UW 1 – Flashcard

The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory reporting. Signs of abuse may include: Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4) Injuries to genitalia Lapsed time between the injury and the time when care is sought Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) (Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures within the home to prevent future injury. Educational objective: The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws.

Explanation: Clients with Huntington disease or other degenerative neurological conditions advance through several phases over the course of their illness. Each stage represents further progression of the disease and decline of the client's physical, emotional, and cognitive abilities. Family members' grief in response to the disease progression is expressed in different ways. Many family members feel that their loved one is being "lost" to the illness and that they have little control over its course. Others are in denial and have difficulty acknowledging the client's worsening condition. Most important for the nurse is to explore family members' concerns, thoughts, and feelings about the situation through therapeutic communication, which may help them accept the reality of the client's condition (Option 3). (Option 1) Although a hospital bed can better meet the client's needs, the nurse should first explore the spouse's resistance. (Option 2) To facilitate open communication, the nurse should ask open-ended questions and avoid limiting conversation by asking closed-ended (ie, yes or no) questions. (Option 4) Changing the subject is a nontherapeutic approach that shows a lack of empathy and does not allow the nurse to explore the spouse's resistance. Educational objective: Family members of a client with a degenerative disease may be resistant to care recommendations during periods of grief (eg, denial). The nurse should use therapeutic communication that focuses on exploring family members' concerns and validating their feelings.

Explanation: Ondansetron (Zofran) is a serotonin-3 receptor antagonist antiemetic that acts peripherally on vagal nerves and centrally in the chemoreceptor trigger zone to relieve nausea and vomiting associated with chemotherapy, radiation, and surgery. It is available in oral and IV form. Nausea should be assessed in the postoperative period and while receiving narcotics. Nausea is subjective and is therefore best assessed by client self-report. A client stating, "The nausea is a lot better" is the best indicator that the ondansetron has been effective (Option 4). (Option 1) A reduction in diarrhea would be the desired effect after giving an antidiarrheal medication. Examples include loperamide (Imodium) and diphenoxylate-atropine (Lomotil), which have antimotility effects, thereby diminishing diarrhea and fluid and electrolyte loss. (Option 2) A reduction in itching would be expected after administration of an antihistamine. Examples include diphenhydramine (Benadryl) and dimenhydrinate (Dramamine), which block histamine receptors on basophils and mast cells, preventing histamine release. (Option 3) Reports of improved pain do not address the effectiveness of ondansetron; however, ondansetron is commonly administered with opioid narcotics to prevent their adverse effect of nausea. Educational objective: Ondansetron (Zofran) is a peripherally and centrally acting serotonin-3 receptor antagonist antiemetic used for the treatment of nausea. It is available in oral and IV form and can be used postoperatively or with narcotic administration. Nausea is subjective, and questioning the client directly best assesses medication effectiveness.

Rapid fluid infusions can cause hypervolemia as excess fluid accumulates within the extracellular space, especially in clients with heart failure or kidney disease. The infusion should be stopped and the client assessed for pulmonary edema (eg, dyspnea, lung crackles) and other signs of fluid overload (eg, peripheral edema, jugular venous distension). If signs are present, the health care provider should be notified as fluid overload can cause respiratory and cardiovascular compromise. (Option 1) Itching is common post surgery from side effects of narcotics (generalized) and the wound healing process (localized). Generalized itching may indicate an allergic drug reaction and should be assessed. This client with localized itching may need ice packs or diphenhydramine but would not be a priority. This client would be seen second. (Option 3) The nurse should notify the health care provider of this client's potassium level and prescribed IV fluids. If IV fluids are still required, the prescription should be changed to normal saline (without potassium chloride). This client is not a priority as the potassium level is still within normal limits (3.5-5.0 mEq/L). The value is critical if the potassium level is >5.5 mEq/L. (Option 4) An angry client waiting for discharge should be addressed before the situation escalates. However, clients with physiologic needs take priority. Educational objective: Fluid overload (ie, dyspnea, lung crackles, peripheral edema, jugular venous distension) can occur with increased infusion rates and should be addressed promptly to prevent respiratory or cardiovascular compromise.

An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical principles of beneficence and nonmaleficence. In addition, underage clients may consent in certain circumstances without parental consent. These circumstances usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases. (Option 2) This client has signs/symptoms of systemic infection and possible dehydration or sepsis, an emergent condition. It is unknown when the parents or guardians can be reached. It would be negligent to not further assess and treat a potentially worsening condition. It is assumed that the parents or guardians would want safe, quality care for the client. (Option 3) Qualifications for the status of emancipated minor are subject to state legislation but usually include individuals age <18 who are parents or pregnant, married, living as financially independent, or in the military. This client needs care that should be rendered regardless of status. (Option 4) Providing follow-up advice will not stabilize a potentially serious medical condition. Care must be provided. Educational objective: An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

Homeless Parent Married Military service Financially independent High school graduate Medically emancipated minor Emergency care Sexually transmitted infection Substance abuse (most states) Pregnancy care (most states) Contraception

Emergency care Sexually transmitted infection Substance abuse (most states) Pregnancy care (most states) Contraception

Weaning is less difficult for mother and child when accomplished gradually over weeks to months based on readiness cues from the child. This helps avoid breast engorgement, which can occur with sudden cessation of breastfeeding. Gradual, spontaneous weaning of exclusively breastfed infants usually begins around age 6 months with the introduction of solid foods. At this age, solid foods may be offered in addition to breast milk or formula, but these milk sources should not be eliminated. Most children are able to begin drinking from a cup with a lid around age 1 year and can begin weaning from bottles at this time. Whole cow's milk may be offered starting at age 12 months (Option 2). (Option 1) Bottles should not be given to children overnight or while sleeping, as this increases the risk for tooth decay, aspiration, and ear infections. (Option 3) Milk is a good source of important nutrients (eg, calcium, protein, fat) required for appropriate growth in childhood. After solids are introduced, nutrients are obtained from complementary sources (eg, yogurt, eggs, cottage cheese) in addition to milk. (Option 4) Infants often breastfeed for comfort as well as hunger, and abrupt cessation may cause emotional distress in addition to breast engorgement. Educational objective: Weaning is best achieved gradually to avoid breast engorgement and infant distress. Gradual weaning from breastfeeding may begin with the introduction of solid foods at age 6 months. Whole cow's milk may be given to children after age 12 months.

Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a person to make decisions on their behalf. (Option 1) Initiating CPR on a client with a DNR status does not respect the wishes of the client to forgo life-saving measures and allow natural death. Nurses must advocate for clients' wishes, even if family members are in disagreement. (Option 2) The client has a terminal illness and in an advance directive expressed wishes that were verified prior to initiating DNR status; therefore, there is no need to clarify with a health care provider. (Option 4) The client's child should be offered support from the hospital chaplain after the client's wishes are explained. Educational objective: Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for medical care are honored over the wishes of family members.

