are needed to prevent dehydration and hyperosmolality, which could result from large fluid losses from persistent vomiting. The liver breaks down fats to form glucose for energy and ketones, leading to DKA. The other options do not address the key issues of dehydration and hyperglycemia. Level of consciousness responds quickly to early changes in pH and restoration of fluid and electrolyte balance. Urine output decreases as hyperglycemia is resolved. The respiratory buffer system takes a few hours to respond to change in ph. Dehydration is usually so severe that several hours of rehydration are needed to reduce pulse (option 2) and resolve orthostatic BP (option 1). Option 4 is inappropriate because eating a full meal is not an early sign of improvement. The candy bar and ice cream may have too much glucose and fat, potentially leading to hyperglycemia. In addition the fat may delay glucose absorption. Immediate absorption of glucose is needed in hypoglycemia. The client should also check the blood glucose within 15 minutes of taking glucose because of signs of hypoglycemia. The priority action of the nurse restores a patent airway. With this in mind, the nurse spreads the retention sutures to reopen the stomal area. The nurse then quickly calls aloud for help so assistance will arrive to aid in tube reinsertion. The nurse is not likely to suction the area at this time, and the nurse would reinsert a new tracheostomy tube if allowed by agency policy, since the tube has been in place for more than 72 hours. Usually the cortex of the adrenal gland (not the medulla as in option 1) increases secretion of cortisol to stimulate the immune system in response to an infection. Thus the replacement dose during illness may need to be adjusted once a client's adrenal glands are removed. Hydrocortisone can irritate gastric mucosa and so clients should not take gastric irritants such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). Dosage may be adjusted during illness. Options 2 and 3 do not address the risk of the drug, which is the issue of the question. The client is at risk for type 2 diabetes mellitus (DM). Polydipsia and polyuria are signs of hyperglycemia, a symptom of DM. Steroids may also increase carbohydrate metabolism, leading to hyperglycemia in clients with insufficient insulin. Thus the nurse should monitor the client's blood glucose. Since hyperglycemia places the client at risk for fluid volume deficit the nurse should calculate the client's fluid balance. The nurse also needs to record the data and report it to the physician. The client is not at risk for hypervolemia (options 2 and 3). Option 4 is not a priority. The presence of a halo effect indicates cerebrospinal fluid (CSF). Glucose present in the nasal drainage also suggests that the drainage is CSF. A persistent headache indicates a CSF leak. The physician needs to be informed of these findings and the client must be maintained on bedrest to stop the leak. A spinal tap may be done to decrease CSF pressure. Option 1 is incorrect because it does nothing for the client. Options 3 and 4 do not address the real problem, a probable CSF leak. With exophthalmos, the eyelids may not cover and protect the cornea of the eye. Thus, eye protection from the sheets or preventing the hands from accidentally touching the eyes is needed while the client is in bed. With Graves' disease clients usually experience heat intolerance, thus less covering and a cool room are preferred (option 1). Hyperglycemia is not usually associated with Graves' disease. The head of the bed should be elevated 30° to minimize eye pressure (option 3). Fluid and electrolyte replacement is the highest priority. Hyperglycemia is treated with regular insulin rather than an oral agent (option 3). Concurrent administration of IV regular insulin would also be done as a priority. The items in the other options can be done after definitive treatment for dehydration is done. Glucagon is given IM or SC for low blood glucose associated with unconsciousness; usually the blood glucose is less than 20 mg/dL. Hypoglycemia associated with a change in level of consciousness or seizure requires immediate interventions. Glucagon will not help urine output or blood pressure, and is not administered routinely when glucose levels fall to 150 mg/dL. Clients taking methylprednisolone, a glucocorticoid, should be monitored for signs of Cushing’s syndrome and hyperglycemia. Increased corticosteroid serum level can cause sodium retention, increased BP, edema, hypokalemia, weakness, and ecchymosis. Long-term corticosteroid therapy can cause Cushing's syndrome. To prevent the osteoporosis associated with Cushing's syndrome, clients should eat diet high in calcium. Extra corticosteroids over the long term can cause weight gain and increased hair on the body. These clients are at risk for gastrointestinal bleeding and should avoid taking aspirin. Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for oxygen, leading to increased cardiac workload and possible heart failure. If fluid volume deficit is present, then there is an additional risk for decreased cardiac output. There is insufficient data to determine fluid volume status. The tachypnea is a symptom of the increased metabolic rate. The pH indicates acidosis; the PCO<sub>2</sub> is low, indicating increased respiratory rate; and the low bicarbonate level is usually associated with metabolic acidosis. The respiratory system is attempting to compensate for the excess metabolic acids but there continues to be an excess of them. The bicarbonate level is low because it is being depleted in an attempt to buffer the metabolic acids. The first action by the nurse is to examine for bilateral breath sounds as an initial indication of correct tube placement. The nurse would next secure the tube and then call for chest x-ray to confirm tube placement. Once the client’s airway and breathing have been attended to, then the nurse can assure the client about alternative communication means. Clients with diabetes mellitus are susceptible to injuries because of the decreased sensation