Evolve: Physiological Adaptation – Flashcards
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An older client experiences urinary frequency and nocturia. While ambulating, the client develops severe back pain and is found to have a vertebral compression fracture. When planning care, the nurse will focus interventions on which type of fracture? Collapse of vertebral bodies
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Osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting. Bones, not the spinal cord, demineralize in osteoporosis. Wearing and tearing of the spinous processes occur in osteoarthritis. The spinal cord does not bulge; the nucleus pulposus bulges toward the spinal cord. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."
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While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition? Decreased activity of sebaceous glands
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Dryness and uneven skin color are caused by a decrease in the activity of sebaceous glands. Wrinkling and sagging are due to a decrease in subcutaneous fat. Dry and flaking skin are due to a decrease in extracellular water. The diminished rate of wound healing is due to a decrease in proliferation capacity.
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A nurse is assessing an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). For what clinical finding associated with this disorder should the nurse assess the infant? Palpable mass in the epigastric area to the right of the umbilicus
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A typical sign of HPS is a mass caused by hypertrophy of the circular muscle of the pylorus. The visible peristaltic waves move from left to right across the epigastric area, not the lower abdomen. There is obvious discomfort because of hunger, but there is no pain or tenderness caused by the hypertrophy. Abdominal distention is not present in HPS; little food reaches the intestines because of the gastric obstruction.
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A nurse is assessing a client who presents with a circumscribed, hypertrophic, flesh-colored papule on the skin. The client reports pain upon lateral compression. What should the nurse suspect in the client? Correct4 Verruca vulgaris
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A client with a painful, circumscribed, hypertrophic, and flesh-colored papule on the skin may have verruca vulgaris. Plantar warts are usually located on the foot and occur due to pressure by walking or prolong standing. Herpes zoster is caused by the varicella zoster virus and may cause grouped vesicles and pustules on the trunk, face, and lumbosacral areas. Tinea corporis is a ringworm infection with a scaly and erythematous appearance on the skin. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
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A client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, and double vision. Which phase of this headache involves double vision? Aura
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The aura phase involves visual changes, flashing lights, or diplopia (double vision). Throbbing and unilateral headaches that are often associated with nausea or sensitivity to light and sound, flashes of light, and double vision may be migraine headaches. There are three types of migraines: migraine with aura, migraine without aura, and typical migraine. The headache phase involves a severe throbbing head ache. The prodromal phase involves specific symptoms, such as food cravings or mood changes. Intensity of the headache will start to decrease in termination phase.
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A nurse is caring for a child with a cardiac malformation associated with left-to-right shunting. What does the nurse consider the major characteristic of this type of congenital disorder? Increased blood flow to the lungs
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With a left-to-right shunt, blood flows through a defect in the ventricular wall of the heart and is shunted from the higher pressure left side to the lower pressure right side. The increased blood flow from the right ventricle results in an increased blood flow to the lungs. Polycythemia and an increased hematocrit are not common in children with a left-to-right shunt. Severe growth retardation is not common in children with a left-to-right shunt. Clubbing is a more common finding in children with a right-to-left shunt. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.
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What is the possible etiology of intertrigo in clients? Obesity
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Intertrigo, which is infection/rash of the overlying surfaces of the skin, may be caused by obesity. Anemia, liver disease, and hypothyroidism are not associated with intertrigo. Anemia may cause pallor. Spider angiomas may be caused by liver disease. Hypothyroidism may cause carotenemia.
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An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote? Correct2 Arcus senilis
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In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.
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While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment? fingertips
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The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.
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What is the priority nursing intervention for an infant during the immediate postoperative period after surgical repair of a cleft lip? minimize crying
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Crying will put tension on the suture line and should be prevented. The elbow restraints should be removed periodically when the infant is under constant supervision. The infant should not have respiratory difficulty and does not need oxygenation. The infant needs to be cuddled frequently; the parents are encouraged to hold the infant as much as possible.
