ATI RN CONCEPT-BASED ASSESSMENT LEVEL 3 STUDY GUIDE 2023

ATI RN CONCEPT-BASED ASSESSMENT LEVEL 3 STUDY GUIDE 2023orthostatic hypotension - caused by DEHYDRATION from fluid loos and electrolyte imbalance gross motor skills - physical abilities involving large body movements, such as walking and jumping -EX: 9 month-old infant SHOULD be able to sit UNSUPPORTED for up to 10 MIN Biofeedback - technique that uses audio and visual signals that allow client to reduce muscle tension by gaining control over autonomic physiologic functions. How should phenytoin be administered? Why? - -administered IV bolus at a rate no greater than 50mg/min. -to prevent HYPOTENSION and BRADYCARDIA Manifestations of Parkinson's Disease - tremor, rigidity, BRADYKINESIA, postural instability, depression and other psychiatric changes, dementia, autonomic symptoms, sleep disturbances Non-Hodgkin's Lymphoma - spreads ERRATICALLY through the LYMPHATIC SYSTEM to other organs. It also manifest in PAINLESS, swollen lymph nodes found in the CERVICAL, AXILLLARY, INGUINAL, & FEMORAL areas. Hodgkin's lymphoma - spreads SYSTEMICALLY from one group of lymph nodes to the next group of nodes. Important teachings for client with new prescription of a DIAPHRAGM. - -should remain in place for 6HR FOLLOWING INTERCOURSE -should remove diaphragm NO MORE THAN 24HRS following intercourse -insert diaphragm NO MORE THAN 6HR PRIOR to intercourse -apply about 10ml (2tsp) of SPERMICIDE inside diaphragm prior to intercourse -replace every 2 yrs. -client should be refitted if their weight FLUCTUATE BY 20% -client should be refitted following a ABDOMINAL SURGERY, PELVIC SURGERY, & after each pregnancy A client with fibrocystic breast condition will... - have BREAST PAIN and tenderness as well ass LUMPS usually in the UPPER OUTER QUADRANT of the breast. Expected findings of INTRADUCTAL PAPILLOMA BREAST disorder? - finding will include: -mass in duct and NIPPLE DISCHARGEExpected findings of DUCTAL EXTASIS BREAST DISORDER? - Enlarged axillary nodes and Nipple discharge. Client with COPD will experience... - DIGITAL CLUBBING, which DECREASES arterial O2 levels. tophi with chronic gout - hard, painless nodule on first toe, collection of NA urate crystals due to chronic gout, sometimes bursts with chalky discharge Swan neck deformity - -hyperextension of PIP joint and flexion of DIP joint -late manifestation of RHEUMATOID ARTHRITIS (RA) scleroderma - chronic progressive disease of the skin and internal organs with hardening and shrinking of connective tissue -EXPECT flexion or contracture of joints. (late manifestation) Preferred meal plan for a patient with DIVERTICULITIS - -advance to high-fiber diet. Best source of fiber is a BANANA which yields 3.1g of FIBER. Diverticulitis - inflammation of the diverticula What type of medication can increase a patient's risk for a stroke? - -oral contraceptives B/C this will INCREASE the risk for developing a THROMBOEMBOLISM. A client with HYPOPITUITARISM places the them at risk for developing what type of condition? - -osteoporosis How does light to moderate drinking, (150ml or 5oz of wine each day) affect the client's risk for having a stroke? - it doesn't increase, it actually DECREASES the risk for stroke. What is Ewing Sarcoma? What are expected manifestations of this disease? - -rare malignant tumor arising in bone; most often occurring in children -client will experience pain in the UPPER THIGH as well as LOCALIZED PAIN, SWELLING, & PALPABLE MASS. What are expected findings of Multiple Sclerosis (MS)? - -decrease visual acuity, diplopia, changes in peripheral vision, & nystagmus (repeat of uncontrolled movements). What are expected finding of Amyotrophic Later Sclerosis (ALS)? - -fascifulcations of the face, twitching of the face or tongue.What is Amyotrophic Lateral Sclerosis (ALS)? - Also known an Lou Gherig's disease, ALS is a motor neuron disease which can lead to paralysis. borderline personality disorder - condition marked by extreme instability in mood, identity, and impulse control. -client's with this condition experience SUICIDAL IDEATION & SUBSTANCE ABUSE. narcissistic personality disorder - characterized by a grandiose sense of selfimportance, a preoccupation with fantasies of success or power, and a need for constant attention or admiration or ARROGANCE historonic personality disorder - Impulsive attention seeking behavaior paranoid personality disorder - A personality disorder characterized by a pervasive distrust and suspiciousness of the motives of others without sufficient basis What are some complications of an infant born at or less than 32 weeks? - -apnea -nectrotizing enterocolitis (due to intestinal ischemia and immature immune system) -hypoglycemia -anemia -polycythemia -hypothermia What teachings should the nurse include for a client that underwent a UTERINE ARTERY EMBOLIZATION? - -client may experience flu-like symptoms for 7 days after procedure (embolectomy syndrome) -inform client that a CLOSURE DEVICE or INJECTION that blocks blood flow to the arteries of the FIBROID TUMOR is used -inform client that SEVERE CRAMPING may occur in the first 24hr after the procedure and can last up to 2 weeks. What teachings should the nurse include for a client who has bipolar disorder and has a new prescription of LITHIUM? - -instruct client to take Li with meals to decrease irritation of gastric mucosa. -maintain adequate intake of salt (low Na can lead to Li retention, which can cause Li toxicity). -drink at least 1.5-3L of fluids each day (dehydration can lead to Li toxicity). -expect WEIGHT GAIN (common adverse effect of Li). Autism Spectrum Disorder (ASD) - A disorder characterized by deficits in social relatedness and communication skills that are often accompanied by repetitive, ritualistic behavior. Immunization schedule - Birth: Hep B 2 mos: Hep B, ROTAVIUS, DTaP, Hib, Pneumococcal, Poliovirus4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus 6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus 12 mos: MMR, VAR, Hep A, Influenza, Hib 11-12 YEARS: Tdap, Meningococcal, HPV ADHD (Attention-Deficit Hyperactivity Disorder) - a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity What should the nurse include in her planning for a patient who has ACUTE phase of DIVERTICULITIS? - -Instruct the client to AVOID COUGHING (this can increase the intra-abdominal pressure and cause BOWEL PERFORATION). -ADMINISTER OPIOID analgesics to relieve pain (this can decrease bowel motility) -DO NOT administer EMEMAS or LAXITIVES (this will increase bowel motility and places client at risk for bowel perforation) -client should be NPO or on a clear liquid diet (this will decrease inflammation of the bowels). sickle cell crisis - condition in sickle cell anemia in which the sickled cells interfere with oxygen