associated with the effects of chronic hyperglycemia, compounded by the diabetes-induced arteriosclerosis. The client should be taught to inspect the feet daily utilizing a mirror to facilitate inspection of hard to see areas. Cotton socks are preferred as they absorb moisture and allow the feet to dry. The use of prophylactic antibiotics is not appropriate; the moisture could lead to skin maceration and breakdown. Glycosylated hemoglobin is elevated due to long-term hyperglycemia. Values greater than 8 percent indicate consistently poor control of blood glucose and the need to determine the client's dietary pattern for the past several months in relation to the treatment plan. The other options do not apply. The exact cause of clubfoot is unknown, though several possible etiologies exist. Abnormal intrauterine position may cause the deformity, along with neuromuscular or vascular problems. A positive family history increases the chance of this deformity. The postoperative care of the child undergoing repair of clubfoot includes elevation, application of ice, monitoring neurovascular status, bleeding and swelling, and pain. Nasogastric intubation is usually not needed and warm blankets are not indicated. All symptoms listed are clinical manifestations of developmental dysplasia of the hip, although the only one that would be found in a 5-year-old would be the telescoping of the femoral head into the pelvis. Other clinical signs in an older child would be lordosis, and a waddling gait with a marked limp. A positive Ortolani-Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than three months, along with asymmetry of thigh and gluteal folds. The exact cause of SCFE is unknown. Predisposing factors include obesity, a growth spurt resulting in a tall and thin stature, and endocrine disorders such as hypothyroidism and hypogonadism. There may be a genetic predisposition to this disorder. All are appropriate interventions for the child who has undergone a spinal fusion, although only the first three are appropriate interventions directly aimed at the client experiencing an altered body image. Teaching cast care is important, but would be appropriate under the nursing diagnosis of knowledge deficit. The nurse would assist with coping, but this does not necessarily involve new hairstyle or clothes. Activity restrictions should be followed for six to eight months following a spinal fusion. Lying, standing, sitting, walking, normal stair climbing, and gentle swimming are generally allowed following spinal fusion. Bending and twisting at the waist is not recommended, along with lifting more than 10 pounds, household chores such as vacuuming, mowing the lawn, physical education classes, and any sports besides walking. Exercise such as swimming is allowed for clients with osteogenesis imperfecta and will help improve muscle tone and prevent obesity. Bowling and wheelchair sports would not be allowed, as the weight involved with both could cause fractures of the upper extremities. A child with DMD would have enlargement of muscles as a result of fatty tissue infiltration. A school-aged child with DMD is generally still ambulatory. Muscles at this age are weak, not paralyzed. A weak cough reflex would occur as the disease progresses. A harsh or crowing sound with inspiration indicates stridor, which is consistent with airway narrowing and edema following endotracheal tube removal. This is of greatest concern because it could lead to upper respiratory obstruction. The nurse needs to notify the physician. The other options are of less concern, since clients may be expected to have secretions or some rhonchi immediately after tube removal. An increase in respiratory rate from 16 to 20 bears watching for trends but is still with normal limits. Bryant's traction is used specifically for children under 3 years of age and weighing less than 35 pounds who have developmental hip dysplasia or fractured femur. This bilateral traction is applied to the child's legs, with the hips flexed at 90° angle, with knees extended and buttocks slightly off the bed. The other distracters describe Russell, Buck, and Dunlop traction. To promote healing of the affected hip in LCPD, the femoral head is contained in the hip socket until ossification is complete, which may take up to two years or more. This is accomplished by keeping the hips abducted by continual use of Petrie casting, or Toronto and Scottish-Rite braces. The child should be encouraged to attend school during this time. Untreated LCPD clients may develop osteoarthritis and hip dysfunction. The other answers are incorrect statements of fact. The sensation of numbness or tingling is a sign of neurovascular impairment. Neurovascular impairment can lead to nerve ischemia and destruction, with possible permanent paralysis of the extremity. Any symptom of neurovascular impairment, such as paresthesia, lack of pulses, edema that does not improve with elevation, pallor, and pain, needs immediate attention. The child with skeletal traction has a pin that passes through the skin into the end of a long bone. This procedure provides an entrance for microorganisms. Frequent monitoring of the pin site, pin care according to institutional policy, and frequent monitoring for signs of infection (i.e. temperature measurement) take priority over the other nursing interventions listed. Slipped capitol femoral epiphysis is a slipping of the femoral head that occurs most frequently before or during the rapid adolescent growth spurt. The onset of symptoms is gradual, and symptoms include limp, holding the leg in external rotation to relieve pain, restricted and painful internal rotation, and knee and hip pain. The therapeutic management of the child with osteomyelitis includes limiting weight-bearing on the affected part, immobilization, and administration of antibiotics. Antibiotic therapy may continue intravenously for 3 to 6 weeks, and orally for another 2 weeks depending on duration of symptoms, response to treatment, and sensitivity of the organism. Discharge teaching needs to include follow-up antibiotic care at