Hurst Readiness Exam 2 Study Guide with Complete Solution

What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs? 1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone - ANSWER Rationale 4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved. It is not an agent used in the management of preterm labor. An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care? 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails - ANSWER Rationale 1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach. A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain. - ANSWER Rationale 3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 2. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 4. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? 1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics. - ANSWER Rationale 1. Correct: Migraine headaches have a pulsating pain quality, unilateral location, moderate or severe pain intensity, aggravated by or causing avoidance of routine physical activity (walking, climbing stairs). During headache at least one of the following accompanies the headache: nausea and/or vomiting; photophobia and phonophobia. 2. Incorrect: This is seen in tension headaches. Headaches last 30 minutes to 7 days. Pain is mild or moderate in intensity. It is not aggravated by routine physical activity. Nausea/vomiting, photophobia and phonophobia are not common manifestations with tension headaches. These usually start gradually, often in the middle of the day. 3. Incorrect: This is associated with cluster headaches, which are severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes. Symptoms include stabbing pain in one eye with associated rhinorrhea (runny nose) and possible drooping eyelid on the affected side. The headaches tend to occur in "clusters": typically one to three headaches per day (but may be as many as eight) during a cluster period. 4. Incorrect: Overuse of painkillers for headaches, can, ironically, lead to rebound headaches. Culprits include over the counter medications such as aspirin, acetaminophen or ibuprofen, as well as prescription medications. Too much medication can cause the brain to shift into an excited state, triggering more headaches. Also, rebound headaches are a symptom of withdrawal as the level of medicine drops in the bloodstream. Rebound headaches may have associated issues such as difficulty concentrating, irritability and restlessness but does not typically include photophobia or visual disturbances as seen with migraines. The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) - ANSWER Rationale 3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure and that value alone would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL). A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit? 1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools. - ANSWER Rationale 3. Correct: Any acute weight gain or loss is fluid. Weight is the best measurement for fluid loss or gain. Acute weight losses correspond to fluid volume deficits. This client has lost 2.3 kg over a 2 day period, indicating a fluid volume deficit (FVD). 1. Incorrect: Although 10 loose stools would result in fluid loss, the stool count of 10 episodes of diarrhea is an inaccurate measurement. The amount of fluid loss can vary depending on the amount of diarrhea, 10 "episodes" does not indicate how much fluid is lost. 2. Incorrect: Weight gains indicate fluid volume retention and excess. This question asks about fluid volume deficit. Also, it does not take into account the client's intake. Only the output is considered, so output has less meaning without being compared to the intake. 4. Incorrect: Daily I&O is good information to have when assessing fluid status, but the diarrhea stools are an inaccurate measurement. The weight remains the best measurement for indicating a fluid deficit. The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes. - ANSWER Rationale 1., 2., & 3. Correct These clients are stable and require predictable care that can be done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency. Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed generally from autoimmune disorders. Secondary adrenal insufficiency can be caused by such things as abrupt stoppage of corticosteroid medications and surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of the RN. 5. Incorrect: A newly diagnosed client may be unstable and would require assessment, care plan development and teaching for the newly diagnosed diabetic which cannot be performed by the PN. The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days. - ANSWER Rationale 3. Correct: The two year old is exhibiting signs of respiratory difficulty with excessive drooling and a weak cough. Partial airway obstruction is likely and maybe the result of acute epiglottitis in which rapid progression to severe respiratory distress can occur . Airway takes priority over the other clients. 1. Incorrect: The partial amputation would have associated bleeding could be seen next, but airway takes priority. 2. Incorrect: Most fevers in children do not last for long periods and do not have much consequence. Elevated temperature would not take priority over airway. Antipyretics can be given in triage. 4. Incorrect: The migraine is not emergent. Take care of life-threatening illnesses/injuries first. Remember, pain never killed anyone. A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school. - ANSWER Rationale 2. Correct. The best action for the nurse to take is to look up how the procedure is done in the agency by looking it up in the policy and procedure manual. The nurse could then discuss the procedure with an experienced nurse and ask the nurse to observe the new nurse while inserting the feeding tube. 1. Incorrect. This is passive and would not benefit the new nurse to strengthen the skills. The best action would be to look up how to do the procedure, discuss with another nurse, and ask that nurse to observe the insertion of the feeding tube. 3. Incorrect. This is not the best option. The new nurse needs to insert the feeding tube in order to become more proficient with this skill. This option will not help the new nurse gain confidence in nursing skills. 