Furosemide is the primary diuretic used in children, particularly in those with congenital heart disease when fluid overload is a frequent problem. Pediatric drug dosages are usually prescribed based on age and weight (unit per kilogram), either per 24 hours or per dose. A pediatric drug reference should be available, and medication prescriptions for the pediatric client must be checked by the nurse prior to administration. Step 1: Convert pounds (lb) to kilograms (kg). 2.2 lb = 1 kg 88 lb/2.2 = 40 kg Step 2: Calculate dosage. 1 mg/kg per dose 1 mg × 40 kg = 40 mg per dose Step 3: Calculate drug volume based on concentration to achieve desired dose. 10 mg/mL for the furosemide oral solution 40 mg ÷ 10 mg = 4 (Amount needed per dose ÷ Amount available) 40 mg = 4 mL Educational objective: Pediatric drug dosages are usually prescribed based on age and weight (unit per kilogram), either per 24 hours or per dose. The nurse calculates the amount of furosemide to be administered by converting pounds to kilograms, calculating the prescribed dose in milligrams, and then converting the prescribed dose from milligrams to milliliters.

Explanation: The goal of therapeutic communication with clients diagnosed with schizophrenia is building trust, self-awareness, reality testing, and self-confidence. The nurse should be aware of client cues that indicate hallucinations (distraction, mumbling, watching a vacant area of the room). This client might be having a visual hallucination, as evidenced by being distracted and grimacing. The nurse must assess for hallucinations that might direct or cause the client to be unsafe or aggressive (eg, suicidal or homicidal themes). It is most therapeutic to ask the client what is being seen, heard, smelled, or felt. Once the specifics of the hallucination are known, the nurse can help the client deal with it. (Option 1) This statement does not help the client now. Later, when the nurse knows exactly what the client is seeing, it might be appropriate to redirect the client to the conversation as a way to ignore the hallucination. (Option 2) Ending the conversation would not be therapeutic as it does not allow the nurse to help the client during the hallucination. (Option 4) This statement is not therapeutic as it addresses the nurse's, not the client's, needs. Educational objective: Communication with a client experiencing a hallucination should first focus on the nature of the hallucination so that the nurse can assess for suicidal or homicidal themes.

Explanation: All sexually active women, including those of a sexual minority (eg, lesbian, bisexual, transgender), are at risk for sexually transmitted infections (STIs) (eg, human papillomavirus, HIV, herpes simplex virus, bacterial vaginosis). Common routes of STI transmission include oral-genital, oral-anal, skin-to-skin, and use of sex toys. Regardless of sexual orientation, all clients should receive education on infection prevention through the use of barrier methods (eg, latex barriers, dental dams, condoms) and hygienic use of single-person sex toys. Interview questions should be framed to elicit information about the client's current methods of risk reduction and infection prevention (Option 3). (Option 1) Asking the client about sexual orientation does not accurately assess risk as sexual orientation does not correlate with risk for STIs. In addition, clients may not identify with specific sexual labels (eg, lesbian, bisexual). (Option 2) Monogamy may decrease the risk for STIs, but the client cannot be assured that sexual partners have not been previously exposed or are not currently engaged in other relationships. (Option 4) STIs can be spread through various female/female sexual acts. Acts with risk of trauma to the genital tract (eg, penetrative intercourse) are more likely to transmit STIs, but risk is not eliminated with less invasive sexual acts. Educational objective: All women who engage in sexual activities are at risk for sexually transmitted infections, regardless of sexual orientation or history. Health-promotion activities and education should be aimed at safe sexual practices (eg, barrier methods, hygienic use of sex toys).

Chest tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood (hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed over the insertion site until the health care provider can assess the client and insert a new chest tube. If such dressings are not immediately available, the nurse should cover the insertion site with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural cavity. (Option 1) The nurse should cover the site and assess the client prior to activating the emergency response system. (Option 2) It may be necessary to provide supplemental oxygen if a chest tube is accidentally dislodged. This intervention would be done after the site is occluded. (Option 3) After the chest tube insertion site is covered, the client should be reassessed. The nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax may occur quickly. Educational objective: Chest tubes are inserted into the pleural cavity to drain air (pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a sterile occlusive dressing is placed over the site. If such dressings are not immediately available, a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After dressing the site, the nurse should reassess the client and notify the health care provider immediately

Myasthenia gravis is an autoimmune disease of the neuromuscular junction causing fluctuating muscle weakness. Autoantibodies are formed against acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine (Mestinon), which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate life-threatening myasthenic crises, characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention. (Option 1) Sumatriptan is prescribed for moderate to severe, acute migraine headaches characterized by severe, pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a changed treatment regimen (eg, ergotamine). (Option 2) Carbidopa-levodopa decreases symptoms of Parkinson disease (eg, bradykinesia, tremor, rigidity). Orthostatic hypotension is an adverse effect of the drug but may also occur from disease-related autonomic nervous system dysfunction. This client should be taught to slowly change positions; this client is not the priority. (Option 4) Trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing. A change in treatment regimen (eg, carbamazepine, gabapentin, baclofen) may be required for improved pain relief. Educational objective: Myasthenia gravis is a chronic neurologic autoimmune disease in which acetylcholine receptors are blocked, causing muscle weakness. Infection, undermedication, and stress can lead to myasthenic crises, characterized by oropharyngeal and respiratory muscle weakness and respiratory failure.

Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: Access to psychiatric medications Availability of help during a crisis (eg, counselor, family) Future goals and plans Home and work environment risks Overall affect and level of energy Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Imipramine (Tofranil) is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be stockpiling medication for a suicide attempt. (Option 3) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 4) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. These agreements do not guarantee safety and are not the best indicator of decreased suicide risk. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, availability of help, access to weapons, and energy level. Clients who articulate long-term personal goals and family milestones are less likely to commit suicide.

Psychiatric disorders, prior suicide attempts Hopelessness Never married, divorced, separated Living alone Elderly white man Unemployed or unskilled Physical illness Family history of suicide, family discord Access to firearms Substance abuse, impulsivity

Explanation: Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram [Lexapro]), which are commonly prescribed antidepressants, usually take 1-4 weeks from the first dose to improve depression symptoms. If a client experiences no improvement after 2 months, re-evaluation is necessary (Option 2). Noncompliance is common with SSRIs due to intolerance of side effects (eg, nausea, weight gain, sexual dysfunction). The nurse should first assess if the client is taking the medication as prescribed (Option 3). Clients may require education on symptom management (eg, taking with food for nausea, nutritional education to manage weight). If the client is compliant but the medication has not relieved depressive symptoms, the health care provider may change the prescribed dose or medication. (Option 1) Assessing for stressors is important when a client is taking an SSRI. However, this can be asked later in the assessment as the priority is to determine compliance. (Option 4) The nurse should assess the client's medication compliance before discussing a change in the prescription with the health care provider. Educational objective: Selective serotonin reuptake inhibitors (eg, escitalopram, sertraline, fluoxetine) take about 1-4 weeks from the first dose to improve depression symptoms. If the medication is ineffective, the nurse should determine client compliance prior to notifying the health care provider.