transport, obstruct capillary blood flow, and cause fever and severe pain in the joints and abdomen. How should the nurse manage care for a client who is experiencing a sickle cell crisis? - -promote fluid intake to prevent dehydration -monitor peripheral capillary refill, pulse O2, and skin temp every 1hr to assess PERFUSION of EXTREMITIES. -EXTEND client's knees to promote perfusion of lower extremities. -elevate head or bed to 30 DEGREES or less to increase perfusion to lower extremities. What are the depressive manifestation of low self-esteem? - -hypersensitivity to criticism -guilt -shame -expression of helplessness -lack of eye contact -pessimistic outcome on life What are the manifestations of spiritual distress? - -express lack of meaning in life -anger -refusing interactions with family -discontinuing spiritual practiceWhat are the manifestations of disturbed thought process? - -impaired problemsolving skills -confusion -difficulty concentration -inappropriate thinking -memory deficits What are the nursing interactions for palliative care of near death clients? - -administer analgesics like morphine SUB Q, SUBLINGUAL, or IV if the client is NOT RESPONSIVE. -APPLY A SOCOPALAMINE TRANSDERMAL PATCH or administer ATROPINE to decrease oral or respiratory secretions. -provide soothing music, use therapeutic touch, and keep noise level low -don place heating pads on extremities What teachings should the nurse include to a client who is preclamtic WITHOUT severe features? - -inform client to use SIDE-LYING POSITION when resting in bed or on couch -monitor blood pressure 2 times a week What teachings should the nurse include to a client who is preclamtic WITH severe features? - -limit fluid intake to PREVENT PULMONARY EDEMA -maintain a DARK, QUIET ENVIRONMENT to avoid stimuli that can cause seizure activity. How should the nurse plan her care to a client with anorexia nervosa? - -observe client for 60 MIN AFTER MEALS -weigh client each day early in the morning after voiding, while wearing the same amount of clothing each day. -EMPHASIZE SOCIAL ASPECTS of eating during mealtimes. What drug may cause an adverse affect when combined with METAMINE? - -SODIUM BICARBONATE (antacid used to treat GI upset) b/c this can increase accumulation of METAMINE which can lead to TOXICITY Teachings for client who has genital herpes - -wear gloves when applying anesthetic ointment -begin ORAL ANTIVIRALS with in 1 day of outbreak -use latex or plyurethane condoms during sexual intercourse. -take a sitz bath 3-4 times a day to help minimize discomfort What meds should the nurse expect to administer for a client who is in post-partum and experiencing hemorrhaging? - -METHYLERGONOUINE (causes contractions of the uterine muscle, which decreases bleeding. Adverse affect is HTN). -MISOPROSTOL (uterotonic med)What meds should the nurse expect to administer for a client who is in PRE-TERM LABOR? - -BETHAMETHASONE (glucocorticoid given to stimulate fetal lung maturity) -TERBUTALINE (tocolytic med which causes relaxation of smooth muscles of the uterine wall). What meds should the nurse expect to administer for a client who is experiencing PREECLAMPSIA? - -MAGNESIUM SULFATE (prevents seizures) -NIFEDIPINE (Ca Channel blocker that relaxes vascular smooth muscles which lower BP). How should a nurse plan care for a client with DEMENTIA? - -USE LARGE CALENDARS that are easy for client to read. -keep client's room dimly lit at night to prevent falls and wandering -speak slowly to client in a NORMAL VOLUME -provide SIMPLE explanation and directions What are some signs/symptoms of OPIOID WITHDRAWAL? - -RHINORRHEA -yawning -tearing -hyperthermia -TACHYPNEA -diaphoresis -enlarged pupils -hyperflexia What are the early manifestations of ALS? - -fascilfulcations of the face -twitching of the tongue -nasal tone of voice leading to DYSARTHRIA (diff speaking) -muscle atrophy of ARMS & HANDS Client teaching for gestation HTN - -gestations HTN will resolve during the 1st week of postpartum but can last for 12 wks. -gestational HTN will begin around 20th week of pregnancy -client will NOT EXPERIENCE vaginal discharge for a few days. What are some contraindications for a client taking ORAL CONTRACEPTIVES? - -patient that is EXPERIENCING a HEADACHE w/aura -client who has a history of DM for 20 yrs w/ vascular disease -client who has liver tumors, HTN, and/or GALL BLADDER disease What are the nursing interventions for a newborn with PDA? - -offer small frequent feedings. -weight infants DAILY at the same time of day using the same scale. -ASSESS APICAL pulse ever 2-4 hours. -elevate infants bed to 30-45 degrees.What should the nurse tell a patient who has experienced sexual violence? - "You are safe here." What are the expected lab values for a client with HELLP SYNDROME? - -WBC <100,000 mm3 -HCT < 33% -SERUM URIC ACID <2.7 OR >7.3 mg/dL (due to decreased renal perfusion) -BUN <10 or >20 mg/dL What are some of the manifestations of DOWN'S SYNDROME? - -DEPRESSED NASAL BRIDGE -small nose -belpharitis (up and outward slant of the eyes) -board, short hands w/stubby fingers -protruding abdomen How should the nurse plan her car to a patient with a gambling disorder? - -ADMINISTER Li, carbamazepine, NALTREXONE, & SSRIs -RECCOMMEND joining a self-help group. aversion therapy - form of behavioral therapy in which an undesirable behavior is paired with an aversive stimulus to reduce the frequency of the behavior Ex: used to treat client who have SEXUAL PARAPHILIAS Disulfiram (Antabuse) - -Used for alcohol aversion therapy. -Clients started on Disulfiram must avoid any form of alcohol or they would develop a severe reaction. -Teach pt to avoid some over-the-counter cough preparations, mouthwash etc. major depressive disorder - -A mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities. -Ex: a client who had a RECENT MOVE ACROSS the country to look for work How to calculate caloric intake for an obese client that is wanting to lose 2lbs of body fat per week and is currently consuming 2500 calories per day? - -know that 1lb of body fat = 3500 calories -multiply 3500 by 2= 7000 (amount of calories client needs to lose per week) -divide 7000 (calories) by 7 (days)= 1000 (calories needed to be subtracted from the current daily caloric intake). -subtract 1000 from 2500= -1500 (calories needed to be consumed DAILY to meet weekly weight loss. Manifestations of major depressive disorder - -Insomnia-Feelings of worthlessness or excessive guilt -Fatigue or loss of energy -Diminished ability to concentrate -Substantial change in appetite or weight -Psychomotor agitation/retardation -Recurrent thoughts of death or suicide bipolar disorder - severe mood swings between major depressive episodes and manic episodes -client may exhibit MANIPULATIVE behavior Nursing Process - Assessment