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A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? Correct4 Diminished breath sounds on auscultation
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Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
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Which musculoskeletal abnormality does the nurse suspect in a client who exhibits short steps and drags a foot? spastic gait
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Spastic gait is a musculoskeletal abnormality, caused by cerebral palsy, that results in short steps and dragging of the foot. Torticollis is a twisting of the client's neck to one side. Pes planus, also called flatfoot, is an abnormal flatness of the sole and arch of the foot. Steppage gait is an increase in hip and knee flexion to clear the foot from the floor; footdrop will be evident in the affected client.
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When does the nurse's teaching say that the client's new sigmoid colostomy should be irrigated?
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when stools start to become formed
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What does the nurse instruct a client to do while performing McMurray's test?
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To flex, rotate, and extend the knees
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The registered nurse is teaching a community event about health promotion activities appropriate for good skin health. Which instructions given by the nurse would be beneficial? Select all that apply.
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"Eat foods rich in vitamin B." "Sleep for longer periods of time." "Avoid exposure to sun after administering ketoconazole."
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The mother of a 10-year-old boy with mild scoliosis asks the nurse, "How long will my son have to continue his exercises before he's better?" How should the nurse respond?
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"Even if he keeps doing the exercises, we won't know how much he's improved until he's fully grown."
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Which activities can a child perform at 3 years of age? Select all that apply.
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Turning doorknobs Holding crayons with fingers Eating with a spoon without rotating it
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. During a community health survey, the nurse is conducting a survey about the language development in preschoolers. What behavior is the nurse able to document in preschoolers? Select all that apply.
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Preschoolers want to know the reason behind an event. Preschoolers have a vocabulary of 8,000 to 14,000 words Preschoolers cannot distinguish between phonetically similar words.
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The nurse is teaching the mother of 24-month-old child effective ways of cleaning the toddler's teeth. Which actions facilitate access to the child's mouth and help stabilize the child's head for comfort? Select all that apply.
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Using one hand to hold the child's chin and the other to brush the teeth. Sitting on a couch or bed with the child's head resting in the mother's lap. Sitting on the floor or a stool with the child's head resting between her thighs
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What instructions should a nurse give an adolescent who is taking benzoyl peroxide for acne? Select all that apply.
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Use light-colored towels and bed sheets while on benzoyl peroxide treatment." "Increase the frequency of the application gradually to prevent the drying effect."
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A client who is scheduled for an amniocentesis tells the nurse, "I'm glad this test will be able to tell me whether or not my baby is well." How should the nurse respond?
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This test is useful in detecting potential defects caused by chromosomal errors."
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The nurse is caring for a 60-year-old client who is at an increased risk of corneal damage. Which instructions should the nurse share with the client? Select all that apply.
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Use saline drops." "Increase humidity at home." "Wear prescribed lens for best vision."
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A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?
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Large snap beads
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A nurse is teaching a client with hypertension about a sodium-restricted diet. Which information should the nurse emphasize?
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Liking the taste of table salt is learned, but it can be modified with practice.
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A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? Select all that apply.
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checkers paper and crayons simple card games
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A school nurse is screening children for scoliosis. In what age group is it usually identified?
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preadolescence
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A nurse is educating a group of mothers about the nutritional needs of toddlers. Which of these statements made by a mother indicate the need for further teaching? Select all that apply.
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"I need to give more than 24 ounces of milk per day." "I should provide more calories from fats than proteins."
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The nurse in the pediatric clinic is assessing the gross motor skills of a 5-year-old child. According to the principles of developmental direction, in which order do these skills develop? Begin with the skill that is accomplished first
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Muscle coordination and equilibrium improve as the neuromuscular system matures. Gross motor skills progress from the simplest to the most complex. The 2-year-old toddler can climb up and down steps. The 3-year-old child can ride a tricycle. The 4-year-old child can skip and hop on one foot. The 5-year-old child can walk backward.
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The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage?
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multifetal pregnancy
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A nursing instructor asks a student to describe the moral developmental theory. Which statement made by the student indicates a need for further teaching?
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"The fifth stage defines 'right' by the decision of conscience in accordance with self-chosen ethical principles."
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The nurse teaches a mother about the dietary measures to be followed for her 5-month-old infant. During the follow-up visit, the nurse finds that the child has indigestion. Which action by the mother is responsible for this situation?
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Feeding properly mashed sweet potatoes to the child
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Which aspect of client tracking using radiofrequency technology (RFT) does the nurse recognize as a major safety strategy of the emergency department (ED) to prevent potentially disastrous consequences in the hospital?
