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Questions and Answers

What type of breathing should be used when feeling short of breath?

Pursed-lip breathing

The nurse should expect a client who is experiencing malnutrition to have _____ hair.

brittle

Which statement indicates understanding of how to handle a hearing aid?

I will make sure the hearing aid is off before inserting it in my ear.

What is the priority intervention when planning discharge for a client with gestational diabetes?

<p>Determine the client's knowledge regarding gestational diabetes.</p> Signup and view all the answers

What dietary instruction should be given to a client with atherosclerosis?

<p>Increase fiber intake to at least 30 g per day.</p> Signup and view all the answers

What instruction should a nurse give to a client with a short-arm plaster cast?

<p>Elevate the wrist above heart level.</p> Signup and view all the answers

Which symptom indicates severe dehydration in an infant?

<p>Absence of tears</p> Signup and view all the answers

What finding should a nurse report in a 2-year-old regarding eye health?

<p>Presence of strabismus</p> Signup and view all the answers

What medication is a risk factor for developing cholecystitis?

<p>Atorvastatin</p> Signup and view all the answers

What precautions should a nurse initiate for a preschooler with pertussis?

<p>Droplet precautions</p> Signup and view all the answers

What medication might be prescribed for a heparin overdose?

<p>Protamine</p> Signup and view all the answers

What instruction should a client with benign prostatic hyperplasia follow?

<p>Void as soon as you feel the urge.</p> Signup and view all the answers

What finding should a nurse expect in a client with primary open-angle glaucoma?

<p>Progressive loss of peripheral vision</p> Signup and view all the answers

Which of the following findings should be expected in left-sided heart failure? (Select all that apply)

<p>Hacking cough</p> Signup and view all the answers

What might a 10-year-old sibling expect after a sibling's death?

<p>Curiosity about what will happen to the client's body</p> Signup and view all the answers

What pain characteristic indicates cholecystitis?

<p>Abdominal pain that radiates to the right shoulder</p> Signup and view all the answers

What medication should be expected for a client with social phobia?

<p>Paroxetine</p> Signup and view all the answers

What should a nurse do for a client with generalized anxiety disorder?

<p>Reframe situations in a positive manner for the client.</p> Signup and view all the answers

What actions should be taken for a client with cellulitis? (Select all that apply)

<p>Administer cefazolin intermittent IV bolus.</p> Signup and view all the answers

What finding indicates a possible small-bowel obstruction?

<p>Visible peristaltic waves in the upper abdomen</p> Signup and view all the answers

What symptom corresponds with hypocalcemia?

<p>Circumoral tingling</p> Signup and view all the answers

What action should a client with hypoglycemia take?

<p>Drink 120 mL (4 oz) of fruit juice.</p> Signup and view all the answers

What indicates understanding of using a peak flow meter?

<p>I will base my peak flow meter score on the best of three attempts.</p> Signup and view all the answers

What instructions should be included for preventing osteoporosis? (Select all that apply)

<p>Reduce excessive caffeine intake.</p> Signup and view all the answers

What should a nurse encourage when teaching a client with a hearing impairment?

<p>Encourage the client to repeat what the nurse has said.</p> Signup and view all the answers

The nurse should rely on the client's nonverbal communications to ensure the client understands the information.

<p>False</p> Signup and view all the answers

What should the nurse do first for a client diagnosed with active tuberculosis and a weight loss of 5.9 kg (13 lb)?

<p>Initiate airborne precautions.</p> Signup and view all the answers

Which instruction should the nurse include for a client postoperative from TURP?

<p>Perform Kegel exercises several times throughout the day.</p> Signup and view all the answers

Which statement indicates a client with COPD understands the teaching?

<p>I should make my abdomen rise with each inhalation.</p> Signup and view all the answers

What reactions to death should a nurse expect from a preschooler?

<p>Believes that their own thoughts can cause death.</p> Signup and view all the answers

What manifestation should the nurse expect in a school-age child with erythema infectiosum?

<p>Facial eruption.</p> Signup and view all the answers

What information should the nurse teach an obese female client about disease management?

<p>Morbid obesity is measured as a BMI over 40.</p> Signup and view all the answers

What is the proper way to care for toenails in older adults with type 1 diabetes?