4. Incorrect. Although the new nurse should have the basic knowledge of feeding tube insertion, the nurse should follow agency policy and procedure. It is then best to discuss the procedure with another nurse and ask the nurse to observe the feeding tube insertion since this nurse has never performed the skill. How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth. - ANSWER Rationale 4. Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face. 1. Incorrect: The size of the client's little finger does not determine the size of the oral airway that should be used. This would result in an inappropriate size oropharyngeal airway to be selected. 2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly measure it. In addition, the measurement would not determine the appropriate size oropharyngeal airway to use. 3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would make the oral airway too long. A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery. - ANSWER Rationale 1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures. The tapes are received from sources where reliability of information is provided. This is the most reliable option for providing accurate information. 2. Incorrect: This is not the best option. Some pre-surgical procedure may be difficult to draw or difficult for the client to understand what was drawn. There is no way to know if the client is understanding what the nurse is trying to communicate through the pictures. Client safety could be compromised if decisions are made based on inaccurate perceptions. 3. Incorrect: This is called "Getting by" and may have to be used when the nurse cannot speak the client's language, and there are no interpreters, audiotapes, or written materials available to inform the client in their language. This is not the best option and should be used only if other more reliable means for interpreting are not available. 4. Incorrect: Disadvantages of using ad hoc interpreters include compromising the client's right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate. This may have to be done at times if tapes or other reliable means of interpreting are not available. However, this is not the best option. To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed - ANSWER Rationale 1., 3., 4., & 5. Correct: The primary healthcare provider should be notified of any rhythm changes or report chest pain/discomfort. These could be signs of re-occlusion. Decreased urinary output (UOP) could be due to poor renal perfusion, which can result from decreased cardiac output and shock. Frequent VS and UOP measurements are needed. Flexion should be avoided at the catheter access site to allow time for the clot to stabilize and reduce the risk of bleeding and hematoma formation. The client should avoid lifting the buttocks off the bed because this increases pressure at the insertion site which increases the risk of hematoma formation/bleeding. 2. Incorrect: Assessments are needed more frequently than every 8 hours. Although policies may differ, assessment of the insertion site is usually every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly for 4 hours. More frequent monitoring may be required. During the assessment, the nurse should observe the catheter access site for bleeding or hematoma formation and should assess the peripheral pulses in the affected extremity. rr-772 Question: During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit. - ANSWER Rationale 2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 1. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. The client would be at high risk of developing a urinary tract infection. The catheter cannot be made sterile by the use of alcohol. 3. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. Inserting the now non-sterile catheter puts the client at risk for infection. There is no reason at this time to start antibiotics. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit. SIC-2795 The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client? 1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom. - ANSWER Rationale 1., 2. & 5. Correct: Initially meet the client's dependency needs as required to keep anxiety from escalating. Anything that increases the client's anxiety tends to increase the ritualistic behavior. Positive reinforcement for nonritualistic behavior takes the focus off of the ritual. A lack of attention to ritualistic behaviors can help to decrease the ritual. By creating a regular schedule when the client goes to the bathroom, (where the handwashing ritual occurs most frequently) allows the client a structured but limited time for the ritual. This can help give the client a sense of control of the maladaptive behavior until the client can start setting own limits on the behavior and develop more adaptive coping mechanisms. 3. Incorrect: A structured schedule is needed for this client. If the client is allowed to perform the maladaptive behavior whenever desired, the client will not begin to problem solve ways to limit the ritual nor lessen the anxiety associated with the ritualistic behavior. The set schedule helps the client to develop trust with the nurse, knowing that time will be allowed for the behavior until better coping skills are developed. 4. Incorrect: Sudden and complete elimination of all avenues for dependency would create intense anxiety in the client. This increased anxiety would only serve to increase the ritualistic behavior. When time is not allowed for the ritual, the client fears that something bad is happening and the anxiety escalates. An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider. - ANSWER Rationale 3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention. 