home, care of the IV site, and continuing antibiotic therapy even though it may seem as if all the symptoms are gone. Food sources such as calcium and protein should be provided for bone healing. All four of the signs are tests for developmental dysplasia of the hip. Ortolani and Barlow signs disappear after 2 to 3 months. Trendelenburg sign will be seen in the child who is able to stand. Allis sign, shortening of the affected limb on the affected side, is a reliable test at 4 months of age. Asymmetric folds would be a positive sign at any age. The child is too young to walk, so a limp would not be observed. Clubfoot is apparent at birth, with the affected foot fixed in an abnormal position. The affected foot is usually smaller, shorter, with an empty heel pad. The affected limb is usually shorter and has some calf muscle atrophy. Children with this disorder have normal calcium and phosphorus and abnormal precollagen type I. This prevents the formation of collagen, the major component of connective tissue. The precollagen remains relatively unstable and unable to undergo final transformation into collagen. Children with mild OI may be able to participate in sports, and many are able to participate in swimming. There are no current medications that stop this disease process. There are a variety of surgical procedures that may be done to help strengthen the bones; one is the insertion of intermedullary rods to provide for stability. The child with OI may participate in school, though care needs to be provided to protect this child from injury. The priority action of the nurse is to submerge the tube in sterile water or saline to reestablish the underwater seal. This will prevent the client from sucking air through the chest tube into the pleural space during inspiration, thereby causing pneumothorax. After this initial action, the nurse would assess the client’s respiratory status, set up a new system, and then check the client’s full vital signs before reporting incident to the physician. Children with muscular dystrophy quickly suffer from complications of immobility. Therefore, when hospitalized, these children should have physical therapy, range-of-motion exercises, and bed-to-chair activity as soon as possible. Children with respiratory infections are treated with vigorous antibiotic therapy, as well as postural drainage and cupping. The Milwaukee brace is worn for scoliosis, when the degree of curve is greater than 20 but less than 40 degrees. It is worn for 23 hours a day. Exercises to increase pelvic tilt, for lateral strengthening, and to correct lordosis should be done several times a day while in the brace. The brace should be worn over a T-shirt to minimize skin irritation. The adolescent may experience muscle aches resulting from new alignment. The initial treatment for clubfoot begins immediately or shortly after birth and consists of weekly cast changes and manipulation. Surgery is completed only if nonsurgical intervention of serial casting is not effective. A Denis Browne splint may be used to maintain correction once it is achieved. Abduction devices are used for hip conditions. Diapers should be placed underneath the straps of a Pavlik harness; a t-shirt should be worn under the straps of the harness. The harness should be worn for 23 hours a day. The child quickly “catches up” once the device is no longer worn if developmental milestones are delayed because of the abduction device. Babies should never be lifted by their legs when changing diapers. Early treatment is usually successful without surgery. The treatment is not painful. Because of their very fragile bones, children with OI experience countless fractures, and the prevention of injury takes highest priority in this child’s care. Pain would be important if a fracture actually occurs, but the key is prevention of fractures, making risk for injury more appropriate. Skin integrity impairment would also not be a concern unless a fracture actually occurred. Swelling and redness of involved joints is a symptom found in juvenile arthritis, not LCP disease. Stiffness in the morning or after rest, an insidious limp after activities, and referred pain to the knee are all consistent with this diagnosis. Once the diagnosis is made, the child should be non-weight-bearing on the affected hip, as weight-bearing can increase the amount of slippage. Wheelchair use should be avoided, as this also may increase the amount of slippage. Back pain is not identified as a symptom of idiopathic structural scoliosis. Skirts that hang unevenly, unequal shoulder height, and uneven waist level are all positive symptoms of this disorder. Adolescents are greatly concerned about their physical appearance as part of their growth and development. Unless there is a clear priority based on physiological need, attention to developmental concerns such as body image is important when caring for the adolescent client. There is some degree of paralytic ileus following a spinal fusion; therefore, nasogastric intubation is required along with frequent auscultation for return of bowel function. The pain experienced by this client is severe and requires intravenous medication, preferably with patient-controlled analgesia (PCA). Logrolling must be done every 2 hours, once allowed, to prevent the accumulation of secretions in the lungs. Urinary retention is common, and an indwelling catheter is used if present rather than repeated straight catheterization. Monitoring the child’s respiratory status is crucial as is the use of an incentive spirometer. The nurse should document this normal finding and continue to monitor. Fluid addition or removal is based on fluid level, not on bubbling action of suction. The nurse should not turn up suction because the gentle bubbling indicates proper function, and increased suction could cause more rapid evaporation of water from the chamber. The child with Duchenne’s muscular dystrophy (MD) has a history of meeting early developmental milestones. Symptoms usually begin at around 3 years of age and include difficulty climbing stairs, running, and pedaling. Duchenne’s