<p>Trim toenails straight across to prevent ingrown toenails.</p> Signup and view all the answers

What finding should the nurse expect in a client with hyponatremia?

<p>Decreased level of consciousness.</p> Signup and view all the answers

What acid-base imbalance is a client with Cushing's disease at risk for?

<p>Metabolic alkalosis.</p> Signup and view all the answers

What finding indicates a client has diabetic ketoacidosis?

<p>Blood glucose 396 mg/dL.</p> Signup and view all the answers

What should a nurse expect from a client with mild anxiety?

<p>Follows directions.</p> Signup and view all the answers

What should the nurse instruct a client taking finasteride?

<p>You might need to take the medication for several months before seeing any relief.</p> Signup and view all the answers

What finding should the nurse expect in a client with pernicious anemia?

<p>Numbness of hands.</p> Signup and view all the answers

What is an important instruction for a client taking rifampin?

<p>Do not drink alcohol while taking this medication.</p> Signup and view all the answers

What should the nurse expect in a newborn with hypothermia?

<p>Hypoglycemia.</p> Signup and view all the answers

What should the nurse teach a client with hypothyroidism about levothyroxine?

<p>This medication causes adverse effects if the dosage is too high or too low.</p> Signup and view all the answers

What is an adverse effect of warfarin that a nurse should recognize?

<p>Increased menstrual flow.</p> Signup and view all the answers

Which intervention should the nurse include to promote elimination of renal calculi?

<p>Encourage intake of at least 3 L of fluid each day</p> Signup and view all the answers

Which client statement indicates an understanding of postoperative education after a laparoscopic cholecystectomy?

<p>The adhesive bandages on my incision will fall off as the incision heals.</p> Signup and view all the answers

Which intervention should the nurse include to prevent MRSA infection for an immunocompromised client?

<p>Bathe the client with chlorhexidine wipes.</p> Signup and view all the answers

What is a common manifestation of type 1 herpes simplex virus?

<p>Cold sore</p> Signup and view all the answers

Which finding should the nurse expect in a client with Graves' disease?

<p>Exophthalmos</p> Signup and view all the answers

What indicates that the client understands teaching about duloxetine?

<p>It might take several weeks to notice an improvement in my symptoms.</p> Signup and view all the answers

Which client statement shows understanding of treatment with lindane lotion for scabies?

<p>I will wash the lotion off 12 hours after I apply it.</p> Signup and view all the answers

Which finding should the nurse report immediately for a client with appendicitis?

<p>Board-like abdomen</p> Signup and view all the answers

What should the nurse include in teaching for gastrointestinal reflux disease?

<p>Plan to finish eating at least 3 hr before bedtime.</p> Signup and view all the answers

Which statement shows understanding of warfarin teaching?

<p>I should contact my provider if I notice a pink-tinged color to my urine.</p> Signup and view all the answers

Which urinalysis result indicates a continuing infection after treatment with ciprofloxacin?

<p>Positive leukocyte esterase</p> Signup and view all the answers

Which finding indicates a client has accepted loss after a colostomy?

<p>Touches the colostomy stoma when the bag is changed</p> Signup and view all the answers

Which finding in a school-age child suggests peritonitis?

<p>Abdominal distention</p> Signup and view all the answers

Which finding is a priority to report for a client with a peptic ulcer?

<p>Hemoglobin 7.6 mg/dL</p> Signup and view all the answers

Which finding indicates heat exhaustion?

<p>Vomiting</p> Signup and view all the answers

Which food is the best nondairy source of calcium?

<p>Collard greens</p> Signup and view all the answers

Which intervention should be included in the care plan for a postoperative DVT client?

<p>Make sure the client's legs are elevated while in bed.</p> Signup and view all the answers

What is the priority finding to report after an ileostomy placement?

<p>The stoma is purple in color.</p> Signup and view all the answers

Which intervention should be included in the care plan for a preschooler with heart failure?

<p>Offer small, frequent meals based on the child's endurance level.</p> Signup and view all the answers

Which action should the nurse take to treat heat stroke?

<p>Apply ice packs to the client's axillae, neck, groin, and chest.</p> Signup and view all the answers

Which medication should be included in asthma attack teaching?

<p>Albuterol</p> Signup and view all the answers

Where should the ileostomy be located after surgery for ulcerative colitis?

<p>Right side of the abdomen, lateral to, and slightly above the umbilicus.</p> Signup and view all the answers

Which finding should the nurse expect in a child with a blood glucose level of 250 mg/dL?

<p>Fruity breath odor</p> Signup and view all the answers

Which statement shows understanding of metformin teaching?

<p>I will call the doctor if I have muscle pain in my back.</p> Signup and view all the answers

What should the nurse teach a client about atenolol?

<p>You should contact your provider if your pulse rate drops below 60 per minute.</p> Signup and view all the answers

Which action can help prevent pneumonia in older adults?

<p>Wash your hands when you return home from running errands.</p> Signup and view all the answers

Which lactose-free food should the nurse recommend?

<p>Soy milk</p> Signup and view all the answers

What dietary recommendation should the nurse make for a client with hyperlipidemia due to nephrotic syndrome?

<p>Less than 30% of daily calories should come from fat.</p> Signup and view all the answers

What is the pH of the ABG result indicating the client is experiencing?

<p>Alkalosis</p> Signup and view all the answers

What is paresthesia?

<p>Numbness and tingling due to a decrease in calcium ionization.</p> Signup and view all the answers

Which instructions should the nurse include for treating pediculosis capitis? (Select all that apply)

<p>Seal items that are not machine washable in plastic bags for 1 week.</p> Signup and view all the answers

What instruction should the nurse provide to prevent the spread of methicillin-resistant Staphylococcus aureus?

<p>Do not return to football practice until the infection has healed.</p> Signup and view all the answers

What acid-base imbalance does a patient with a pH of 7.28 and HCO3- of 14 mEq/L have?

<p>Metabolic acidosis.</p> Signup and view all the answers

Which herbal supplement can help treat hyperlipidemia?

<p>Garlic.</p> Signup and view all the answers

What should the nurse say to the parent struggling to cope with a terminally ill child?

<p>Let's talk about a few ways you have dealt with stress in the past.</p> Signup and view all the answers

Which finding should the nurse instruct a client who had lithotripsy to report?

<p>Painful urination.</p> Signup and view all the answers

What action should the nurse take for a client with left hemiparesis?

<p>Encourage the client to use wide-grip utensils when eating with the right hand.</p> Signup and view all the answers

Adolescents cope with death better than children of other ages.

<p>False</p> Signup and view all the answers

Which symptom indicates mild hypothermia?

<p>Slurred speech.</p> Signup and view all the answers

It is okay for a client who had cataract surgery to lift a 2-year-old child.

<p>False</p> Signup and view all the answers

What is the priority action for a client experiencing panic-level anxiety?

<p>Protect the client from harm.</p> Signup and view all the answers

What indicates a venous ulcer rather than an arterial ulcer?

<p>Discoloration and edema of the right ankle.</p> Signup and view all the answers

What should a nurse do when a client begins a panic attack?

<p>Remain with the client until manifestations subside.</p> Signup and view all the answers

What acid-base imbalance is indicated by a pH of 7.28 and a PaCO2 of 49 mm Hg?

<p>Respiratory acidosis.</p> Signup and view all the answers

What should be the first action for a traumatic amputation?

<p>Call 911 and examine the amputation site.</p> Signup and view all the answers

What electrolyte imbalance should be suspected in a client taking antacids frequently?

<p>Hypermagnesemia.</p> Signup and view all the answers

What finding requires intervention during preoperative screening for knee arthroplasty?

<p>Coagulation time.</p> Signup and view all the answers

What should the nurse prioritize for a client with respiratory acidosis?

<p>Apply oxygen therapy.</p> Signup and view all the answers

What clinical name should be documented for a client with a fear of open spaces?

<p>Agoraphobia.</p> Signup and view all the answers

What is the best way to maintain bone health for osteoporosis?

<p>Maintain bone health by eating fruits, vegetables, and protein.</p> Signup and view all the answers

What statement indicates understanding of home care for gastroesophageal reflux?