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Interactions between client and caregiver
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Which agency's operations would the registered nurse consider to be most in need of incident command system (ICS) training?
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NIMS (National Incident Management System
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Which behavior of the nurse as a leader would be considered a smart trust action according to Covey?
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Focusing first on developing character
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Which behavior of the nurse as a leader would be considered a smart trust action according to Covey
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Focusing first on developing character
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A nurse is using evidence-based practice to formulate a treatment plan for a client. The nurse uses the PICOT format to ask a clinical question. What should be the next step in the decision-making process?
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Gathering the most relevant and best evidence
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Which intervention should the charge nurse perform to manage a task when the unlicensed nursing personal (UNP) is lacking competence?
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Provide additional support and temporarily lower expectations.
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What are the roles and responsibilities of a senior nurse leader while implementing strategies for improving the quality of the organization? Select all that apply.
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Setting priorities for staff effectiveness and client health outcomes Providing support systems for staff who have been involved in a sentinel event Building infrastructure, providing resources, and removing barriers for improvement
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A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention?
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Alerting the staff to schedule 24-hour observation of the client
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The nurse manager delegates client-care tasks to members of the health care team in the intensive care unit. Which element of the delegation may extend to direct corporate liability for the institution?
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Failure of the nurse manager to delegate and supervise the task within acceptable standards
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The registered nurse is caring for an elderly client who is admitted with severe asthma. Which task delegated by the nurse is most suitable to be performed by the client attendant?
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Assisting the client during nebulization
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A client suffering with cancer is at the last stage of life. Which actions should be performed by the nurse to support the client's family members? Select all that apply.
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Helping the family to set up home care Giving the family about the information of dying process Making sure that the family knows about what to do at the time of death
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Which of these records can a nurse use to document information specific to the client's health in a story-like format?
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Narrative documentation
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The registered nurse is caring for a client suffering from skin infections. The nurse delegates the client care tasks to the health care team. Which task delegated is correct as per guidelines?
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Topical administration of medication by the licensed practical nurse (LPN)
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A student nurse lists the 10 rules of performance designed by the Institute of Medicine (IOM) that should be followed to provide appropriate care for clients. Which rules listed by the student nurse are accurate? Select all that apply.
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Knowledge is shared and information flows freely. "Care is individualized based on client needs and values." "The client is the source of control participating in shared decision making."
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A primigravida at 38 weeks of gestation presents to the clinic with a blood pressure of 142/94 mm Hg, edema in all extremities, and a weight gain of 5 lb (2.3 kg) since the previous checkup 1 week ago. The client has delivered and is receiving magnesium sulfate postpartum. What is the priority nursing action during the immediate 4 hours after delivery?
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Observing amount of lochia
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A registered nurse is caring for a client according to the total client care model of nursing. Which activity performed by the nurse manager would be appropriate in this situation? Select all that apply.
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Weighing the expenses of a registered nurse (RN) vs. LPNs Deciding the type of care provided by nursing assistive personnel
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What are the various challenges related to delegation? Select all that apply.
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Providing clear direction to the delegatee Understanding the skill set of the delegatee Maintaining an open line of communication with the delegatee
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A hospital is planning to implement the functional model of nursing. Which action performed by a nurse leader would be effective under this model?
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Assigning individual duties to different nurses and nursing students for different tasks
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After an earthquake, there were a large number of deaths and casualties who required acute care for several days in the field. Which teams activated by state and federal government authorities would the nurse consider to be the most suitable in managing the event? Select all that apply.
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Medical Reserve Corps (MRC) Disaster Mortuary Operational Response Teams (DMORTs)
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What is the correct order of steps that should be followed by a leader to create a vision and foster major organizational transformation?
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According to the Kotter's eight-step change model, the first step towards creating a vision and fostering major organizational transformation is creating urgency. Generating open dialogue about external and internal realities will impact the need to change. The next step is forming a powerful coalition. Developing a core group of change advocates will help build momentum as well as support individuals through the change experience. Next, creating a vision for change may involve lots of small alterations, and may or may not be a larger or inspiring vision. Communicating the change vision to people is the next step. People tend to pay attention to what is reinforced, so communicating regularly and consistently is required to sustain the effort. The next step is removing obstacles. This includes having alerts for barriers in the structure and processes that limit the ability to change and removing these barriers. The last step is to report the changes and honor the people who helped make it happen, in order to inspire others.