Diagnosis Planning Implementation Evaluation What are the nursing interventions/teaching for a client who has ACUTE GLOMERULONEPHRITIS? - -restrict fluid intake based on previous day's urine output -restrict fluid intake to 500-600 ml above 24hr urine output to prevent FVO, increased BP, and edema -measure weight and BP daily & report any increase in measurement -inform client that URINE can appear SMOKY, REDDISH-BROWN, RUST, or COLA COLOR -inform client to decrease Na intake to prevent FVO What are the nursing interventions/teaching for a client who has DEMENTIA? - -AVOID turning on the television in the evening b/c over-stimulation can disturb client's ability to fall asleep -limit # of choices about clothes to wear ( this can cause frustration and confusion). -place pictures of family on wall -USE PICTURES & GESTURES when giving instructions. Expected lab finding of ACUTE PANCREATITIS - -ELEVATED WBC (norm: 5,000- 10,000 mm3) -DECREASED Ca levels (norm: 9.0-10.5 mg/dL) -INCREASED AMAYLASE (norm is 30-220 units/L) Teachings of taking SILDENAFIL for Erectile Dysfunction (ED). - -instruct client to take med 30-4hr BEFORE sexual intercourse -monitor for DIZZINESS while on this med -take no more than ONCE PER DAY(adverse affect is PRIAPISM, HEARING LOSS, and MI). -explain to client that this drug can cause INSOMNIA rather the drowsiness.What can the nurse expect from a client who is at 35 weeks gestation and is experiencing PLACENTAL ABRUPT ION? - -OLIGURIA, secondary to hypovolemia -fundal height > than 34 cm -UTERINE HYPERTONICITY -HYPOTENSION What med(s) can the nurse expect to administer to a client that has GONORRHEA? - -CEFTRIAXONE (anitbiotic given IM) How should the nurse plan her care for a client who has PTSD? - -stay with client during flashbacks or nightmares to promote safety & sense of security -ASSIST client to IDENTIFY STAGE OF GRIEF -maintain a consistent care-giving staff -have client acknowledge and verbalize their feelings. What discharge teachings should the nurse include to the parents of a newborn who underwent a circumcision? - -do not remove yellow film (will fall off in 2-3 days) -apply diaper loosely -CLEAN PENIS with WARM WATER. -DO NOT use SOAP until 5-6 days after circumcision -report any signs of swelling b/c this could be a manifestation of INFECTION What medication can the nurse expect to administer for a client experiencing INFERTILITY? - -CLOMIPHENE (stimulates growth and release of eggs thus increasing chance of conception). What medication can the nurse expect to administer for a client experiencing GESTATION HTN? - -LABETOALOL (beta blocker that decreases BP) What medication can the nurse expect to administer for a client experiencing UTERINE ATONY? - -MISOPROSTOL (uterine oxytocin that causes contractions of uterine muscle). Manifestations of right-hemispheric stroke - -EUPHORIA -impaired visual-spatial perception -left sided neglect. -CONSTANT SMILING -impaired sense of humor -disorientation to time and place -inability to recognize familiar faces -loss of hearing -impulsiveness -denial of illness -lack of awareness Manifestations of left-hemispheric stroke - -right visual field defects-anxiety -low tolerance of frustration -DIFFICULTY READING -inability to discriminate letters and words -aphasia -memory deficits manifestations of chronic pancreatitis - -Tend to be insidious - Upper abdominal pain - Indigestion - Losing weight without trying - Steatorrhea (FOUL SMELLY BULKY STOOL) - Constipation - Flatulence -destruction of pancreatic islets may lead to diabetes--> resulting in HYPERGLYCEMIA discharge teachings for a patient in pre-term labor - -explain to the client that if contractions occur, DRINK 2-3 glasses of water (dehydration can lead to UTERINE CONTRACTIONS). -to report PAINLESS contractions to provider adverse effects of VALPROIC ACID - -Hepatotoxicity: liver failure (EX: YELLOW SCLERA) -Pancreatitis (check serum amylase) -Teratogenic effects -Indigestion & anorexia -hypothermia adverse effects of phenytoin - anti-epileptic med: -gingival hyperplasia (bleeding gums) -CNS effects -teratrogenic (cleft palate) adverse effects of diazepam - -benzodiazepine to manage status epilepticus -Sedation, psychological and physical dependence Newborn home safety teachings - tell parents of newborn to: -increase temp of room to 79-81 F to prevent hypothermia -not cover newborn with blankets while sleeping (increases risk of SIDS) -set the water heater temp to no more than 120 F (49 C) -place crib AWAY from heating vents, radiators, and portable space heaters. discharge teaching for placenta previa - explain to client that: -if any vaginal bleeding occurs, return to hospital IMMEDIATELY -do not place ANYTHING in their vaginas (no sexual intercourse) -must maintain BED REST only allowed to move for bathroom privileges-CLIENTS SHOULD HAVE CLOSE SUPERVISION and access to transportation manifestations of alcohol withdrawls - -hypertensive with in 12-72 hours of last drink -tachycardia with in 12-72 hours of last drink -disturbed sleep with in 12-72 hours of last drink -have mild TREMORS What increases a client's risk for developing Alzheimer's Disease (AD)? - -PRESENCE of APOLIPOPROTEIN E-4 gene -viruses (herpes zoster) -exposure to toxic metals like Zn or Cu -age (older than 60 yrs), gender (more common in women), and family history phases of battering (power and control wheel) - • Phase 1: Tensions build, Minor battering incidents occur and conflict builds • Phase 2: An explosive beating or otherwise abusive incident • Phase 3: Calm, Honeymoon phase as batterer often promises never to be abusive again teaching for managing fatigue of end-stage COPD - instruct client to: -walk at a self-pace rate & stop when fatigue occurs (rest-walk-rest until 20min is complete) -avoid eating dry foods b/c this will stimulate coughing thus causing fatigue -REST ELBOWS on table during activities -raise height of table to prevent back strain -sleep with head UPRIGHT to avoid DYSPNEA Instructions for epi-pen (auto-injector) - -carry pen in CLEAR PLASTIC CASE the manufacturer provides -use injector pen REGARDLESS OF SEVERITY of manifestations -inject epi-pen med THROUGH CLOTHING -expect medication to REMAIN CLEAR and not cloudy Instructions for epi-pen auto-injection for client with severe BEE ALLERGY - -inject medication IM into OUTER THIGH -hold for 10 sec, then massage injected area for 10 secs -monitor for adverse reactions like: NERVOUSNESS, PALPITATIONS, INCREASED PR, SWEATING, DIZZINESS, or HA. -Give a 2nd injection if 1st FAILS TO ENTIRELY REVERSE the reaction -store extra unused syringes AT ROOM TEMP. What indications shown by a client with OCD demonstrate that his/her therapy has been effective? - -client indicates that hey are more SOCIALLY INTERACTIVE -use of THOUGHT-STOPPING techniques -adhering to activity schedule -expect client to gradually spend less time completing ritualistic behaviorsdietary management of HYPEREMISIS GRAVIDUM - -encourage dairy products b/c they mie be better tolerated. -consume foods at cold temps -avoid empty stomach by eating EVERY 2 HRS -consume SWEET FOODS FIRST, then protein-rich foods. How should the nurse provide safety for a newborn diagnosed with HYPERBILIRUBINEMIA and is undergoing PHOTOTHERAPY? - -apply opaque eyeshield on newborn -expose as much as the skin as possible this includes the scalp and trunk of the body. Teachings about disease management for client who has Parkinson's Disease - Instruct client to: -eat HIGH CALORIE MEALS which are HIGH in PROTEIN -schedule appointment LATER IN THE DAY -take meds at SAME TIME EACH DAY -instruct client to STAND UP STRAIGHT and look FORWARD Teachings on how to use bulb syringe on newborns - -COMPRESS the bulb FIRST, then insert syringe tip -SUCTION THE MOUTH FIRST, then each nare -INSERT tip of syringe on SIDE OF THE MOUTH. -DISCONTINUE suctioning when newborn's cry sounds are CLEAR. expected findings for client who has MELANOMA - -irregular shaped, colored papule with various colors expected findings for client who has ACTINIC KERATOSIS - -dry, scaly macule (malignant and occur on the UPPER BODY). expected findings for client who has SQUAMOUS CELL CARCINOMA - -nodular lesion with ulceration (malignant and occurs on SUN-EXPOSED areas of the UPPER BODY). expected findings for client who has BASAL CELL CARCINOMA - -pearly papule w/ waxy border (malignant and can occur on sun-exposed are of the BODY education planning about bullying - -children who are victims of bullying have an increased risk for depression, and more likely to attempt suicide. -victims of bullying behavior are at an increased risk for low self-esteem, feelings of insecurity, depression, and loneliness. client teachings of Pelvic Inflammation Disease (PID) - instruct client to: -check temp 2x day -avoid sexual activity until antibiotic therapy is complete-restrict ambulation and recline in the SEMI-FOWLER's position -apply HEAT therapy to lower abdomen and back to relieve discomfort Pancreatic enzyme replacement therapy teachings - Instruct client to: -take PANCRELIPASE CAPSULE after an antacid or H2 blocker med (decreases gastric pH). -capsule can be opened and mixed with APPLESAUCE or other ACIDIC FOODS. -TAKE HALF THE MED dose rx whenever having a snack -take capsule BEFORE or WITH EACH MEAL and to drink a glass of H2O. diagnostic criteria for gambling disorder - -clients asks others for money to compensate for gambling losses -gambling is done when client is feeling DISTRESSED over past 12 months. -client had made REPEATED but UNSUCCESSFUL attempts at controlling, cutting back, or stopping addictive behavior OVER PAST 12 MONTHS. -client experiences need to INCREASE AMOUNT of money gambled each week. examples of tactile distractions for client who is end-stage cancer. - apply warm compress Penile Implant Teaching - -VACUUM DEVICE uses NEG pressure to draw blood into the penis -VACUUM CONSTRICTION device uses a rubber ring at the base of penis to maintain erection. -implant can be DEFLATED by pushing button in the SCROTUM. Teachings of Adalimumab (Humira) - treats arthritis -check solution is clear with no particulate matter through the prefilled window. -administer EVERY OTHER WEEK for a client who has RA -HAVE A TB SKIN TEST before 1st dose. If patient has TB this can cause a flare up. -Administer medication SUBQ tissuse of THIGH or ABDOMINAL area. Nursing responses to a client with SCHIZOPHRENIA - "I understand that you believe the government is here, but I don't see any evidence of this." Manifestations of GRAFT VERSUS HOST DISEASE (GVHD) - -diffuse rash -inflammation of mucosa of the eyes -abdominal pain How would the nurse INCREASE cerebral perfusion for a patient who had a stroke? - -position client's head to MIDLINE POSITION -lower head of bed to <25 deg elevation -avoid flexing client's hips -avoid suctioning and DO NOT ENCOURAGE client to and symptoms of PTSD - anxiety, intense fear, flashbacks, irritability, difficulty concentrating, sleep disturbances, and HYPERVIGILENCE Manifestations of elder neglect - -sunken eyes (sign of dehydration) -malnutrition -contractors -excessive body odor Nursing PRIORITY for patient experiencing ECLAMPSIA - -keep clients head to one side Nursing PRIORITY for patient experiencing POST-PARTUM DEPRESSION - -determine if client plans to harm self Manifestations of POST-PARTUM DEPRESSION - -fatigue -restlessness -insomnia -episodes of crying -emotional liability -thoughts of harming oneself or new born Client teachings of PREVENTING sickle cell crisis - -contact provider at 1st indication of illness or infection -engage in LOW-IMPACT exercise 3x week -AVOID both EXTREME hot and cold temps. -drink at least 3-4L (100-135oz) of fluids daily Nursing PRIORITYs for client in POST-PARTUM experiencing VAGINAL BLEEDING - -MASSAGE CLIENT'S FUNDUS Manifestations of ACUTE COCAINE TOXICITY - -pupil dilation -HTN due to vasoconstriction -Agitation, dizziness, and TREMOR -hyperthermia Teachings of child with Juvenile Idiopathic Arthritis (JIA) - -offer child high-protein, high fiber foods -participate in PHYSICAL ACTIVITIES like bicycle riding, swimming, and throwing/kicking ball -DISCOURAGE NAPS during daytime (this will increase joint stiffness making it harder to sleep). -warm baths/showers can help alleviate joint stiffness and decrease pain Juvenile Idiopathic Arthritis (JIA) - Affects children (onset before age 10). Persistent joint swelling (synovial thickening, accumulation of synovial fluid)Nonsurgical treatment for MELANOMA - -targeted therapy (oral medication of VEMURAFENIB) Nonsurgical treatment for MULTIPLE ACTINIC KERATOSIS - -topical chemotherapy (for superficial basal cell carcinoma) Nonsurgical treatment for PROSTATE CANCER - -brachytherapy Nonsurgical treatment of Large, deeply invasive basal cell tumors - -radiation therapy. Medication for alcohol use disorder - NALTREXONE (can also be used to treat opioid use disorder) meds for nicotine withdrawal - 1. buproprion (also can be used for OPIOID WITHDRAWL) 2. nicotine replacement therapy such as nicotine gum, or patch Meds for opioid withrawal support (detox) - Methadone, Clonidine, Subutrex What lab findings should the nurse report to the provider for a client taking Li for a bipolar disorder? - -WBC > 10,000 MM3 (this can cause leukocytosis) -BUN level outside normal ranges (10-20 mg/dL) -Na level outside normal ranges (136-145 mEq/L) -K level outside normal ranges (3.5-5.0 mEq/L) What lab findings are expected for a child who has ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS? - -Increase creatinine -NEG urine culture -Increase specific gravity -Increase BUN The child with Down syndrome should be evaluated for which condition before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots) - C. Atlantoaxial instability - Children with Down syndrome are at risk for atlantoaxial instability. Before participating in sports that put stress on the head and neck, a radiologic examination should be done. Child with Down Syndrome delayed development - -nurse should ensure the child is enrolled in an early stimulation program which provides PHYSICAL THERAPY to develop motor skills. manifestations of increased ICP - -decreased LOC-vomiting (often projectile) -rising bp -increasing pulse pressure -bradycardia -papilledema -fixed and dilating pupils -posturing (decorticate and decerebrate) -HTN -Cheyne-stokes respirations -wide pulse pressure manifestations of acute glaucoma - -headache -eye pain -rapid onset of elevated IOP -vision alterations -severe pain -photophobia manifestations of DKA - dehydration, eyeballs soft and sunken eyes, ab pain, anorexia, KUSSMAUL RESPIRATIONS, fruity breath What nursing interventions should take priority on a client with placenta previa at 36 weeks gestation? - -initiate large-bore IV access Education for preventing child-hood obesity - -avoid using foods as a reward for good behavior -have healthy foods like fruits and veggies available for snacking -limit television watching to 2hr or less each day -avoid offering juice drinks (high sugar content) positive symptoms of schizophrenia - Delusions of reference, delusions of persecution, delusions of grandeur, thought broadcasting, though insertion -magical thinking -auditory hallucinations -clang association disorganized thought, disorganized behavior, catatonia negative symptoms of schizophrenia - -disturbance of affect -blunting (severe reduction in the intensity of affect expression) -flat affect -inappropriate affect (might laugh hysterically while describing someones death)-emotional ambivalence nursing priority for patient with WILMs Tumor - -avoid palpation of abdomen to avoid tumor rupture What is Wilm's tumor? - Renal tumor of embryonal origin that is most commonly seen in children 2-5yrs Assoc w/ Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia, visceromegaly), NF, and WAGR syndrome (Wilms' Aniridia, Genitourinary abnormalities, mental retardation) Nursing intervention for child born at 33wks and is 2 days old - -position newborn SIDE-LYING or Prone while in nursery. -bathe child in PLAIN WATER ONLY -initiate skin-to-skin contact regardless of age or weight of newborn -lights should be dimmed during the night and at intervals during the day intimate partner violence teaching - -nurses priority is to provide safety and develop a safety plan. Teaching for minimizing behavioral problems with client who has Alzheimer's disease (AD) - -briefly leave the room when client becomes agitated -use a soft, calm tone of voice -avoid crowds of people when taking client on outings. manifestations of prenatal complications - -swelling of finders, face, and sacral area (these are hypertensive conditions like PREECLAMPSIA) PYROSIS - heartburn; burning sensation in upper abdomen due to reflux of gastric acid leukorrhea - a profuse, whitish mucus discharge from the uterus and vagina Nursing actions for client with bipolar disorder experiencing mania - -give client short, firm direction when communicating -encourage frequent rest periods during the day -offer client high-fiber foods and extra fluids -supervise client and give step-by-step directions. risk factors for postpartum hemorrhage - usual suspects plus: -grand multiparitiy multiple gestation, large infant, polyhydraminos dysfunctional labor, oxytocin induction or augmentation VBAC, general anesthesiatherapeutic response lab values for client with ANOREXIA NERVOSA - -BUN 18mg/dL (norm: 10-20 mg/dL) -hematocrit 40% (norm: 42-52% males; 37-47% female) -Na 138 mEq/dL (norm: 136-145 mEq/dL -K 3.7 (norm: 3.5-5.0 mEq/dL) Nursing action for client receiving IV OXYTOCIN and FHR shows VARIABLE DECELERATIONS - -administer O2 at 10 L/min via nonrebreather -reposition client to relieve compression to umbilical chord. A nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following ndings should the nurse report to the provider? A. Behavioral changes B. Client report of headache C. Urine output 40 mL/hr D. Client report of nausea E. Increased urine specfic gravity - A. Behavioral changes B. Client report of headache D. Client report of nausea A nurse is teaching a female adult client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to have a mammogram every 2 years beginning at age 45." B. "I should have a colonoscopy every 15 years beginning at age 60." C."I will need to have an annual breast examination every year after 40." D."I should have a fecal occult test done every 3 years." - C."I will need to have an annual breast examination every year after 40." A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Have the client keep a food diary. B. Encourage tooth brushing before and after meals. C. Assess laboratory test report of ferritin. D. Monitor for changes in mental status. E. Explain that fluid intake should occur between meals. - A. Have the client keep a food diary. B. Encourage tooth brushing before and after meals. C. Assess laboratory test report of ferritin. E. Explain that fluid intake should occur between meals. A nurse in an oncology clinic is reviewing the health record of a client who had surgery to stage ovarian cancer. The nurse reviews the following diagnostic notation on thepathology report: T2-N3-MX. Which of the following is an expected finding that supports this diagnosis? A. The tumor is 4 cm in size involving the ovary and adjacent tissues. B. No lymph nodes contain cancer cells. C. The tumor is receptive to current medication therapy. D. The cancer has metastasized to other areas in the body - A. The tumor is 4 cm in size involving the ovary and adjacent tissues. A nurse in a clinic is caring for a client who has suspected uterine cancer. Which of the following assessment techniques should the nurse anticipate the provider will perform on this client? A. Bimanual pelvic examination B. Papanicolaou (Pap) test with cultures C. Digital rectal examination D. Percussion of the upper abdominal quadrants for tympany - A. Bimanual pelvic examination A nurse is completing preprocedure teaching for a client who will undergo nuclear imaging for suspected cancer. Which of the following is an appropriate statement by the nurse? A. "The presence of a liver enzyme will be identified." B. "You will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." D. "The tumor will be aspirated." - B. "You will be given an injection of a radioactive substance." A nurse is reviewing preoperative teaching with a client who will undergo a shave biopsy for suspected cancer. Which of the following statements by the client indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained." - A. INCORRECT: A bone marrow aspiration is a type of needle biopsy. B. INCORRECT: A sentinel node biopsy involves excision of a lymph node. C. INCORRECT: A needle biopsy involves aspiration of a tumor for fluid and tissue sampling. D. CORRECT: A shave biopsy is a sampling of the outer skin layer using a scalpel or razor blade. NCLEX® Connection: Physiological Adaptations, Illness Management A nurse is planning care for a client who will undergo genetic testing for suspected cancer. Which of the following interventions should be included in the plan of care? A. Obtain a signed informed consent form. B. Withhold all medications prior to the procedure.C. Verify the prescription for a tumor marker assay. D. Ensure the client is placed in a recovery position after testing. - A. CORRECT: A signed informed consent form should be obtained prior to the procedure. B. INCORRECT: Medication does not affect the results of genetic testing. C. INCORRECT: A tumor marker assay is a laboratory test to identify the presence of specific body proteins in blood, body secretions and tissue and is not a component of genetic testing. D. INCORRECT: Genetic testing involves collection of blood or saliva and a recovery positioning is not required following testing. A nurse is planning care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling. B. Administer epoetin alfa as prescribed. C. Place the client in a private room. D. Have the client use an oral topical anesthetic before meals - A. CORRECT: The nurse should implement bleeding precautions for the client who has thrombocytopenia. B. Epoetin alfa is administered to the client who has anemia. C. The client who has neutropenia is placed in a private room. D. A topical oral anesthetic is used for the client who has mucositis. A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? A. Use a glycerin-soaked swab to clean the client's teeth. B. Encourage increased intake of citrus fruit juices. C. Obtain a culture of the lesions. D. Provide an alcohol-based mouthwash for oral hygiene. - A. Glycerin-based swabs should be avoided when providing oral hygiene to a client who has mucositis. B. Acidic foods should be discouraged for a client who has oral mucositis. C. CORRECT: The nurse should obtain a culture of the oral lesions to identify pathogens and determine appropriate treatment. D. Nonalcoholic mouthwashes are recommended for a client who has mucositis. A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the planof care? (Select all that apply.) A. Encourage a high-fiber diet. B. Remove plants from the room. C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet. - A. There is no benefit to a high-fiber diet for a client who has neutropenia. B. CORRECT: Neutropenic precautions include the client not having contact with flowers and plants due to the presence of surface infectious agents in the water and soil. C. CORRECT: Neutropenic precautions include having the client wear a mask when leaving the room to reduce the incidence of infection. D. CORRECT: Neutropenic precautions include having equipment available that is only for use in caring for the client to reduce the incidence of infection. E. CORRECT: A client who has neutropenia should avoid consuming raw foods due to the presence of surface infectious agents on peeling and rind. A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "Your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C."Try eating several small meals throughout the day." D."Increase your intake of red meat as tolerated." - A. Nausea usually occurs to the same extent with each session of chemotherapy. B. Cold foods are better tolerated than warm or hot foods because odors from heated foods can induce nausea. C. CORRECT: Several small meals a day are usually better tolerated by the client who has nausea. D. Red meat is not tolerated well by the client undergoing chemotherapy because the taste of meat is frequently altered and unpalatable. A nurse is caring for a client who has cervical cancer and is scheduled for brachytherapy. Which of the following actions should the nurse take? (Select all that apply.) A. Permit visitors to stay with the client 30 min at a time. B. Place the client on bed rest. C. Insert an indwelling urinary catheter. D. Administer fiber laxatives.E. Dispose soiled linens in hamper outside client's room. - A. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. Visitors should remain for no more than 30 min at a time and maintain a distance of at least 6 ft. B. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. Bed rest is needed to prevent displacement of the implant. C. CORRECT: The client who has cervical cancer will have a vaginal radiation implant. A catheter is needed to prevent displacement of the implant during ambulation. D. Fiber laxatives, which stimulate bowel movements, are not used to prevent displacing the vaginal radiation implant. E. The nurse should dispose all the client's linens in a metal container inside the client's room due to the exposure of radiation. A nurse is caring for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. Plan for the client to take rest periods throughout the day. B. Encourage the client to cough, turn, and deep breath every 2 hr. C. Assess temperature every 4 hr. D. Monitor platelet counts. - A. The nurse should offer the client rest periods throughout the day. However, another action is the priority. B. The nurse should encourage the client to cough, turn and deep breathe every 2 hr. However, another action is the priority. C. The nurse should assess the client's temperature every 4 hr. However, another action is the priority. D. CORRECT: The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to initiate bleeding precautions, such monitoring platelet count. A nurse is reviewing the health record of a client who has suspected ovarian cancer. Which of the following findings supports this diagnosis? (Select all that apply.) A. Previous treatment for endometriosis B. Family history of colon cancer C. First pregnancy at age 24 D. Report of scant menses E. Use of oral contraceptives for 10 years - A. CORRECT: Endometriosis is a risk factor for ovarian cancer. B. CORRECT: A family history of breast, ovarian, or colon cancer is a risk factor for ovarian cancer. C. A first pregnancy after 30 years of age or nulliparity is a risk factor for ovarian cancer. D. Dysmenorrhea or heavy bleeding is a risk factor for ovarian cancer. E. Birth control pills offer protection against ovarian cancer.A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A. Urine specific gravity B. Blood glucose C. Serum amylase D. D-dimer - A. Alterations in urine specific gravity following a liver lobectomy are not expected. B. CORRECT: Blood glucose should be monitored during the first 24 to 48 hr following a liver lobectomy due to decreased gluconeogenesis and stress to the liver from surgery. C. Alterations in serum amylase following a liver lobectomy are not expected. D. Alterations in the D-dimer following a liver lobectomy are not expected. A nurse is providing teaching about colon cancer to a group of women 45 to 65 years of age. Which of the following statements should the nurse include in the teaching? A. "Colonoscopies for individuals with no family history of cancer should begin at age 40." B. "A sigmoidoscopy is recommended every 5 years beginning at age 60." C."Fecal occult blood tests should be done annually beginning at age 50." D."An endoscopy provides a definitive diagnosis of colon cancer." - A. A colonoscopy is recommended every 10 years beginning at age 50 for a client who has no family history of cancer. B. A sigmoidoscopy is recommended every 5 years beginning at age 50. C. CORRECT: Fecal occult blood tests should be done annually by clients ages 50 to 75. D. A biopsy performed during an endoscopic procedure confirms this diagnosis. A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant melanoma? (Select all that apply.) A. Diffuse vesicles B. Uniformly colored papule C. Area with asymmetric borders D. Rough, scaly patch E. Irregular colored mole - A. Diffuse vesicles are consistent with an allergic reaction. B. A uniformly colored papule is consistent with a birthmark or skin injury. C. CORRECT: A lesion with asymmetric borders is considered suspicious for a melanoma. D. A rough, scaly patch is consistent with skin irritation due to friction. E. CORRECT: A lack of uniformity of pigmentation of a mole is considered suspicious for a melanoma. A nurse is caring for a client who has chronic cancer pain and has a permanent epidural catheter for administration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of the following findings? (Select all that apply.)A.Respiratory depression B.Hypotension C.Sedation D.Muscle spasticity E.Sensory blockage - A.Respiratory depression B.Hypotension C.Sedation E.Sensory blockage A nurse is caring for a client who will undergo a neurolytic ablation. The client asks the nurse the reason for this procedure. Which of the following responses should the nurse make? A."It attempts to provide permanent pain relief." B."It treats adverse effects of your pain medication." C."It treats decreases in immunity." D."It treats decreases in cells that stop bleeding." - A."It attempts to provide permanent pain relief." A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse take? A.) Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin. B.) Apply alcohol to the client's skin before attaching the electrodes from the TENS unit. C.) Attach the electrodes from the TENS unit over painful incisions or skin damage. D.) Avoid other pain medications when using the TENS unit. E.) Apply cold to the skin where electrodes are applied. - A.) Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin. A nurse is planning care for a client who has cancer and will undergo cryoanalgesia. Which of the following interventions should the nurse include in the plan of care? A.) Monitor oxygen saturation during the procedure. B.) Instruct the client to apply heat to the insertion site. C.) Assess for irritation of the mucous membranes in the mouth following the procedure. D.) Evaluate bladder control after the procedure. - D.) Evaluate bladder control after the procedure A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids - B. Loss of cognitive function A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? ( Select all that apply). A. Areas of parethesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia - A. Areas of parethesia B. Involuntary eye movements E. Ataxia A nurse is teaching a client who has multiple sclerosis and a new prescription for BACLOFEN. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color." - D. "This medication may cause your skin to appear yellow in color." A nurse is admitting a client who has multiple myeloma and a WBC count of 2,200/mm3. Which of the following foods should the nurse prohibit the family members from bringing to the client? A. Fried chicken from a fast food restaurant B. A case of canned nutritional supplements C. A factory-sealed box of chocolates D. A fresh fruit basket - D. A fresh fruit basket A nurse on the medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 ,g/dL B. Client who reports right calf pain and shortness of breath. C. Client who has blood on a pressure dressing in the femoral area following a cardiac catherterization. D. Client who had dark red coloration of left toes and absent pedal pulse. - B. Client who reports right calf pain and shortness of breath. A nurse is caring fora client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomitingB. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids. - B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. E. Infuse IV fluids. A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids. - A. Remove wet clothing. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids. A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Heat-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head. - A. Heat-tilt, chin-lift A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation B. Prepare for transcutaneous pacing. C. Administer IV epinepherine D. Elevate the client's lower extremities - C. Administer IV epinepherine A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid (Nydrazid) 250 mg PO daily, rifampin (Rifadin) 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol (Myambutol) 1 mg PO daily. Which of the following client statements indicate understanding of the teaching? Select all that apply. A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens."E. "I don't need to worry where I go once I start taking my medications." - B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol (Myambutol)? A. "Your urine may turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily." - C. "Watch for any changes in vision." A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times." - B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. "You may notice yellowing of your skin." B. "You may experience pain in your joints." C. "You may notice tingling of your hands." D. "You may experience a loss of appetite." - C. "You may notice tingling of your hands." A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching? Select all that apply. A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum - A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory tests should the nurse expect to be elevated? (Select all that apply.) A. HematocritB. Erythrocyte sedimentation rate C. WBC D. Folic acid E. Albumin - A. Hematocrit is decreased as a result of chronic blood loss. B. CORRECT: Increased erythrocyte sedimentation rate is a finding in a client who has Crohn's disease as a result of inflammation. C. CORRECT: Increased WBC is a finding in a client who has Crohn's disease. D. A decrease in folic acid level is indicative of malabsorption due to Crohn's disease. E. A decrease in serum albumin is indicative of malabsorption due to Crohn's disease. A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority? A. Client reports difficulty sleeping. B. The client's urine is positive for glucose. C. Client reports having an elevated body temperature. D. Client reports gaining 4 lb in the last 6 months. - A. The client is at risk for sleep deprivation because prednisone can cause anxiety and insomnia. However, another finding is the priority. B. The client is at risk for hyperglycemia because prednisone can cause glucose intolerance. However, another finding is the priority. C. CORRECT: The greatest risk to the client is infection because prednisone can cause immunosuppression. Therefore, the nurse should identify indications of an infection, such as an elevated body temperature, as the priority finding. D. The client is at risk for weight gain because prednisone can cause fluid retention. However, another finding is the priority. A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? A. "Take the medication 2 hr after eating." B. "Discontinue this medication if your skin turns yellow‐orange." C."Notify the provider if you experience a sore throat." D."Expect your stools to turn black." - A. Sulfasalazine should be taken right after meals and with a full glass of water to reduce gastric upset and prevent crystalluria. B. yellow‐orange coloring of the skin and urine is a harmless effect of sulfasalazine. C. CORRECT: Sulfasalazine can cause blood dyscrasias. The client should monitor and report any manifestations of infection, such as a sore throat. D. Sulfasalazine can cause thrombocytopenia and bleeding. Black stools are a manifestation of gastrointestinal bleeding, and the client should report this to the provider. A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie‐dense foods. B. Drink canned protein supplements. C. Increase intake of high fiber foods.D. Take a bulk‐forming laxative daily. - A. A high‐protein diet is recommended for the client who has Crohn's disease. B. CORRECT: A high‐protein diet is recommended for the client who has Crohn's disease. Canned protein supplements are encouraged. C. A low‐fiber diet is recommended for the client who has Crohn's disease to reduce inflammation. D. Bulk‐forming laxatives are recommended for the client who has diverticulitis. A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A. "I will plan to limit fiber in my diet." B. "I will restrict fluid intake during meals." C."I will switch to black tea instead of drinking coffee." D."I will try to eat three moderate to large meals a day." - A. CORRECT: A low‐fiber diet is recommended for the client who has ulcerative colitis to reduce inflammation. B. A client who has dumping syndrome should avoid fluids with meals. C. Caffeine can increase diarrhea and cramping. The client should avoid caffeinated beverages, such as black tea. D. Small, frequent meals are recommended for the client who has ulcerative colitis. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply.) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN - A. Positive ANA titer C. 2+ urine protein E. Elevated BUN A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 min in the tanning bed." B. " I will apply powder to any skin rash." C. "I should use a mild hair shampoo." D. "I will inspect my skin once a month for rashes." - C. "I should use a mild hair shampoo." A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivationD. Depression E. Cardiovascular disease - A. Diuretic use B. Obesity E. Cardiovascular disease A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? A. weight gain B. Petechiae on thighs C. systolic murmur D. Alopecia - D. Alopecia A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feelings of heat in the fingers. - B. Pallor of toes with cold exposure A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply). A. Recent influenza B. Decreased range of motion C. Hypersalivation D. Increased blood pressure E. Pain at rest - A. Recent influenza B. Decreased range of motion E. Pain at rest A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A. "You can experience morning stiffness when you get out of bed." B. "You can experience abdominal pain." C. "You can experience weight gain." D. "You can experience low blood sugar." - A. "You can experience morning stiffness when you get out of bed." A nurse is caring fora client who has RA. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) A. Urinalysis B. Erythrocte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. WBC count - B. Erythrocte sedimentation rate (ESR)D. Antinuclear antibody (ANA) titer E. WBC count A nurse is assessing a client who reports severe HA and a stiff neck. The nurse's assessment reveals positive Kernig's sign. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights - B. Implement droplet precautions A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (select all that apply) A. Place client in a supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee - A. Place client in supine position C. Place hand's behind client's neck D. Bend client's head toward chest A nurse is planning care for a client who has meningitis and is at risk for increased ICP. Which of the following actions should the nurse plan to take? (select all that apply) A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for pain D. Turn off room lights and television E. Monitor for impaired extra-ocular movements F. Encourage the client to cough frequently - A. Implement seizure precautions D. Turn off room lights and television E. Monitor for impaired extra-ocular movements A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (select all that apply) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat - B. Provide an emesis basin at bedside C. Administer antipyretic medication D. Perform a skin assessmentA nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age. - C. The vaccine is recommended for adolescents before starting college. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client. - A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the floor to prevent falling. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. INCORRECT: The nurse should not restrain the client, which may cause an injury or more seizure activity. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Prov