<p>I should add 1 teaspoon of rice cereal to my infant's formula.</p> Signup and view all the answers

What action should a nurse take for a client receiving total parenteral nutrition?

<p>Administer the prescribed regular insulin.</p> Signup and view all the answers

What acid-base imbalance is indicated by a pH of 7.48 and HCO3- of 30 mEq/L?

<p>Metabolic alkalosis.</p> Signup and view all the answers

What finding indicates effective treatment after isotonic IV fluids in severe dehydration?

<p>Brisk skin turgor.</p> Signup and view all the answers

What lab result indicates an adverse reaction to exenatide?

<p>Lipase 185 units/L.</p> Signup and view all the answers

Study Notes

Renal Calculi Care

  • Encourage the intake of at least 3 liters of fluid daily to promote urine production and facilitate calculi elimination.

Postoperative Cholecystectomy Education

  • Inform clients that adhesive bandages will typically fall off in 7 to 10 days as the incision heals.

MRSA Prevention for Immunocompromised Clients

  • Implement bathing with chlorhexidine wipes to reduce the risk of hospital-acquired MRSA infection.

Herpes Simplex Virus Identification

  • Recognize cold sores on the lips as a manifestation of type 1 herpes simplex virus infection.

Graves' Disease Symptoms

  • Expect exophthalmos (protruding eyeballs) as a key symptom associated with Graves' disease, an autoimmune disorder.

Duloxetine for Peripheral Neuropathy

  • Inform clients it may take several weeks to notice symptom improvement with duloxetine.

Scabies Treatment with Lindane Lotion

  • Instruct clients to wash off the lindane lotion after 8 to 12 hours to effectively treat scabies.

Appendicitis Assessment

  • A board-like abdomen is an urgent finding indicating possible peritonitis in appendicitis that requires immediate reporting to the provider.

Gastroesophageal Reflux Disease Management

  • Advise to finish eating at least 3 hours before bedtime to help prevent reflux episodes.

Warfarin Education for Deep-Vein Thrombosis

  • Monitor for signs of blood in urine; contact a provider if pink-tinged urine is noticed while on warfarin.

Urinalysis for Pyelonephritis

  • Positive leukocyte esterase indicates a continuing infection post-treatment of pyelonephritis.

Grief Acceptance Post-Colostomy

  • Touching the colostomy stoma during care indicates acceptance of the body image change related to grief.

Peritonitis in School-Age Children

  • Abdominal distention is a key indicator of peritonitis, requiring timely assessment.

Peptic Ulcer Complications

  • A hemoglobin level of 7.6 mg/dL is a priority finding indicating potential chronic bleeding from a peptic ulcer.

Heat Exhaustion Indicators

  • Recognize vomiting as a common sign of heat exhaustion due to dehydration from excessive sweating.

Calcium Sources for Lactose Intolerance

  • Recommend collard greens as a high-calcium, nondairy food alternative.

Deep-Vein Thrombosis Postoperative Care

  • Elevate legs in bed and use antiembolic stockings to prevent venous insufficiency.

Ileostomy Postoperative Assessment

  • Report a purple-colored stoma immediately as it indicates inadequate blood supply, necessitating urgent intervention.

Pediatric Heart Failure Nutrition

  • Offer small, frequent high-calorie meals based on the child's comfort and endurance levels.

Heat Stroke Treatment

  • Use ice packs on the axillae, neck, groin, and chest to cool a client with heat stroke effectively.

Asthma Management

  • Albuterol, a short-acting beta agonist, should be used during asthma attacks for bronchodilation.

Ileostomy Location

  • Expect an ileostomy to be positioned on the right side of the abdomen, above the umbilicus.

Diabetes Mellitus Signs

  • A blood glucose level of 250 mg/dL may result in fruity breath odor, signaling possible ketoacidosis.

Metformin Side Effects Awareness

  • Instruct clients to contact their provider for muscle pain, which may indicate lactic acidosis, a serious condition.

Atenolol Monitoring

  • Advise clients to contact their provider if their pulse drops below 60 beats per minute while taking atenolol.