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Which statement made by a nurse indicates being an effective community opinion leader?
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"I will try to build a society that treats males and females equally.
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The nurse manager receives a report on the following laboring clients. Which client should the nurse see first?
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G6 P5 with intact membranes at 5 cm of dilation
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A client is scheduled for a computed tomography (CT) scan of the chest with intravenous (IV) contrast. Which assessment is the priority before the test is performed?
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serum creatine level
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The Quality and Safety Education for Nurses (QSEN) initiative addresses the challenge to prepare nurses with the competencies that are required to improve the quality of client care. Which scenario is representative of the teamwork and collaboration competency?
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A nurse discusses the development of a special diet chart with a dietician for a diabetic client
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The registered nurse is teaching hurricane victims about the precautions to be taken to prevent infections. Which statements made by a victim indicate the need for further teaching? Select all that apply.
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"I will avoid ultraviolet pens." "I will avoid using toilet liners." "I will avoid using a camp stove to boil water.
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What are the similarities between Medicare and Medicaid? Select all that apply.
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Both programs assist older clients. Both programs pay for home care services.
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The registered nurse (RN) is caring for a client who underwent knee surgery. Which activity delegated to the novice unlicensed assistive personnel (UAP) in the immediate postoperative period would be most appropriate to achieve an effective care outcome?
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Feeding the client with fluids
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A nurse in the pediatric clinic is evaluating a 6-year-old child with sickle cell anemia whose spleen autoinfarcted by age 4. What is the priority nursing care at this time?
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Determining parental knowledge about infection
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The nurse manager appointed a registered nurse (RN) to provide hospice care for a client and explained the tasks to be performed. Which tasks has the nurse manager delegated to the RN? Select all that apply.
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Providing total client care Teaching the client and family members Teaching the client about personal hygiene
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A school-aged child is admitted to the pediatric unit with the diagnosis of a brain tumor. During breakfast the child vomits. What are the priority nursing interventions? Select all that apply.
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Notifying the practitioner Requesting a reevaluation
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A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first?
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Administer oxygen as prescribed
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A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse best support the client's spouse?
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Assist the couple to maintain open communication.
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A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa?
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the client behaves and looks normally
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nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?
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A group can offer increased support
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A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse?
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you dont feel able to make a decision at this time?
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The nurse is providing care to a preschool-age client of Chinese descent diagnosed with lead toxicity. Which question is most appropriate for the nurse to include in the assessment process to determine the source of the lead?
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"Do you use Ba-Baw-San to treat your child's colic pain?
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What clinical findings may be expected when a nurse assesses an individual with an anxiety disorder? Select all that apply.
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Worrying about a variety of issues Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development
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A client who is a polysubstance abuser has been ordered by the court to seek drug and alcohol counseling. When working with the client, the nurse identifies several treatment goals. List in priority order the outcome criteria for this client.
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The client must first acknowledge that a substance abuse problem exists and creates chaos in his life. The client can then discuss the numerous ways in which drug use has changed and controlled his life. Assistance from the nurse may be required at this time for the client to express and process negative feelings. Finally the client will require assistance in establishing the relationship between substance use and his current problems.
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When working with a client who is in an alcohol detoxification program, what nursing action is most important?
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address the clients holistic needs
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Which questions should the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply.
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"How is your family dealing with your condition?" "How do you rate your distress on a scale of 0 to 10?"
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Which activities should the nurse suggest to the parents of a latchkey school-age client to decrease loneliness? Select all that apply.
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Suggesting that the parents get the child a pet Calling the child if the parent will be late coming home Helping the child talk about his or her feelings about being alone after school
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A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous (AA) meeting. What is a basic principle of this group?
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Amends must be made to each person who has been harmed.
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A nurse watches as a new mother timidly approaches her critically ill preterm son for the first time in the neonatal intensive care unit. Which statement by the nurse would best foster the bonding process between the mother and her baby?