MD, is also called pseudohypertrophic MD as the muscles appear enlarged. The appearance of the hips is normal. Serum laboratory studies in a child with osteomyelitis will reveal an increased WBC count, C-reactive protein, and sedimentation rate. The blood culture is usually positive. This disease process does not affect the HCT or BUN. Aerobic exercises, such as swimming, help the client to maintain maximum range of motion (ROM) and mobility while minimizing strain on joints. Isotonic exercises such as tennis, jogging, and volleyball place excessive strain on diseased joints. Swan neck deformities of the hand are classic deformities associated with rheumatoid arthritis secondary to the presence of fibrous connective tissue within the joint space. Clients with RA do experience morning stiffness, but it can last from 30 minutes up to several hours. RA is characterized by symmetrical joint involvement, and Heberden's nodes are characteristic of osteoarthritis. Aspirin interferes with the action of uricosuric drugs. Acetaminophen, naproxen, or ibuprofen may be used effectively as an analgesic in the treatment of pain associated with acute gout, and they do not interfere with the action of uricosuric drugs. Options 2, 3, and 4 are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilatation. Serum alkaline phosphatase is elevated because of increased activity of bone cells. Inflammation is in the bone and usually doesn't reveal an elevated serum WBC, ESR, or the presence of <i>Staphylococcus</i>. Osteosarcomas are most commonly seen in males during optimal growth years. Middle-aged males (option 1), females age 50 to 60 (option 2), and females of childbearing age (option 3) are less likely to develop osteosarcoma. Although the etiology of SLE is unknown, certain environmental factors have been associated with the onset of symptoms. The administration of procainamide (Procan SR) and hydralazine (Apresoline) have been associated with SLE symptoms, which usually subside after the drug is discontinued. Raynaud's disease is characterized by spasms of the blood vessels within the fingers of the hands resulting in diminished circulation. Gloves protect the hands from cold temperatures and provide warmth, which promotes blood flow to the affected areas. Raynaud's phenomenon is in the CREST syndrome, a type of scleroderma. Continuous bubbling in the water seal chamber most often indicates a leak or loose connection in the system, and air is being sucked continuously into the closed chest drainage system. If the client experienced a new large pneumothorax, there could be rapid bubbling, but this is not the most likely explanation. Turning up the suction on the wall unit would increase the bubbling in the suction control chamber, not the water seal chamber. Taping the connections too tightly is not a concern. During earlier stages of bone healing, overproduction of callus enlarges the bone and acts as a splint. Callus is eventually replaced with mature bone during the ossification phase of bone healing, and then the excess callus is resorbed during the remodeling phase to return the bone to its original shape. Edema is expected immediately following a fracture, but because the fascia is non-elastic, excessive swelling will lead to increased capillary pressure within the area resulting in nerve and muscle damage if left untreated. Damage is irreversible if the capillary pressure reaches 30 mmhg. A pulse may still be present during early stages of compartment syndrome. One factor that can differentiate pain associated with trauma from the fracture, and that from compartment syndrome, is the ineffectiveness of analgesics when compartment syndrome occurs. Although Checking for edema, pulses, and the presence of drainage is important in the care of a client with a fracture, pain unrelieved by analgesics is the symptom most indicative of compartment syndrome. When clients with scleroderma develop Raynaud's phenomenon, which is characterized by vasospasms of the arteries and veins of the hands, beta blockers are the treatment of choice. Bradycardia is not specific to scleroderma. Clients may experience pericarditis, but this is not treated with beta blockers. Hypercalcemia (option 1) can occur as a complication of Paget's disease secondary to increased osteoclast activity. The other tests are not specific to Paget's disease although they are all abnormal values. Ewing's sarcoma is a primary bone tumor associated with rapid metastasis to the lung. It occurs most frequently in males during optimal growth periods. The pathophysiology of gouty arthritis is related to overproduction or decreased excretion of uric acid in the primary form. The other options are incorrect. Although all the items listed are important in the plan of care for the client diagnosed with osteomyelits, maintaining aseptic technique and preventing the spread of infection is crucial to resolving the disease process. Symptoms of muscular dystrophy usually manifest themselves in the toddler years. The child has a waddling gait and experiences frequent falls. There is no cure for the disease, and as muscles become progressively weak. Most children are wheelchair confined by the teen years. As the disease progresses, heart and lung muscle are affected, resulting in cardiac and pulmonary failure. These complications frequently occur by the age of 20. Articular cartilage is responsible for decreasing friction during joint movement and displacing the force of the workload onto the subchondral bone. In OA, the composition of the articular cartilage is changed because of a malfunction in the production in proteoglycans. Consequently, the articular cartilage can no longer perform its original function. Herpes zoster is caused by the herpes virus varicella zoster. It can be transmitted by direct contact with the client. It is not transmitted via droplets or air currents. Neutropenic precautions are not indicated because the client is not at risk for contracting an infection from the nurse or other individuals. The client should be premedicated approximately 30 minutes prior to chest tube