Pneumonia Prevention for Older Adults

  • Stress the importance of hand hygiene, particularly washing hands after public exposure to reduce pneumonia risk.

Lactose-Free Dietary Options

  • Soy milk is a beneficial lactose-free alternative for clients with lactose intolerance.

Nephrotic Syndrome Dietary Recommendations

  • Instruct clients to limit fat intake to less than 30% of daily calories to manage hyperlipidemia associated with nephrotic syndrome.

Respiratory Alkalosis Symptoms

  • Expect paresthesias (numbness and tingling) as a common symptom of respiratory alkalosis.

Pediculosis Capitis Treatment

  • Recommend washing all bedding and clothes in hot water to eliminate lice contamination effectively.

MRSA Infection Management for Adolescents

  • Advise against returning to contact sports until the methicillin-resistant Staphylococcus aureus infection has fully healed.

ABG Interpretation for Dehydrated Client

  • Assess renal function and hydration status based on arterial blood gas results indicating acidosis.### Acid-Base Imbalances
  • Metabolic acidosis is indicated by a pH below the expected range, normal or low PaCO2, and low HCO3-. Common cause: diabetic ketoacidosis.
  • Respiratory acidosis occurs with a pH below normal, PaCO2 above normal, and normal or slightly elevated HCO3-. Common causes include opioid use and airway obstruction.
  • Metabolic alkalosis is characterized by a pH above normal, HCO3- above normal, and normal or above normal PaCO2. Common causes: prolonged vomiting, NG suctioning, and excessive antacid use.

Herbal Supplements for Hyperlipidemia

  • Garlic is effective in improving cholesterol levels and reducing plaque buildup in arteries; can also lower blood pressure.

Support for Grieving Parents

  • Encourage parents coping with their child's terminal illness to discuss past stress management techniques, fostering a supportive environment.

Post-Lithotripsy Care

  • Instruct clients to report painful urination immediately, as it may indicate infection or stone recurrence.

Stroke Rehabilitation

  • Encourage the use of wide-grip utensils for clients with hemiparesis to promote independence in eating.

Adolescent Reactions to Death

  • Adolescents may isolate themselves when grieving due to difficulty in communication.

Mild Hypothermia Assessment

  • Slurred speech is a common manifestation of mild hypothermia, along with shivering and decreased coordination.

Cataract Surgery Recovery

  • Clients should be informed that full vision improvement may take 4 to 6 weeks post-surgery, despite immediate visual gains.

Anxiety Management

  • The priority for a client with panic-level anxiety is to protect them from harm. This may involve reducing environmental stressors.

Peripheral Ulcer Assessment

  • Discoloration and edema of the ankle characterize venous ulcers, as opposed to diminished pulses or atrophy which suggest arterial ulcers.

Panic Attack Management

  • Remain with the client during a panic attack to ensure safety and assist with anxiety management techniques.

Opioid-Induced Respiratory Depression

  • Identify respiratory acidosis when ABG shows a low pH and elevated PaCO2. Common causes include opioid administration.

Traumatic Amputation First Aid

  • Call emergency services, control bleeding, keep the extremity elevated, and prepare the amputated part for possible reattachment.
  • Frequent antacid use, especially those containing magnesium, can lead to hypermagnesemia, which presents with hypotension and lethargy.

Preoperative Screening in Clinics

  • Report elevated coagulation times (INR) before procedures to prevent intraoperative bleeding risks.

Effective IV Fluid Therapy in Children

  • Brisk skin turgor after administering isotonic IV fluids indicates successful treatment for severe dehydration.

Monitoring for Diabetic Treatments

  • Elevated lipase levels can indicate pancreatitis, a potential adverse effect of exenatide treatment for type 2 diabetes.

COPD Self-Care Techniques

  • Instruct clients to use pursed-lip breathing to manage dyspnea effectively.

Recognizing Malnutrition

  • Look for brittle hair, indicative of malnutrition, along with other signs such as poor wound healing.

Hearing Aid Use and Care

  • Ensure the hearing aid is turned off before use to prevent loud noises and discomfort during insertion.

Gestational Diabetes Education

  • Assess the client’s knowledge of gestational diabetes as part of the educational process to tailor further teaching effectively.