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"I know it's hard for you to see him like this, hooked up to so many machines, and you don't know what to expect.
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Which herbal remedies used by clients of Mexican descent should the nurse include in the assessment process to determine the source of lead poisoning for a toddler-age client? Select all that apply.
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greta azarcon tamarindo jellied fruit candy
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A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety.
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Confirming that the client is experiencing verbal hallucinations is the priority. Determination of the nature of the message that the voices are delivering takes place next. The risk for injury to the client and others is assessed after the focus of the hallucination is identified. Finally the nurse will assist the client in managing the reaction to the hallucination
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Which gross-motor skills would the nurse explain are developed in children between 3 to 5 years of age?
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jumping rope walking stairs
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Which is the most important observation for the nurse when assessing the psychosocial stage of development for a preschool-age client?
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interactions with others during play
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Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the most important intervention for a client who is given an as-needed medication and confined to involuntary seclusion?
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evaluate clients progress towards self control
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A nurse working in a disaster management team is caring for clients who suffered severe injuries in a train accident requiring cardiopulmonary resuscitation. Which statements by the nurse are correct? Select all that apply.
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"A 16-gauge needle should be used to obtain intravenous (IV) access in the antecubital region." Presence of radial pulse indicates a minimum systolic blood pressure of 80 mm Hg." "Hypotension occurs after the body's compensatory mechanism to maintain vital signs is exhausted.
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The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply.
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"I will elevate the head of the client's bed to 30 degrees." "I will instruct the client to take baths in lukewarm water. "I will ensure that the client's fluid intake is 2000 to 3000 mL/day.
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The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first?
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Draw peripheral blood cultures.
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What is the correct order of steps involved in secondary survey?
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It starts with obtaining a full set of vital signs. Then the nurse provides comfort measures such as verbal reassurance, listening to the client, reducing stimuli, and developing a trusting relationship with the client. After providing comfort measures, the nurse takes the patient's history, which helps to provide clues to the cause of the crisis. The nurse then performs head-to-toe assessment. Finally, the nurse inspects posterior surfaces by logrolling the client.
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A client is admitted to the medical unit with pulmonary edema. The registered nurse admits the client, writes a plan, and assigns the work to another registered nurse (RN). Which factors are transferable in this case? Select all that apply.
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Responsibility Accountability
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The nurse is delegating someone to care for a client with diabetes mellitus. Which instruction given by the nurse better explains the selling relationship with the delegatee?
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You will take complete care of the client with diabetes and make sure to record the blood glucose level.
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A pregnant woman at 6 weeks' gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement. What should the nurse recommend to the client? Select all that apply.
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Stop taking the supplement immediately. Discuss the use of the supplement with the practitioner discuss the use of any over-the-counter products with the practitioner.
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A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. Which is the priority nursing intervention for this client?
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provide pain medication
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Which roles require the nurse to prioritize when implementing a primary nursing model of client care? Select all that apply.
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manager advocate decision maker care coordinator
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Which statements are related to nursing roles and function changes in the health care organization? Select all that apply.
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Conflict management technique is beneficial. Society needs nurses who can engage in political policy development
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In what order should the tasks be performed by the nurse leader when implementing evidence-based practice?
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search, appraise, integrate, evaluate, dissemenate
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A hospital management team has conducted a randomized controlled trial to decrease the occurrence of ventilator-associated pneumonia .The trial was successful and had positive outcomes. The nurse manager, in collaboration with other hospital management staff, conducted the same trial in another hospital, but the results were different. Which research strategy implementation would the nurse manager consider to be beneficial in preventing dramatic differences in trial results?
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practiced based evidence
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To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs in a respectful manner. What is the primary underlying principle guiding this process?
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Caring is the underlying component of nursing that promotes client care.
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A healthcare provider prescribes doxorubicin for a client with acute myelogenous leukemia. Which specific interventions should the nurse implement? Select all that apply.
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Monitor for jaundice Increase fluids by mouth Provide frequent oral care assess vital signs frequently
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Steroid therapy is prescribed for a client with common signs and symptoms of multiple sclerosis. In response to the steroid therapy, what symptom does the nurse expect to decrease?
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episodes of vision loss
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The nurse is caring for a client with type 1 diabetes. Which signs or symptoms will indicate to the nurse that the client is experiencing hypoglycemia? Select all that apply.
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headache diaphoresis
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A child is admitted to the hospital with diarrhea and is prescribed antidiarrheal medications. Which nursing actions indicate that the nurse is skilled in safe drug administration to pediatric clients? Select all that apply.
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The nurse calculates the drug dose according to the age. The nurse promotes fluid and electrolyte balance. The nurse assesses the child for the presence of any eating disorders
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A primary healthcare provider prescribes teriparatide, a parathyroid hormone agonist, for a client with osteoporosis. Which statement about this drug does the nurse recognize as accurate?
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Osteoblastic activity is stimulated more than osteoclastic activity
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Nitrofuratoin used during the fifth week of pregnancy places the neonate at risk for which condition?
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cleft lip
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A client is lonely and extremely depressed, and the healthcare provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse?
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increase appetite and make you feel better
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Oxytocin is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply.
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Stopping the infusion Notifying the primary healthcare provider Verifying the duration of contractions
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A 25-weeks pregnant client who is being treated with tenormin reports labor pain. What medication would the primary healthcare provider prescribe?
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nifedipine
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A nurse educates a mother about the proper administration of oral medication to her 4-year-old child. What statement made by the mother indicates effective learning? Select all that apply.
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"I should use a disposable oral syringe to prepare liquid doses."
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methylprednisolone
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polyuria
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A nurse administers carbidopa-levodopa to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to produce?
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replacement of neurotransmitter in the brain
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A nurse teaches a client about the side effects and precautions associated with the antipsychotic haloperidol. The nurse concludes that the teaching has been understood when the client makes which statement?
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"I'll avoid direct sunlight and make sure to use sunscreen when I go outside."
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A child who is infected with human immunoefficiency virus is admitted to the hospital with the diagnosis of Pneumocystis jiroveci pneumonia. The nurse administers the prescribed trimethoprim/sulfamethoxazole. Which common side effects will the nurse anticipate? Select all that apply.
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vomit photosensitivity crystaluria
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Olanzapine is prescribed for a client who experienced agranulocytosis with clozapine. Which statements indicate that the nurse's teaching about olanzapine has been effective? Select all that apply.
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weight gain enjoy fun activities
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A 4-year-old child diagnosed with sickle cell anemia is at a high risk of acquiring pneumococcal diseases even after receiving one or two doses of the pneumococcal conjugate vaccine (PCV). Based on the immunization protocol, what dose of PCV should the nurse administer?
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2 more doses
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Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine?
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increase fiber and fluids
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The primary healthcare provider prescribes medication to prevent transplant rejection from increased concentration of interleukin-2. Which drugs could the nurse most likely administer? Select all that apply.
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tacro cyclosporine
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Antipsychotic drugs can cause extrapyramidal side effects. Which responses does the nurse document as indicating pseudoparkinsonism? Select all that apply.
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ridgitity bradykinesia tremors
question
A client in active labor is considering combined spinal-epidural analgesia. She states that she is concerned about her ability to walk after receiving this type of analgesia. What is the most accurate response by the nurse?
answer
"This analgesia gives you pain relief without compromising your ability to ambulate."
question
A nurse teaches the parents of a 7-year-old girl who has been prescribed long-term phenytoin therapy about care pertinent to this medication. Which statement indicates that the teaching has been effective?
answer
"We'll have her massage her gums and floss her teeth frequently."
question
The nurse has administered an immunosuppressant that acts on T helper cells to prevent production and release of IL-2 and γ-interferon to a client. Which side effects should the nurse monitor for in this client? Select all that apply.
answer
Hirsutism gingival hyperplasia nephrotoxicity
question
What is the most appropriate time for the nurse to administer an intravenous opioid analgesic to a client in active labor?
answer
When a contraction starts
question
The practitioner prescribes a regular diet, gait training, elastic stockings, and benztropine mesylate for a client. The client experiences orthostatic hypotension, a side effect of benztropine mesylate. What should the nurse anticipate as the priority nursing action?
answer
apply elastic socks
question
A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas?
answer
administer histamine blocker