1. Incorrect: This response dismisses the client's feelings and may only anger the client further. The response does not address the reason for the client's anger. The statement may be true; however, the client does have the right to request and receive a copy of the medical record. 2. Incorrect: The primary healthcare provider does not have to be contacted, as there should be policies in place to grant the request for a copy of the medical record. Also, telling the client to speak to the healthcare provider would not address the reason for the client's anger. This would dismiss the client's feelings. 4. Incorrect: The client has a right to the medical record. Records may also be requested by other providers with consent of the client. The client's feelings should be addressed and the client should be informed that the medical record will be provided as requested. moc-2331 Question: A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs. - ANSWER Rationale 1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place. pa-1567 Question: A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make? 1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. " - ANSWER Rationale 4. Correct: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 1. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 2. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. 3. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. The problem being presented in the stem is not related to general prevention of neural tube defects. Folic acid would not prevent the harm to the fetus caused by catopril. ppt-1918 Question: The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout. - ANSWER Rationale 2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform. 1. Incorrect. The UAP can do this task as well as the LPN. In order to be most effective with the nurse's time, this task can be delegated to the UAP. 3. Incorrect. The RN with special training can insert a PICC line. The LPN cannot complete this task. 4. Incorrect. The RN must complete this task. The LPN should not initiate PCA morphine. moc-2405 Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients? 1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation. - ANSWER Rationale 4. Correct. A rigid abdomen may indicate bleeding or other causes of peritonitis which takes priority over the other three, more stable clients. This could lead to shock in this client. Conditions requiring immediate treatment include cardiac arrest, anaphylaxis, multiple trauma, shock, poisoning, active labor, drug overdose, severe head trauma, and severe respiratory distress. 1. Incorrect. Although this condition may be uncomfortable and could lead to renal problems if not resolved, it does not take priority over a client who is bleeding. 2. Incorrect. This person is likely experiencing pain, but this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing into the peritoneum. Remember, pain never killed anyone. 3. Incorrect. This client with a corneal laceration would be experiencing pain and needs attention to avoid vision loss. However, this client does not take priority over a client who has peritonitis and may be going into shock from bleeding or third spacing in the peritoneum. Remember, ascites is fluid in the peritoneal cavity. moc-2408 Which factors should the nurse include when teaching a parent about risk factors for otitis media? 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5 - ANSWER Rationale 2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter months. 1. Incorrect: Breast-feeding decreases the incidence of otitis media. Ear infections are more common in children who drink from bottles or sippy cups, especially when lying on their back. 5. Incorrect: Age under 5 is a risk factor. The Eustachian tube is shorter, narrower, and more vulnerable to blockage in the younger children. It also lies more horizontal and does not drain as well as older children and adults. This, along with immature immune systems, puts the younger child at higher risks for otitis media. pa-1561 Which interventions should be included in the plan of care for an adult client with constipation? 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal. - ANSWER Rationale 1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines. 5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal when peristalsis is increased may be helpful; however, if the urge occurs at other times, the client should go to the bathroom at that time to prevent constipation. bcc-1014 The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye. - ANSWER Rationale 4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement. 1. Incorrect: Everting the eyelid and examining for a foreign body are not measures that should be performed before placement of eye shield. You should never attempt to remove a foreign body, so examination would not be needed at this point. 2. Incorrect: Measuring visual acuity is not a priority and is not performed before placement of eye shield. The goal is to protect the eye from further injury and reduce movement of the eye. The shield will help accomplish this goal. 3. Incorrect: Notifying immediately for transfer should not be done before placement of eye shield. The eye should be protected first to reduce further injury. pa-1575 The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently? - ANSWER Rationale 2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. 1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary. 3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe respiratory distress. 4. Incorrect: This question would be appropriate if botulism were suspected in a client. pa-2045 A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium - ANSWER Rationale 4. Correct: Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations. 1. Incorrect: Wernicke's Encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue. 2. Incorrect: Korsakoff's Psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement. 