removal if the client has an analgesic order and the medication can be given at this time. It is the physician’s responsibility to determine the results of the daily chest x-ray. Obtaining equipment for removal and explaining the procedure to the client can be done earlier or later than the timeframe indicated. DMARDs are now being used earlier in the treatment regime for RA because evidence suggests that they may play a role in arresting the disease process. NSAIDs are used in combination with this drug classification for pain management. Systemic corticosteroids are not used until NSAIDs are no longer effective because of the severe side effects associated with their use. Osteoporosis is characterized by excessive bone resorption that exceeds the body's ability to produce new bone. It is more prevalent in postmenopausal women with low levels of estrogen. A decrease in the number and activity of osteoblasts and an increase in the number and activity of osteoclasts occurs. Proteinuria in a client with SLE indicates renal involvement. The nurse should record I & O and analyze the results of additional labwork including blood urea nitrogen (BUN) and creatinine (CR). Scleroderma is not drug-induced. Systemic sclerosis may result in changes to the esophagus, intestines, lungs, heart, and kidneys. Depending on which organs are involved, the condition may be life-threatening. CREST syndrome and limited scleroderma are self-limiting and associated with a good prognosis. Although the etiology of scleroderma is unknown, the disease process is related to overproduction of collagen leading to fibrosis and inflammation, which causes damage to the affected area. Serum ESRs and ANAs are elevated in scleroderma but are also indicative of other conditions. A skin biopsy reveals collagen thickening and confirms the diagnosis. The rheumatoid factor is only significant for rheumatoid arthritis. Immobilizing the fracture is the priority nursing intervention in the emergency management of a client with a fracture. After the area is immobilized, the nurse should follow through with interventions outlined in options 2, 3, and 4. A fat emboli is a common complication following the fracture of a long bone. Symptoms of fat emboli include tachycardia, a petechial rash, and tachypnea. Compartment syndrome occurs as a result of an excessive pressure within the joint cavity which results in obstruction of both arterial and venous blood flow. Hence, the symptoms of decreased or absent pulse, pallor, and decreased capillary refill. An adequate intake of calcium, either in the diet or through supplements and regular participation in weight-bearing activities are the most effective way to prevent osteoporosis. Walking, jogging, and weight-lifting are examples of weight bearing exercises; swimming is not. Estrogen replacement is effective in preventing osteoporosis in postmenopausal women. The maximum amount of fluid that should be used to irrigate a nephrostomy tube is 5 milliliters. The nurse should also use strict aseptic technique to prevent infection of the renal pelvis as a result of the procedure. Although clients with osteoporosis are predisposed to pathological fractures, loss of height is usually one of the first indicators of osteoporosis. Application of heat prior to exercising may help improve joint function. Jogging is not recommended because it puts excessive stress on joints. Clients with OA should maintain their weight to prevent excessive stress on joints. A firm mattress is recommended for support of the lumbar spine. A client admitted to the emergency department and diagnosed with an acute episode of gout will be in severe pain. Although a serum uric acid level should be obtained, pain management should be the first priority for the nurse. Clients prescribed uricosuric drugs for prevention of further gouty attacks should be instructed to increase fluids to prevent kidney stones associated with their use, however teaching should be conducted after the client is relieved of pain. Hematogenus osteomyelitis originates as a blood borne infection and occurs most commonly in children under 10 years of age with a recent history of a throat, ear, or skin infection. Options 1, 2, and 4 are examples of direct entry osteomyelitis. Paget's disease is characterized by two phases. The osteoblastic phase is characterized by slowing down of bone resorption and enlarging of bones. Muscular dystrophy is a genetic disorder of the recessive gene on the X-chromosome (mother to son). Option 1 would be true if all future pregnancies were males. The most common sites for metastatic bone tumors are the ribs, spine, and pelvis. The tissue of origin associated with osteosarcomas is the metaphyseal of long bones. The formation of chrondrosarcomas originate in cartilage, and Ewing's sarcoma originate in the nerve tissue within the bone marrow. Gently supporting limbs and bony structures during transfers and position changes is the most effective way to prevent pathological fractures associated with bone tumors. Option 1 might cause limited range-of-motion (ROM); options 2 and 3 aren't applicable. Although the etiology of SLE is unknown, hormonal imbalances associated with pregnancy are thought to precipitate the onset of the disease. Women of childbearing years are at a greater risk. The nurse should ensure that the tubing is free of kinks or other obstructions to urine flow. The tube is irrigated according to physician order only. The tube should never be clamped. Taping the drainage bag to the bedrail is dangerous because it could cause traction when the client moves in bed and become dislodged. The joints most often affected in osteoarthritis are the weight-bearing joints; hips, knees, lumbar and cervical spine, and the phalangeal joints. During chronic osteomyelitis infection spreads through the bone, bone cells become necrotic and break off into segments called sequestra. Although options 1, 2, and 4 are all important interventions in the health teaching of clients with rheumatoid arthritis, instructing the client on energy conservation techniques and pacing activities early in the teaching plan will help to provide immediate symptom control. Decreasing activity (option 2) may further limit range-of-motion. In adult males, the most prevalent contributing factor in the development of osteoarthritis is history of joint trauma. An athletic male may have had trauma to the knee from a sport many years earlier in high school. Tophi are hard movable nodules with irregular surfaces associated with chronic untreated gout. Acute pain and hyperuricemia are not exclusive to chronic gouty arthritis. The most common causative agent in clients with osteomyelitis is <i>Staphylococcus aureus</i>. The other organisms could contribute but are not usually the <i>primary</i> organism; look for key words. Increased head size, headaches, and hearing loss indicate that Paget's disease has progressed and involves the cranium. Symptoms of muscular dystrophy present around 2 to 3 years of age. Children usually present with a waddling gait, toe walking, and frequent falls. Kyphosis occurs with disease progression, and recurrent URIs occur with involvement of lung tissue. The etiology of fibromyalgia is unknown, but it is believed that it may be precipitated by stress. The condition may be acute or chronic, non-steroidal antiinflammatory drugs (NSAIDs) will help to control joint and muscle pain associated with the condition but is not a cure. Options 1 and 3 are characteristic of malignant tumors. Soft tissue sarcomas are not detected on x-rays; a computed tomography (CT) scan or magnetic resonance imagery (MRI) must be performed. Gastric pH is acidic and readings should be 4 or less if the tube is placed properly in the stomach. The other options indicate placement in the intestine or higher up in the esophagus, since normal body pH is 7.35 to 7.45. SLE is an autoimmune disease in the body, characterized by production of autoantibodies against DNA secondary to hyperactivity of B-cells. Bouchard's nodes are located on the Proximal Interphalangeal (PIP) joints of clients with osteoarthritis. Swan neck deformities, ulnar drift, and boutaniere deformities are characteristic of rheumatoid arthritis (RA). Women of menopausal age are at risk for osteoporosis, and foods high in calcium should be encouraged. All the foods in option 3 are high in calcium. Chicken and eggs are high in protein; wheat and corn are high in carbohydrates. The factors presented in option 1 put the client at risk for osteoporosis. Smoking, alcohol intake, and dietary deficiency of calcium and vitamin D are major factors in the development of osteoporosis. Deficient protein and carbohydrate intake, obesity, depression, and history of falls do not contribute to the development of osteoporosis. Fosamax is the drug that prevents bone resorption. Calcitonin (Micalcin) increases bone mass and is dispensed as a nasal spray; raloxifene (Evista) is a selective receptor modulator. The client with hip surgery should avoid all activities that will cause hip adduction, internal rotation, and flexion beyond 90 degrees. The focus of the teaching on clients with hip surgery is to avoid dislocation and the risk for further injury. Extremes of internal rotation, adduction, and 90-degree flexion of the hip should be avoided 4 to 6 weeks after surgery to prevent dislocation. Although use of elevated seats prevents excess flexion of the hip, it alone does not suffice in preventing dislocation. Bending activities (such as putting on shoes) place the client at risk for dislocation. Abduction pillows are used to prevent external rotation and must be used postoperatively. Musculoskeletal injuries and subsequent treatment have the potential to cause complications. Bleeding and swelling from the surgery may cause compression of nerves that can lead to permanent neurological damage and paralysis. Frequent data collection of the neurovascular status of the client is essential following laminectomy. Neurovascular data collection includes monitoring for pain, pulses, pallor, paresthesia, and paralysis. The physician usually orders ambulation. Vital signs are not done every 30 minutes unless the client is in the post-anesthesia care unit. Although loss of bladder tone may indicate nerve damage, it may also be a residual effect of the anesthesia. Determining the ability to void becomes of prime importance if the client is due to void, usually 6 to 8 hours after last voiding. The pull of traction on the affected limb should never be disturbed to ensure healing and union of the bone in proper alignment. This intervention is an independent nursing activity and does not require a physician's order. A change in weight is not indicated. Elevating the client's feet will not correct the situation. A major complication of skeletal traction is infection. The nurse must provide pin site care using aseptic technique to prevent infection. The nurse correctly measures the distance from tip of nose to earlobe and then to the xiphoid process and marks the tube at this length prior to insertion. The other options identify one or more incorrect landmarks. Unrelieved pain, diminished pulses, pallor, paresthesias, and pain on passive motion are all symptoms of compartment syndrome. This is a medical emergency because the pressure must be relieved in the affected limb. Otherwise, the swelling in the closed compartment may lead to further permanent complications, such as loss of the limb. Options 2 and 3, although appropriate, are not the priority interventions in this case. The administration of oxygen is an inappropriate initial action in this situation. The elevated temperature, chills, malaise, and pain are all clinical manifestations of osteomyelitis. Symptoms of fat embolism include acute respiratory distress. Symptoms of compartment syndrome include progressively worsening pain distal to the affected site unrelieved by analgesics. Malunion of the bone will not cause an elevated temperature. An arthogram involves injecting dye into a joint for diagnostic purposes. It is critical that the nurse evaluate the client for history of allergic reaction to contrast dye before the procedure since this can lead to a life-threatening response such as anaphylactic shock. The other options are not priority data collections or are irrelevant. Low bone mass, structural deterioration of bone tissue leading to bone fragility, and increased susceptibility to fractures is seen with osteoporosis. The client also has risk factors associated with osteoporosis: smoking, sedentary lifestyle, and being female and postmenopausal. After laminectomy it is critical that proper body alignment is maintained to prevent postoperative complications such as neurological damage. Logrolling technique ensures that the client turns as a unit. All the other options put stress on the spine. Handling a cast that is not completely dry with the fingertips creates indentations in the cast. These indented areas are thinner and are prone to cracks when the cast is completely dry. A wet cast should be handled with the flat part of the hands and exposed to air to assist in drying. Counter-traction will prevent the client from sliding to the foot of the bed. This can be achieved with Trendelenburg position of the bed or raising the foot of the bed slightly if the client's body weight is not sufficient. The other options do not add to counter-traction. Clients with joint replacement require aggressive physical therapy postoperatively to regain range of motion in the joint caused by pain and swelling. The other nursing diagnoses are not a priority at this time. A classic sign of scoliosis is asymmetrical dress or skirt tail/hem caused by unevenness of the affected shoulder and hip. The lateral curvature resulting from the spinal deformity causes the asymmetry. The other options do not necessarily cause all the manifestations listed in the question. Weights help to keep the fractured extremity in proper alignment to facilitate healing and therefore should not be manipulated. Nursing interventions for clients on traction should include ensuring that the weights hang freely at all times to maintain the line of pull. Traction is not released to maintain a steady pull. In order for the tube to migrate to the area of intestinal blockage, the tube must pass through the pyloric sphincter of the stomach. Recall that this tube has a weighted tip and thus gravity will affect its movement, as will peristalsis. Positioning the client with head elevated and on the right side will utilize gravity to help the tube migrate into the intestines. The other responses will lead to less effective tube movement. Estrogen therapy decreases bone demineralization preventing progression of osteoporosis. It also increases bone density in the spine and hip and therefore reduces the risk of fractures. The other options do not appropriately describe the action of estrogen in the preventive and therapeutic management of osteoporosis. A client who undergoes surgery to the hip must be careful to avoid flexing the joint to greater than 90 degrees postoperatively to prevent dislocating the hip. There is no portable Buck’s traction, although traction may be used preoperatively to immobilize the limb. A soft cushion is not essential. The client may need to use a walker for assistance, but does not need crutches. Standard x-rays will not provide the detail necessary to evaluate soft tissue or cartilage damage; arthroscopy is used to examine the interior of a joint; a bone scan is used to diagnose bone malignancies. A fractured extremity will be shorter than the unaffected extremity because of contraction of the muscle, swelling at the site, and misalignment of the bone fragments. Pain with movement and bruising are not caused solely by hip fracture, and thus they are not distinctive signs. Routine stretching and warm-up exercises are essential before strenuous physical activities to prepare the muscle to withstand the stress of the motion. The intake of supplemental electrolytes (such as what is contained in Gatorade) and high-protein drinks do not prevent strains from occurring. The use of a back brace impedes movement during an activity such as tennis and is not the best strategy to preventing future muscle strain. Russell's traction can partially immobilize the extremity to reduce spasms. It is important that the nurse monitors the skin under the traction for breakdown, especially over bony prominences and other pressure areas. Option 1 is incorrect because this is a type of skin traction, and therefore there is no insertion site. Examination of the skin for dehydration does not necessarily have to be done under the skin traction; rather it can be done in other areas. Skeletal pain is a classic symptom of Paget's disease. The location of the pain depends on the bone affected. Arthritis may result from damage to joint cartilage, but Paget's disease does not result from bone deformities or from poor calcium uptake. There is excessive bone resorption followed by bone formation which leads to weakened bone, pain, deformity, and pathologic fractures. Joint pain with movement seen with osteoarthritis is aggravated by continual activity. A planned rest period is a very important intervention for managing the discomfort. Clients with osteoarthritis should maintain a regularly scheduled exercise program to maintain joint flexibility and mobility. The application of heat and cold on the affected joint is for temporary pain relief. A high-calorie intake does not address the management of joint stiffness. The combination of foods in option 1 has the highest amount of calcium. Each food in this meal is high in calcium overall. Strengthening the back muscle is a critical intervention to preventing injury. This goal can be accomplished by regular exercise. Teaching a client the principles of good body mechanics, maintenance of good posture, and the importance of adhering to a prescribed exercise routine are important to strengthen back and abdominal muscles. The goal of managing back pain is to prevent its recurrence. The use of back brace and sporadic exercise are not appropriate in decreasing the episodes of back injury. Nasoenteric tubes are not taped in place until they have migrated to proper position and been confirmed by x-ray. The nurse should note the data collection finding on the medical record. The nurse does not need to call the physician, and it is unnecessary to immediately determine the x-rays that are scheduled. It is normal to continue to have sensation in the amputated limb site since nerve endings are still present. The client feels real pain, and interventions should be provided to relieve it. Fat embolism (option 3) is usually a complication of bone fracture and may have a clinical presentation of confusion. However, other signs accompany fat embolism. Heberden's nodes are bony enlargements on the distal interphalangeal joints (DIP), and Bouchard nodes are bony enlargements on the proximal interphalangeal joints (PIP). The figure shows the typical changes of the DIP and PIP. Ulnar deviation and Boutonniere and swan neck deformities are typically associated with rheumatoid arthritis. Emollients will ease the problem of dry skin that increases pruritus and causes the psoriasis to be worse. Washing and drying the skin with rough linens or pressure may cause excoriation. Constant occlusion may increase the effects of the medication and increase the risk of infection. In order to plan the appropriate management of contact/irritant dermatitis, the cause of the inflammation should be identified. Removal of the cause may be all the treatment needed. Antihistamines and hydrocortisone creams are treatment options. Skin testing may be helpful to determine the allergen if not evident in the history. Lice are transmitted by direct contact with infested persons or by sharing hats, brushes, or combs of infected persons. Classrooms are excellent areas for close contact, and children often do not know when other classmates have lice. Options 1, 3, and 4 are incorrect. The disease is ten times more common in fair-skinned people who work indoors. This population often experiences severe sunburns and blistering in childhood and tends to vacation in areas of intense sun exposure. Remember, episodic intense sun exposure is more damaging than constant exposure. There is no sensation of pain to light touch in full thickness burns because the pain and touch receptors have been destroyed. There may not be pain with some partial thickness degree burns, but the appearance described is characteristic of full thickness. A burn involving the face, neck, or chest may cause airway closure because of the edema that occurs within hours. Remember the ABCs: airway, breathing, and circulation. Airway always comes first, even before pain. The nurse will also determine skin integrity (option 1), blood pressure and pulse (option 2), and pain (option 4), but these are not the highest priority Data Collections. Pediculosis capitis is head lice, and nits are cemented to the hair shaft. They are most commonly seen on hair on the back of the head near the nape of the neck. A papular excoriation may be present at the nape of the neck secondary to scratching. If the client previously had a reaction to a wasp sting, immediate treatment must be administered. If a reaction is anticipated, do not complete the exam or wait for symptoms to develop, be proactive. Pain often causes the blood pressure to rise. The client who has never been stung should be monitored closely. A Sengstaken-Blakemore tube is inserted to control bleeding from esophageal varices, which is the primary health problem of concern with use of this tube. The underlying health problem that causes the bleeding is portal hypertension, which is a complication of cirrhosis of the liver. Abdominal ascites may also accompany cirrhosis. Candidiasis (oral thrush) often develops as a result of the overgrowth of bacteria after a client has been on an antibiotic. Since a wart is a virus-induced epidermal tumor, it may reappear at the original site or another body area despite the fact that the original wart was removed. Immunity may develop to further warts after 5 years. Dermatomal pain, itching, or burning may be severe and often begins 4 to 5 days before eruption occurs. The trunk is affected in the majority of cases. An insect bite usually manifests immediately, warts do not burn or itch, and scabies usually do not burn. Scabies form lines in the folds of the skin. Folliculitis is an inflammation of the hair follicle caused by infection, chemical irritants or injury. It is most commonly caused by <i>Staphylococcus aureus</i>. Using a clean razor each time he shaves will decrease the risk of reinfection. All three diagnoses are a bacterial infection of the skin arising from the hair follicle, where bacteria can accumulate, grow, and cause a localized infection. Options 1 & 3 are incorrect. Impetigo is an infection of the skin typically beginning with a vesicle or pustule. The lesion ruptures, leaving an open area that discharges a honey-colored serous liquid that hardens into a crust. Impetigo spreads quickly if not treated. Psoriasis is a chronic disease with factors such as stress precipitating an exacerbation. A healthy lifestyle is recommended and includes a well-balanced diet, frequent exercise, moderate alcohol intake, and avoidance of tobacco products. The disease cannot be transferred to another person, keeping the skin moist relieves the itching, and medications can be effective. Normally, the keratinocyte migrates to the outer layer of the skin in 14 days. Psoriatic skin cells complete this journey in 4 to 7 days producing an abnormal keratin that forms thick, flaky scales at the surface of the skin. Options 2, 3 and 4 do not have white, flaky skin as a characteristic. Melanomas tend to have asymmetry (A), border irregularity (B), color variegation (C), and diameter (D) greater than 6 mm. The ABCD rule can be applied to any skin condition, but malignant melanoma is the most severe and has changes in all 4 of the rules. Restrictive jewelry and clothing are removed immediately from the burn victim to prevent circumferential constriction of the torso and extremities. Examination of the fingers and interference with treatment may require removal of jewelry, but the primary reason is option 2.