Atherosclerosis Self-Care

  • Advise increasing daily fiber intake to at least 30 g to assist in lipid elimination and reduce atherosclerosis risk.

Post-Cast Care Instructions

  • Clients should elevate the wrist above the heart level to minimize pain and swelling after applying a plaster cast.

Managing Contact Dermatitis in Children

  • Provide personalized guidance based on the specifics of the child’s condition, focusing on effective disease management strategies.### Pediatric Care Notes
  • Wash child’s exposed clothing in cold water with powder detergent to remove potential irritants.
  • Keep child away from others for 10 days after lesions appear to prevent transmission.
  • Clean affected areas with antibacterial soap every other day to maintain hygiene.
  • Place child in a tepid oatmeal bath for 15 minutes to alleviate itching.

COPD Management

  • Effective treatment with nebulized acetylcysteine is indicated by thin, white mucus, signifying effective mucus thinning and absence of infection.

Gastroenteritis in Infants

  • Expect infant with severe dehydration to show absence of tears, flat anterior fontanel, and a capillary refill time of 2 seconds.

Pediatric Eye Assessment

  • Strabismus, or eye crossing, should be reported if present past 4 months of age to prevent amblyopia.

Gallstones Risk Factors

  • Atorvastatin use raises the risk of gallstones due to increased serum cholesterol levels.

Infectious Disease Precautions

  • For a child with pertussis, initiate droplet precautions to mitigate transmission risk; use surgical masks within close proximity.

Heparin Therapy Monitoring

  • Anticipate prescribing protamine if a client shows signs of heparin overdose, particularly when aPTT levels are elevated.

Benign Prostatic Hyperplasia (BPH) Management

  • Instruct BPH clients to void as soon as they feel the urge to reduce urinary retention risks.

Primary Open-Angle Glaucoma (POAG) Signs

  • Clients with POAG typically experience progressive loss of peripheral vision, indicating the need for visual field testing.

Left-Sided Heart Failure Symptoms

  • Expect symptoms such as nocturia, dyspnea, and a hacking cough, which are common in left-sided heart failure.

Child’s Reaction to Sibling’s Death

  • A 10-year-old sibling may display curiosity about the deceased's body and the funeral process, normalizing their grief experience.

Cholecystitis Presentation

  • Clients with cholecystitis often have abdominal pain that may radiate to the right shoulder, typically triggered by fatty foods.

Social Anxiety Disorder Treatment

  • Paroxetine, an SSRI, is commonly prescribed for managing social anxiety disorder.

Generalized Anxiety Disorder Interventions

  • Reframe situations positively to help clients with generalized anxiety disorder adjust their thought patterns.

Cellulitis Management

  • Elevate the affected area and administer cefazolin IV as part of treatment for lower extremity cellulitis.

Small-Bowel Obstruction Indicators

  • Visible peristaltic waves in the upper abdomen signal a potential small-bowel obstruction.

Hyponatremia Symptoms

  • With hyponatremia, expect decreased level of consciousness as a reaction to cerebral edema.

Hypoglycemia Management for Diabetics

  • Instruct clients experiencing hypoglycemia to consume 120 mL of fruit juice, providing quick relief with carbohydrates.

Peak Flow Meter Use in Asthma

  • Peak flow rates should be recorded based on the best of three attempts for accurate asthma monitoring.

Osteoporosis Prevention

  • Encourage increased dairy intake, weight-bearing exercises, and reduced caffeine use for osteoporosis prevention.

Postoperative TURP Care

  • Observe for multiple red clots in the catheter tubing post-TURP as a sign of potential bleeding, necessitating provider notification.

Osteoarthritis Symptoms

  • Joint pain in osteoarthritis typically improves with rest, particularly early in the disease.

Communication with Hearing Impairments

  • Engage clients with hearing impairments by encouraging them to repeat back information shared to ensure understanding.

Tuberculosis Precautions

  • Initiate airborne precautions immediately for clients diagnosed with active tuberculosis to prevent airborne transmission.

Diabetes Foot Care

  • Instruct diabetic clients to trim toenails straight across to avoid ingrown toenails, reducing infection risks.

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