3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia. psi-799 A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse - ANSWER Rationale 3. Correct: Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body. 1. Incorrect: Although the nurse does need to check immunizations, the hints in the stem indicate several problems that should direct the focus to lead poisoning, which is the priority. Immunization should be administered if the child is not on schedule, but consequences of lead poisoning is much more serious. 2. Incorrect: There was nothing in the stem indicating school problems. This would not take priority over lead exposure assessment. 4. Incorrect: Although poverty and poor housing conditions have been identified as environmental factors for potential abuse, the stem of this question does not provide additional cues that would indicate abuse. Assessment for lead poisoning would be the priority in this situation based on the environmental issues identified. SIC-617 An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority - ANSWER Rationale 1. Correct: Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops. 2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity). 3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression. 4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result. A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts. - ANSWER Rationale 3. Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion. 1. Incorrect: Arguing with the client who has delusions only upsets the client and may provoke violence. The client can not understand the logical argument, so the delusional ideas are not dispelled. Also, the argument can interfere with the development of trust. 2. Incorrect: Disagreement may anger the client. The client needs empathy and understanding from the nurse. This is dismissing the client's feelings. The focus should not be on what the nurse thinks. The focus should always be on the client's feelings. 4. Incorrect: In-depth detail of delusions only reinforces the delusion. The nurse should encourage reality based conversation. Interacting about reality is beneficial for the client to move them away from delusional thoughts. An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client? 1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home? - ANSWER Rationale 3. Correct: Suicide assessment should begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation. 1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present. 2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct enough to use in suicide assessment. 4. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or if he has a history of suicide attempts with a gun. The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer. - ANSWER Rationale 2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. Overmedicating the affected eye could reduce the intraocular pressure too much. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye. The changes of the eyelashes (increased length, thickness, pigmentation and number of lashes) are typical with these eye drops and are viewed as a benefit by many clients. The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication. - ANSWER Rationale 1. Correct: Yes, having a pain level of less than 2 is the best goal for pain and the use of a Faces scale, instead of a numerical scale is age appropriate. Sickle cell crisis is extremely painful, and often times, the pain is not completely relieved during the acute stage. 2. Incorrect: The goal should be client centered. This option is a nursing intervention, not a client goal. 3. Incorrect: We are focusing on client response, not limiting pain meds. The goal of a pain crisis should be aimed at reducing the client's pain. 4. Incorrect: Sickle cell crisis is very painful, and pain medication is needed. What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest. - ANSWER Rationale 1., 2., 3., & 4. Correct: A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage. 5. Incorrect: The closed drainage unit should be placed below the level of the client's chest to prevent drainage from flowing backward into the pleural space. A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home? Exhibit: Two story, four bedroom home located in quiet neighborhood. Yard uncluttered. Five steps leading to front door. Sturdy railings on both sides of steps. Interior home clean and well organized. No clutter noted on floors. Multiple throw rugs throughout the downstairs living area. Three bedrooms and two bathrooms located upstairs. One bedroom and one bathroom located downstairs. Client's bedroom is upstairs. Shower stall in downstairs bathroom. 1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply nonskid strips to shower stall. - ANSWER Rationale 1., 2., 3., 5. Correct: The client will have difficulty navigating the steps, both outside and inside the home. The client may trip on throw rugs, and shower stalls are slippery when wet. These things, along with the generalized weakness, makes the client more prone to falls. These interventions will promote safety for the client and decrease the risk of falling. 4. Incorrect: Do not have client rely on furniture for support while walking as they may not provide the consistent support needed to prevent falls. The client should use prescribed assistive devices, which are designed to help prevent falls when used properly. The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM - ANSWER Rationale 2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak. 1. Incorrect: 8:30 AM: Rapid acting insulin will begin peaking in 30 minutes. 3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30 PM this would be a time of worry. 4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting insulin. But you would also be worried about long acting insulin as well. Which starts to peak at 6 hours. The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water. - ANSWER Rationale 3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation