Which data indicates to the nurse that a client may be experiencing ineffective coping?
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Solution
Answer: 1
Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.
When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.
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Solution
Answers: 2, 5, and 6.
Anatomical changes to the eye affect the individual’s visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.
When caring for a 3-year-old child, the nurse should provide which toy for this child?
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Solution
Answer: 2.
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.
An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client’s life. With regard to informed consent for the surgical procedure, which of the following is the best action?
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Solution
Answer: 4.
Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.
Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.
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Solution
Answers: 1, 2, 3, and 6.
Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client?
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Solution
Answer: 4.
If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery.
The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response?
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Solution
Answer: 1.
The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat, but it is generally at a bodyweight of 9 kg (20 lb) and an age of 1 year. Options 2, 3, and 4 are incorrect.
The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.
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Solution
Answers: 1, 4, 5, and 6.
Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.
A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?
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Solution
Answer: 1.
Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.
A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.
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Solution
Answers: 2, 5, and 6.
While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.