Second-degree (partial-thickness) burns appear as moist or weeping wounds with blisters and shiny, fluid-filled vesicles, and clients have moderate to severe pain. Both the epidermis and dermis are damaged. Immediate care of minor burn injuries involves removal of clothing and debris from the affected area, cooling and cleansing of the wound, and pain management. Minor burn injuries can be treated on an outpatient basis with wound care and dressing changes. Major burn injuries require hospitalization and emergency interventions (eg, airway management, fluid resuscitation). (Option 1) First-degree (superficial) burns are dry with blanchable redness. They usually damage the epidermis only. (Options 3 and 4) Third-degree (full-thickness) burns are dry and inelastic with waxy white, leathery, or charred black color. They destroy the dermis and may involve subcutaneous tissue. Fourth-degree (full-thickness) burns have the same appearance as third-degree burns, with additional involvement of fascia, muscle, and/or bone tissue. Due to nerve damage, pain is not the major feature, unlike with second-degree burns. Educational objective: Second-degree (partial-thickness) burns damage both the epidermis and the dermis, and appear as moist or weeping wounds with redness, blisters, shiny fluid-filled vesicles, and moderate to severe pain.

Personal protective equipment (PPE) is necessary when a client is on contamination precautions (eg, droplet, airborne, contact). A gown is not normally required in an airborne precaution room; however, if contamination is probable (eg, dressing change, contact with bodily fluids), a gown is necessary. The proper removal of PPE limits self-contamination. The exact procedure for donning and removing PPE varies with the level of precautions and location of nursing practice. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials (Option 2). To remove gloves: Grasp the first glove by its palmar surface and pull off inside out. Next, slide fingers of the ungloved hand under the second glove at the wrist and peel off over the first glove. Discard gloves in an infectious waste container. (Options 1, 3, and 4) Face shield/goggles, gown, and mask/respirator can be removed after gloves, which are considered the most contaminated piece of PPE. Educational objective: The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials.

Intermediate-acting insulins (NPH) can be safely mixed with short- (regular) and rapid-acting (lispro, aspart) insulins in a single syringe (Option 4). With the client's blood glucose reading of 322 mg/dL, 12 units of regular insulin are needed in addition to the scheduled 25 units of NPH insulin. To prepare the mixed dose: Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles in the syringe. Draw 25 units of NPH insulin into the syringe, for a total of 37 units in one syringe. Any overdraw of NPH insulin necessitates wasting the entire quantity of insulin in the syringe. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and are typically packaged in prefilled injection pens. (Option 1) The 2 insulins can be safely given together before a meal, as regular insulin has a rapid onset of action and NPH insulin has a slower onset but longer duration. (Option 2) The 2 insulins can be given as 2 separate injections; however, this increases client discomfort and the risk of infection. (Option 3) Regular insulin should be drawn up first to avoid contaminating the vial of regular insulin with NPH insulin (mnemonic - RN: Regular before NPH). Educational objective: NPH insulin and regular insulin can be safely mixed and administered as a single injection. Regular insulin should be drawn up before intermediate-acting insulin to avoid contaminating multidose insulin vials (mnemonic - RN: Regular before NPH).

Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes: NPO status is required for 6-8 hours prior to treatment except for sips of water with medications (Option 4). Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. Driving is not permitted during the course of ECT treatment (Option 2). Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT (Option 3). Post-treatment nursing care includes monitoring vital signs, maintaining a patent airway, monitoring mental status, and providing frequent reorientation during periods of postictal confusion. (Option 1) Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT. Educational objective: Electroconvulsive therapy (ECT) uses an electrical current applied to the scalp to induce a generalized seizure in an anesthetized client. Prior to the procedure, the client should be NPO and not take anticonvulsant medications. Temporary confusion and memory loss are common after the procedure. Clients should be instructed not to drive during the course of ECT treatment.

Severe anxiety impairs the ability to attend to stimuli in the environment other than the anxiety-producing event or factor. Physiological responses to anxiety include hyperventilation, palpitations, shortness of breath, and diaphoresis. Behavioral responses (eg, fixation on specific details, pacing) serve as coping mechanisms to manage anxiety. Unrelieved anxiety may become severe and escalate to a panic attack. The nurse should ensure safety and support the client with severe anxiety to prevent injury and escalation. The client is unable to attend to details, so the nurse should communicate in a calm, accepting manner; answer questions directly; and use simple statements (Option 4). (Option 1) Clients with severe anxiety are unable to attend to their own safety or needs. The nurse should not leave the client alone at this time. (Option 2) Anxiety is "contagious," so nurses' anxiety can exacerbate clients' anxiety (ie, reciprocal anxiety). Nurses should accept their own feelings about the situation and remain calm without transferring their frustrations to clients. (Option 3) Clients should be allowed to engage in coping behaviors (eg, repetitive acts, pacing) during episodes of severe anxiety as long as they do not risk harm. These behaviors relieve tension and prevent escalation. Educational objective: When caring for a client experiencing severe anxiety, nurses should provide a calm presence, reassure clients of safety, use simple statements, and answer questions directly. Nurses should not leave the client alone, interfere with coping behaviors, or transfer their own frustrations to the client.

Explanation: During seizure activity, the priority is client safety. Nursing interventions include: Assist seated or standing clients to lie down, while protecting the head, and position on the side to maintain a patent airway and prevent aspiration (Option 3). Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). Record and document the time and duration of the seizure (Option 4). (Option 2) Although clients may require oxygen if they are symptomatic (decreased oxygen saturation level), artificial airways or other objects are never inserted into the mouth or nose during a seizure due to risk of trauma. A nasopharyngeal airway would not prevent the tongue from obstructing the airway during a seizure. When seizure activity has stopped, suctioning and/or insertion of an oral airway may be necessary if the client's airway is obstructed. (Option 5) The client should never be restrained during a seizure. Strong muscle contractions occur during seizures; therefore, if the client is restrained, injury could occur. Educational objective: During seizure activity, the priority nursing interventions are to assist the client to safely lie down (if seated or standing), position on the side to maintain a patent airway, loosen restrictive clothing, provide oxygen as needed, and remove objects from the immediate area. The nurse also documents the time and duration of seizure activity.

Explanation: Learning that their newborn has a genetic disorder (eg, Down syndrome) is an overwhelming experience for most parents. They may initially react with shock, disbelief, and/or denial. Once they accept the diagnosis, parents may be filled with uncertainty and doubt and experience an array of emotions, including guilt, depression, and anger about the presumed loss of their perfect child. When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). (Option 1) This is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling. (Option 3) This is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis. (Option 4) This is accusatory and nontherapeutic. The nurse should avoid asking "why" questions when attempting to gain more information. Educational objective: Parents of newborns diagnosed with Down syndrome or other developmental disabilities may experience shock or disbelief along with a wide array of emotions. Nurses should be supportive by using therapeutic communication techniques that encourage the family to talk about what they are experiencing and/or feeling.

Children often develop respiratory distress and bradycardia before going into cardiac arrest. When the collapse of a child with apnea and a pulse is witnessed, emergency services should be contacted and then rescue breathing should be implemented. If, after rescuing breathing is performed for 2 minutes, the pulse remains ≤60/min and there are signs of poor perfusion (eg, skin pallor), then compressions should be initiated. In infants and children (1 year to puberty), a heart rate ≤60/min with signs of poor perfusion is treated as pulseless. (Option 2) If the heart rate increases to >60/min with signs of adequate perfusion, the nurse would continue with only rescue breathing. The correct rescue breathing rate for children is 1 breath every 3-5 seconds or 12-20 breaths per minute. (Option 3) Abdominal thrusts are performed during the Heimlich maneuver to aid a choking victim. They are powerful upward squeezes to the victim's diaphragm to expel an object from the trachea. There is no indication that this child was choking. (Option 4) If the child was initially found to be in a witnessed cardiac arrest, the nurse would retrieve the defibrillator prior to starting CPR. Educational objective: Infants and children with a heart rate ≤60/min with signs of poor perfusion are treated as pulseless. If the child is apneic with a pulse ≤60/min, rescue breaths should be implemented. If pulse remains ≤60 with signs of inadequate perfusion after rescue breaths, compressions should be initiated.

Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination when urine stings the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period (Option 4). Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days (Option 3). However, sexual activity is not a significant cause of infection or reinfection of Candida, so partner evaluation is unnecessary. In contrast, trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted, so partners should be evaluated and treated. Other teaching points for this client should include: Ensuring proper hygiene of the perineum: Cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1) Wearing loose-fitting cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2) Refraining from douching, which can introduce organisms higher in the vaginal canal and cervix Educational objective: Miconazole cream is commonly prescribed to treat vaginal candidiasis. Miconazole is best applied at bedtime so that it will remain in the vagina longer. Clients being treated for vaginal candidiasis should wear loose-fitting cotton underwear and refrain from douching and sexual intercourse during treatment.

Duchenne muscular dystrophy (DMD) is the most common form of childhood MD. The condition is X-linked recessive (ie, carried by females and affects males) and is due to lack of a protein called dystrophin needed for muscle stabilization. Disease onset is age 2-5 years. Muscles of the proximal lower extremities and pelvis are affected first. Calf muscles hypertrophy (pseudohypertrophy) initially in response to proximal muscle weakness and are later replaced by fat and connective tissue. The Gower sign involves the use of one's hands to rise from a squat or from a chair to compensate for proximal muscle weakness. There is no effective cure. Most children are wheelchair bound by adolescence and die by age 20-30 from respiratory failure. It is important to avoid floor clutter (eg, throw rugs) and prevent falls/injury (Option 3). (Option 1) Iron deficiency is not related to MD. Diet should be assessed to ensure adequate fluid, whole grains, fruits, and vegetables to maintain bowel function to reduce the risk for constipation from immobility. (Option 2) Clients are encouraged to participate in regular gentle recreation-based exercises and swimming to avoid disuse muscle atrophy and social isolation. Overexertion such as weight lifting is not recommended due to the risk of muscle injury. (Option 4) Skeletal muscle relaxants such as baclofen (along with benzodiazepines) are used in cerebral palsy to control spasticity and seizures. Cerebral palsy is characterized by abnormal muscle tone and lack of coordination with spasticity. MD is characterized by weak muscles from the muscle tissue being replaced by connective tissue. Educational objective: MD is the replacement of muscle fibers with connective tissue, resulting in lower-extremity weakness. It is important to eliminate floor clutter to prevent injury. Clients are encouraged to participate in regular gentle recreation-based exercises and swimming to avoid disuse muscle atrophy and social isolation.

Thromboembolic deterrent stockings (TED hose) are elastic stockings that provide graduated compression to the leg to promote venous return and reduce risk of venous thromboembolism. Correct sizing and application of TED hose are essential to effectively promote venous return. Stockings that are too large will not provide adequate compression, and stockings that are too tight or applied incorrectly may impair perfusion. When applying TED hose, the nurse should: Select a size of knee-length stockings by measuring length from the heel to the popliteal area and circumference at the widest point of the calf (Option 2). Ensure stockings are free of folds, rolls, or wrinkles; these may have a tourniquet-like effect, exacerbating venous stasis and impairing perfusion (Options 3 and 5). Discrete wounds should be covered with occlusive dressings (eg, hydrocolloid) before TED hose application. (Option 1) Stockings should be worn continually and may be removed 1-3 times a day for vascular assessment. It is especially important to wear TED hose when the legs are in a dependent position while sitting or standing, usually during the day. (Option 4) Friction against nonintact skin (eg, stasis ulcers, lacerations) is alleviated by applying an occlusive dressing. Applying a size larger than recommended based on measurements will not provide adequate compression. Educational objective: Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism. TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles.

Atypical antipsychotic medications (eg, risperidone [Risperdal], quetiapine [Seroquel], olanzapine [Zyprexa]) are used in the treatment of schizophrenia, bipolar disorder, and other mental health disorders. The nurse should teach clients and caregivers about potential side effects of antipsychotic medications. Key teaching points include: Extrapyramidal symptoms (EPS) include akathisia (restlessness, fidgeting) and Parkinsonism (tremors, shuffling gait). These specific symptoms are important to watch for as EPS is easily mistaken for agitation or negative schizophrenic symptoms (Option 4). Fever and muscle rigidity may indicate neuroleptic malignant syndrome, a potentially fatal condition requiring emergency intervention (Option 1). Clients may experience anticholinergic effects (eg, dry mouth, constipation). Clients should change positions slowly to prevent orthostatic hypotension (Option 2). Sedating effects (eg, drowsiness, hypersomnia [excessive sleeping]) are common (Option 3). Symptoms are evaluated on an individual basis, and most minor symptoms can be managed with a decrease in dosage or change in medication. The health care provider may prescribe medications to treat EPS (eg, benzodiazepines, diphenhydramine, benztropine). Educational objective: Atypical antipsychotic medications (eg, risperidone) are often used to treat symptoms of schizophrenia. Clients should be instructed that they may experience side effects such as anticholinergic effects and sedation, and to watch for adverse reactions such as extrapyramidal symptoms and neuroleptic malignant syndrome.

Extrapyramidal side effects Acute dystonic reaction: Sudden-onset, sustained muscle contractions Akathisia: Subjective restlessness with inability to sit still Drug-induced parkinsonism: Tremor, rigidity, bradykinesia, masked facies Tardive dyskinesia Involuntary movements after chronic use (eg, lip smacking, choreoathetoid movements) Neuroleptic malignant syndrome Fever, rigidity, mental status changes, autonomic instability

Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option 3). (Option 1) Asking a client if a spiritual leader or clergy member is coming to visit may alarm the client or raise suspicion about the surgery. It also assumes that the client's religious or spiritual practices involve a spiritual leader or clergy person. (Option 2) The nurse should attempt to gather more information before notifying the perioperative team. Simply documenting the questionnaire response does not address the client's spiritual needs. (Option 4) The chaplain should not be called until the nurse has assessed the client's specific needs. The client may not wish to see a chaplain. Educational objective: Spiritual, cultural, and religious needs are an important part of the nursing assessment and plan of care. Clients have the right to verbalize and practice their beliefs; the nurse should facilitate spiritual practices within the plan of care.

Perform hand hygiene, open sterile catheterization kit, and apply sterile gloves from kit (Option 2). Maintaining sterility of gloves, place sterile fenestrated drape with opening centered over penis (Option 3). Arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks. Firmly grasp penis with nondominant hand, retracting foreskin if present (Option 6). Nondominant hand is now considered contaminated and remains in this position for duration of procedure. With dominant (sterile) hand, cleanse meatus with antiseptic solution using cotton balls or swab sticks (Option 4). Use new cotton ball or swab stick with each swipe. Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5). Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced. Educational objective: To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves, place fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse meatus using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.

Sedated infants are at increased risk for skin breakdown due to limited mobility, sensory deficits, and incontinence. Ischemia occurs when tissues are compressed between a bony area (eg, occiput) and an exterior surface (eg, bed), causing a pressure injury. The occiput is the highest pressure point in infants due to the increased weight of the head in proportion to the body; shearing may occur as the infant slides down in bed. The head of the bed is elevated ≤30 degrees to reduce pressure on the head and prevent sliding (Option 3). To prevent skin breakdown, moisture barriers (eg, barrier cream) are used to protect the skin from incontinence, perspiration, and drainage (Option 1). Baby powder is not recommended for preventing moisture and friction. The powder's texture can be very abrasive to skin, which increases pressure injury risk. It also carries the risk of respiratory irritation and damage if inhaled. Pulse oximetry sites should be changed every 4 hours to prevent burns and breakdown of the infant's thin skin (Option 2). (Option 4) Donut pillows reduce pressure in the center of the occiput; however, they increase pressure in surrounding areas, causing venous congestion, edema, and skin breakdown. Educational objective: Sedated infants are at increased risk of pressure injuries due to limited mobility, sensory deficits, and incontinence. The nurse should elevate the head of the bed ≤30 degrees to reduce pressure, apply a moisture barrier to any vulnerable tissue areas, reposition the pulse oximeter every 4 hours, and avoid the use of baby powder and donut pillows.

Explanation: Clients with inflammatory bowel disease may undergo a total colectomy with ileostomy creation to control symptoms of chronic abdominal pain and diarrhea. Peristomal skin irritation is the most common ileostomy complication. Peristomal skin care and prevention or treatment of irritation include: Cleansing peristomal skin with mild soap and water Ensuring that the ostomy appliance fits well so that skin is protected from liquid stool drainage Trimming the appliance opening to 1/8 inch (0.32 cm) larger than the stoma so that it "hugs" the stoma without touching stoma tissue (Option 3) (Option 1) Ileostomies are formed from small intestine that bypasses the colon, which results in incontinence of liquid stool that cannot be regulated with irrigation. Irrigation is used to achieve regular emptying of the colon in clients with descending colostomies. (Option 2) To prevent skin irritation, stoma appliances are changed only every 5-10 days. The bag is emptied whenever one-third full to prevent it from becoming heavy and pulling away from the skin. (Option 4) Clients with ileostomies are at risk for dehydration, hyponatremia, and hypokalemia due to increased fluid loss through liquid stool. Clients are encouraged to increase fluid intake. Educational objective: When caring for a client with an ileostomy, the nurse encourages the client to cleanse peristomal skin with mild soap and water, ensure that the ostomy appliance fits well, change appliances every 5-10 days, and increase fluid intake.

Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear. This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole). (Option 1) Eczema is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious. (Option 2) Oral candidiasis, or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother's breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child's mouth. However, oral candidiasis is significantly less contagious than tinea corporis. (Option 3) Psoriasis is a chronic autoimmune disease that most often affects the skin by causing dry, scaly, red rashes. Psoriasis is not contagious. Educational objective: Tinea corporis (ringworm) is a highly contagious fungal skin infection. It is treated with topical antifungals. Clients should be instructed not to share items such as grooming tools, towels, bedding, and hats. Athletic equipment should be cleaned routinely.

Frostbite occurs when vasoconstriction restricts blood flow, intracellular fluid freezes, and cell membranes rupture; tissue may appear pale, waxy, blue, or mottled. Clients with peripheral vascular problems (eg, advanced age, diabetes, smoking) are at a higher risk for developing frostbite. A warm water bath (eg, 98.6-102.2 F [37-39 C]) is administered to thaw and reestablish as much circulation to viable tissue as possible. Subsequent edema and/or superficial blistering may develop as the damaged tissue is rewarmed. Blisters are opened to reduce pressure and sterile dressings are applied. The client will need analgesics as the rewarming process is very painful. (Options 1 and 3) Manual friction (eg, massage, ambulation) applied to tissues affected by frostbite is contraindicated as it may further damage the tissues. (Option 2) Comfort care (eg, warm blankets) may be provided after emergent interventions to salvage the client's lower extremities. However, the nurse should consult with the health care provider before providing food or drink to the client. Educational objective: Tissue damaged by frostbite may appear pale, waxy, blue, or mottled due to frozen intracellular fluid. Affected extremities are thawed in a warm water bath (98.6-102.2 F [37-39 C]), and analgesics are administered. Manual friction (eg, massage, ambulation) is contraindicated as it may further damage the tissue.

The nurse promotes client safety by implementing fall risk precautions. Standard fall risk precautions (eg, bed in lowest position, call light within reach) are appropriate for all clients. A client with multiple fall risk factors (eg, altered mental status, advanced age) has an increased risk for falls and requires additional precautions. The nurse should activate the bed alarm, place the client in a room close to the nurses' station, and place a bedside commode next to the bed. (Option 2) Keeping the lights dim increases the risk for falls, particularly when the client is in an unfamiliar environment. A well-lit room promotes orientation and helps the client avoid obstacles during ambulation. (Option 5) Restraints increase agitation and are associated with serious complications (eg, impaired perfusion and skin integrity). Restraints are indicated only if less restrictive measures fail to keep the client safe. The nurse should first consider alternatives such as family involvement or supervision by a trained staff sitter. Educational objective: The nurse promotes client safety by implementing fall risk precautions. A client with multiple fall risk factors (eg, altered mental status, advanced age) has an increased risk for falls and requires additional precautions (eg, bed alarm, room close to nurses' station).

When a violent client threatens the safety of clients and staff, nurses should use crisis-management techniques to ensure the safety of all clients. Interventions for crisis management of violent clients include: Assemble a crisis team, including security personnel, and identify a leader (eg, charge nurse). Form a plan for the crisis team, with specific tasks (eg, restraining an arm) assigned to each member. Remove all other clients from the area to prevent any further injury (Option 1). Restrain, seclude, and/or medicate (eg, intramuscular haloperidol injection) the client, as needed. Calmly explain the necessity of all interventions to the client. (Option 2) Therapeutic communication may be helpful for calming a client, but in a crisis, the nurse's priority is to ensure the safety of other clients in the area. (Options 3 and 4) Seclusion or restraint of a violent client may be necessary to ensure the safety of other clients and staff, but the priority is to remove other clients from the area. Both seclusion and restraints are restrictive interventions that are traumatic to the client and would violate client rights, if used inappropriately (eg, convenience of staff). Educational objective: When dealing with a violent client, nurses should use crisis-management techniques to ensure the safety of all clients. Interventions include assembling a crisis team to create a specific plan, removing other clients from the area, communicating calmly, and implementing restrictive interventions (eg, restraints, seclusion).

Rabies is caused by a virus present in the saliva of an infected animal (eg, bat, dog) and can be transmitted to a human through a bite, a scratch, or mucous membrane contact. Rabies affects the central nervous system, and can cause viral encephalitis with eventual death from cardiovascular and respiratory collapse if untreated. Clients with actual or suspected rabies exposure should receive rabies postexposure prophylaxis, including: Immediate wound care: Aggressive scrubbing and cleaning with povidone-iodine solution or soap and water to decrease the viral count and the rabies transmission risk (Option 4) Administration of tetanus toxoid vaccine (if the client is not current with immunizations): Tetanus is associated with a high mortality rate and can be transmitted through animal bites (Option 2) Administration of the human rabies immunoglobulin: Provides passive immunity and is injected into the proximal wound area (Option 3) Administration of the human rabies vaccine: Provides active immunity and is administered intramuscularly on the day of exposure and again on days 3, 7, and 14 postexposure (Option 1) Educational objective: The rabies virus affects the central nervous system and is transmitted by the saliva of infected animals (eg, bat, dog) usually via a bite or scratch. Postexposure prophylaxis includes immediate wound care with povidone-iodine or soap and water; vaccines for tetanus and rabies, or rabies immunoglobulin, may be given afterward.

A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum disorder (ASD). The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical day at home, including meal times, bath time, and play time. In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease anxiety and help the client with ASD anticipate what will happen next. (Option 1) A common nursing diagnosis associated with ASD is impaired social interaction characterized by unresponsiveness to people. Limiting the number of visitors can help avoid client overstimulation and facilitate a trusting relationship with the caregiver. (Option 3) Invasive procedures may be particularly difficult and painful for clients with ASD due to their hypersensitivity to touch. Strategies such as distraction and being held by parents or caregivers are preferred over the use of restraints. (Option 4) The young client with ASD may be overwhelmed and overstimulated if given too many choices. The best approach is for family members to bring in some of the client's favorite toys. Educational objective: Structure and consistency are crucial when caring for a client with autism spectrum disorder. A daily schedule of activities can decrease anxiety and help the client anticipate what will happen next. Limiting the number of visitors and choices can help avoid overstimulation and enhance communication with the caregiver.

Medications appear different when produced by different manufacturers, and the client's home medications may vary in color, size, or dosage per tablet. If a client expresses concern about a medication, the nurse should first compare the actual tablet with the client's current prescription (Option 2). (Option 1) Once the nurse verifies that the administered medications match the current prescriptions, the nurse can compare them with the client's home medications and explain any changes in prescriptions. In acute care settings, clients may be on different medication regimens than they are at home. Additional medications may be given in the hospital and some medications may be withheld or decreased/increased in dose (eg, antihypertensives are withheld if the client is hypotensive). (Options 3 and 4) Reassuring a client that an unknown medication was given the previous day or prescribed by the health care provider does not address the client's concern about taking the medication. The nurse should first investigate to ensure that the medication is correct before providing reassurance or education. Educational objective: If the client is concerned about an unknown medication, the nurse should investigate to ensure that the appropriately prescribed medication is being administered before reassuring and educating the client about the medication.

Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by impaired social interaction and behavior. Each child with ASD has unique communication needs, which the nurse should incorporate into an individualized plan of care. When performing a procedure on a child with ASD, the nurse should engage the following communication techniques to ease the child's anxiety and increase cooperation: Provide brief, concrete, and developmentally appropriate communication or demonstrations, explaining each step during the procedure. Children with ASD may respond to pictures, as they tend to be visually oriented (Option 1). Encourage caregivers to remain near the child to provide comfort and reassurance (Option 2). Reduce stimulation by limiting the number of staff members in the room (Option 4). Introduce staff or equipment slowly, preferably with caregivers nearby. (Option 3) Children with ASD may experience stress in response to touching and eye contact. Limit physical contact until conferring with the child's caregiver to assess which actions are soothing and which may trigger behavioral outbursts. Educational objective: Children with autism spectrum disorder (ASD) respond well to brief, concrete, and developmentally appropriate communication. The nurse can ease anxiety during procedures by involving caregivers and reducing stimulation. Physical touch and eye contact may activate a stress response in children with ASD.

Verapamil is a calcium channel blocker sometimes used for the prevention of migraines. Calcium channel blockers may decrease neurovascular inflammation, thereby reducing the occurrence of migraines. Because verapamil affects the cardiac system, the pulse rate should be checked prior to administration due to possible bradycardia (Option 2). The medication should be held, and the client's health care provider contacted, if the heart rate is <60/min. Clients should also have periodic blood pressure evaluations to ensure that hypotension is not occurring. Intake of grapefruit (including grapefruit juice) should be avoided, as it can increase serum levels of verapamil by reducing hepatic clearance of the drug (Option 1). Increasing fluids and fiber helps to prevent constipation, a common side effect of most calcium channel blockers, particularly verapamil (Option 4). (Option 3) Verapamil is taken daily to prevent migraines and does not provide relief during an acute migraine episode. The most common treatment for acute migraine symptoms is administration of nonsteroidal anti-inflammatory drugs (eg, naproxen) or triptan medications (eg, sumatriptan). Educational objective: Clients taking verapamil, a calcium channel blocker, for the prevention of migraines should take the medication daily, check their pulse prior to administration, avoid grapefruit, and increase their intake of fluids and fiber to prevent constipation.

Cyclosporine is an immunosuppressant prescribed to manage rheumatoid arthritis (RA) and psoriasis, and to prevent transplant rejection. This medication inhibits the normal immune response by interfering with T cell response, which slows the progression of certain autoimmune diseases. Clients taking cyclosporine have an increased risk for infection and are instructed to avoid large crowds (eg, concerts, movie theaters) and known sick contacts (Option 1). It can take 1-2 months for the full effect of therapy and relief of symptoms from autoimmune disease (eg, joint stiffness in RA, psoriasis symptoms) to occur. This medication is for long-term use, and it is therefore important to monitor clients for adverse effects. The incidence of secondary malignancies (eg, skin cancer, lymphoma) is increased in these clients. (Option 2) Cyclosporine can cause increased hair growth (ie, hirsutism). Waxing and hair removal creams are safe for use. Gingival hyperplasia is also common and clients require education on proper oral care. (Option 3) Cyclosporine is associated with hypertension and nephrotoxicity. (Option 4) Grapefruit juice can increase serum levels of cyclosporine and is avoided during therapy. Educational objective: Cyclosporine is an immunosuppressant. Clients are at increased risk for infection and secondary cancers (eg, skin cancer, lymphoma). Consuming grapefruit increases the risk for drug toxicity. Gingival hyperplasia, hirsutism, uncontrolled hypertension, and kidney toxicity are other common adverse effects.

Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). (Option 1) A BMI of 25-29.9 kg/m2 indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing. (Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis. (Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing. Educational objective: Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing.

Symptoms of ectopic pregnancy may include lower abdominal and pelvic pain; amenorrhea, possibly followed by vaginal spotting or bleeding; and a palpable adnexal mass on pelvic examination. An ectopic pregnancy may implant in one of many locations outside the uterine cavity, including the fallopian tubes, ovaries, or abdominal cavity. As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening maternal hemorrhage. Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain (Option 4). Shoulder pain results from irritation of the diaphragm by intraabdominal blood. A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention. (Option 1) Abdominal pain with an ectopic pregnancy may start out as mild, dull, and one-sided, and progress to severe and generalized as the pregnancy grows. However, a ruptured ectopic pregnancy is more dangerous than an unruptured ectopic pregnancy. (Option 2) Pelvic inflammatory disease increases the risk for ectopic pregnancies. Although this important piece of the client's history raises suspicion for a diagnosis of ectopic pregnancy, it is not the most concerning finding. (Option 3) Initially, a client with an ectopic pregnancy may report typical early pregnancy symptoms, such as morning sickness. Nausea and vomiting are not uncommon in ectopic pregnancies, and gastrointestinal distress may worsen after rupture. Educational objective: An ectopic pregnancy may rupture prior to diagnosis, causing life-threatening maternal hemorrhage. Symptoms of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain. Ruptured ectopic pregnancy is a surgical emergency requiring immediate intervention.

The best way for health care workers to protect themselves against possible HIV infection is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients with HIV as the virus is not spread through casual contact, droplets, or aerosolized particles. Some experienced nurses hold to the common misconception that "double-gloving" reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3). (Option 1) In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary. (Option 2) Washing hands with soap and water is required to remove Clostridium difficile spores; hand hygiene with foam or gel alone is ineffective. (Option 4) An N95 respirator is worn when the client has an illness that can be aerosolized and spread through the air (eg, tuberculosis, varicella-zoster). Educational objective: HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. Standard precautions are sufficient for preventing the spread of infection when caring for a client with HIV. Despite the common misconception, "double-gloving" is not necessary for reducing the risk of contracting HIV.

Clients with end-stage renal disease are unable to excrete potassium; therefore, the nurse should teach them to choose foods low in potassium to maintain normal serum potassium levels (3.5-5.0 mEq/L). Grilled chicken sandwich on white bread and applesauce are low in potassium (Option 2). (Options 1, 3, and 4) Legumes (eg, black beans), tomatoes, melons (eg, cantaloupe), beef, whole grains, carrots, chocolate, fish (eg, salmon), potatoes, and strawberries are all high in potassium. Educational objective: The kidneys' ability to excrete potassium is compromised in clients with end-stage renal disease. These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels (3.5-5.0 mEq/L).

Clients in physical restraints must be regularly assessed to prevent skin breakdown, neurovascular deficits, and other safety concerns. Facilities may determine the frequency of client monitoring; however, general guidelines include: Performing hourly neurovascular checks (eg, pulses, color, skin temperature, sensation, movement) (Option 3) Briefly releasing restraints for skin integrity assessment and range of motion exercises every 2 hours (Option 4) Offering fluids, nutrition, and toileting every 2 hours and as needed (Option 2) (Option 1) Restraints should be a last resort and discontinued as soon as possible. The nurse should regularly reassess (eg, every hour) the client's continued need for restraints. (Option 5) Once restraints are discontinued, a new prescription is required to reapply them. Trial discontinuations are not permitted. Educational objective: The nurse should monitor clients in physical restraints according to governmental and regulatory agency guidelines and facility policy. Guidelines include regularly assessing neurovascular status; releasing restraints for skin assessment and range of motion exercises; and offering fluids, nutrition, and toileting.

Unlicensed assistive personnel (UAP) are able to do basic tasks related to activities of daily living and routine/predictable tasks of care. Emptying a urinary drainage bag, providing perineal care for a client with an indwelling urinary catheter, and reapplying previously initiated sequential compression devices are all basic tasks that can be safely performed by UAP (Options 1, 4, and 5). However, sterile procedures, such as obtaining a urine specimen from an indwelling urinary catheter, are not appropriate for delegation to UAP. (Option 2) Although UAP can measure the drainage from a wound drainage system (eg, Hemovac, Jackson-Pratt), assessing the quality of drainage (eg, serous, purulent) requires nursing judgment and therefore cannot be delegated to UAP. (Option 3) With a disgruntled visitor, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by either a nurse or a security officer. Educational objective: Unlicensed assistive personnel (UAP) are able to do basic, nonsterile tasks related to activities of daily living and routine/predictable tasks of care. Emptying a urinary drainage bag, providing perineal and catheter care, and reapplying sequential compression devices can all be safely performed by UAP.

By age 6 months, infants are able to roll over and sit up for short periods. Development of eye-hand coordination allows them to locate and grasp objects. In addition, they have an oral fixation and tend to put small objects in their mouth. Caregivers of infants at this stage should employ the following safety strategies: Keep small objects off of the floor Avoid toys with small, removable parts (eg, stuffed animals with hard plastic eyes glued or sewn on) Lock all cabinets in which toxic substances are stored (eg, under kitchen sink) (Option 3) Place sharp or fragile items on high shelves (Option 5) (Option 1) Infants and toddlers should sit in a rear-facing car seat until age 2 years or the child exceeds the car seat's maximum allowable height/weight. (Option 2) Although they are not yet ambulatory, infants can roll and easily fall from heights if inadequately guarded. Childproof gates should be in place once the infant is able to roll over. (Option 4) The infant should never be left alone on a changing table, even with a restraining belt. One hand should be held on the infant at all times if the caregiver must turn away. Educational objective: Safety strategies for caregivers of 6-month-old infants include preventing falls (eg, childproof gate at the top of stairs, hand placed on the child on a changing table), aspiration (eg, no small objects on the floor), and poisoning (eg, locking of cabinets with toxic substances) as well as using a rear-facing car seat until age 2 years.

Alcoholism can have profound, negative effects on family members. Individuals who have experienced physical or emotional abuse or other pathological conditions while living with a substance abuser may have a sense of powerlessness, loss of self-esteem, and a tendency to neglect personal needs to meet the demands of others. Many resources and self-help groups provide support to alcohol-addicted individuals and codependents, including: Alcoholics Anonymous (AA) - provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety. Adult Children of Alcoholics (ACOA) - provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism. Al-Anon - provides help for spouses, significant others, family, and friends of alcoholics to share their personal experiences and coping strategies. Alateen - part of Al-Anon; provides support to adolescent children of alcoholics (Option 3). National Association for Children of Alcoholics (NACOA) - raises public awareness of alcoholism and its effects through leadership in public policy, advocacy for prevention services, and online resources. (Option 1) ACOA is for adults. (Option 2) Al-Anon provides help for the family and friends of alcoholics; however, Alateen is a resource specifically for adolescents, which would be more beneficial to this child. (Option 4) AA provides help to the individual with alcoholism. Educational objective: Alcoholism affects the whole family. Alcoholics Anonymous provides help to alcoholic individuals, Alateen provides support to adolescent children, and Al-Anon provides help for spouses and significant others.

Preeclampsia is a multisystem disorder that occurs after the 20th week of pregnancy. Preeclampsia is defined as new-onset hypertension (≥140/90 mm Hg) after 20 weeks gestation plus proteinuria or signs of end-organ damage. Proteinuria diagnostic of preeclampsia is defined as ≥300 mg/24 hr urine collection, protein/creatinine ratio ≥0.3, or dipstick of ≥1+ (Option 2). Cerebral symptoms, such as headache and visual changes, are potential manifestations of preeclampsia and reasons for concern (Option 4). With severely elevated blood pressure, there is risk of cerebral edema, hemorrhage, and stroke. It is important to prevent the progression of preeclampsia to eclampsia (new-onset seizure in the presence of preeclampsia) to tonic-clonic seizures. Edema occurs in many normal pregnant women as well as those with preeclampsia. Although edema is not part of the diagnostic criteria for preeclampsia, it is a common manifestation of the disease process (Option 1). (Option 3) Frequent urination is common in pregnancy and is not associated with preeclampsia. (Option 5) Pregnancy causes an intravascular volume expansion larger than the rise in red blood cells, resulting in hemodilution. Inadequate iron stores or intake can also play a role. Anemia is defined as hemoglobin <11.0 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester. Anemia is not a specific indicator or criterion for preeclampsia. Educational objective: Preeclampsia is defined as new-onset hypertension (≥140/90 mm Hg) plus proteinuria and/or signs of end-organ damage after 20 weeks gestation. Although edema is not a diagnostic criterion for preeclampsia, it is a common manifestation of the disease process.

Each of the 12 cranial nerves has a sensory function, a motor function, or both. Cranial nerve II, the optic nerve, allows the brain to sense what the eye sees. The client with an impaired cranial nerve II may have altered visual acuity or visual fields. To ensure that the client understands interventions, the nurse should verbally explain all procedures in detail (Option 4). (Option 1) Chewing is affected by cranial nerve V (trigeminal). (Option 2) Although raising the head of the client's bed to prevent aspiration is an appropriate nursing action, it is not necessary with an alteration with cranial nerve II. Swallowing is affected by cranial nerves IX (glossopharyngeal) and X (vagus). (Option 3) Using a pen and paper to ask the client questions would be appropriate if cranial nerve VIII (vestibulocochlear or acoustic) were impaired, causing a hearing deficit. Educational objective: Clients with impairment of cranial nerve II have altered visual acuity or visual fields. To ensure that the client understands interventions, the nurse should verbally explain all procedures in detail.

An incident/adverse event is an unforeseen or unintended outcome that results in harm, or has the potential to cause harm, and may or may not be preventable. Adverse events may involve clients, staff, or visitors, and require completion of incident reports (ie, variance reports, occurrence reports). Health care facilities use incident reports to aid ongoing quality improvement. When a nurse realizes that a reportable incident has occurred, an incident report should be completed separately from the medical record. Completion of this report is not mentioned in the medical record, which should contain only an objective description of observed events. Examples of client incidents include falls, mislabeled laboratory specimens, and medication administration errors (Options 1, 4, and 5). Communication errors may also be classified as adverse events, as the omission or miscommunication of critical information may result in harm, incomplete treatment, or inadequate follow-up (Option 3). Other incident types involving health care staff may include needlestick injuries or confidentiality breaches of protected health information. (Option 2) Under the ethical principle of autonomy, the client has the right to refuse any recommended medical treatment, even if doing so could result in potential harm to the client. Educational objective: Adverse events are unforeseen or unintended outcomes that result in harm, or have the potential to cause harm, and require the completion of incident reports. Examples of client incidents include falls, mislabeled laboratory specimens, medication administration errors, and communication errors.

End-of-life care (eg, hospice) keeps clients as comfortable as possible throughout the dying process. Symptom management and pain control take priority over treating disease because the client and/or family have elected to forgo aggressive and painful treatments and allow a natural death (Option 5). The nurse can use nonverbal pain assessment tools (eg, Face Legs Activity Cry Consolability [FLACC]) to assess symptoms of pain (eg, grimacing, restlessness) in the dying client. An improved FLACC score (eg, less agitation, relaxed facial expression) is a reliable indicator that the client's pain level has improved (Option 1). Education for staff and family members at a client's end of life includes: Reminding the family that pain relief measures are priority and should not be denied or delayed. Encouraging family members to continue to speak with the client even if the client is unable to respond. As senses decline, hearing is often the last one lost. Nurses should assume the client can hear and understand, and continue to verbally explain all interventions (Option 3). Supporting family presence and culturally appropriate physical contact (eg, holding hands) during care to nurture client security, provide comfort, and decrease anxiety (Options 2 and 4). Educational objective: Hospice care helps the client live as comfortably as possible throughout the dying process. Nonverbal pain assessment tools can be used to assess symptoms of pain (eg, grimacing, restlessness) in the dying client. Nurses should manage client's pain, encourage family presence and physical contact, and continue verbally communicating with the client.

Human papillomavirus (HPV) is a common sexually transmitted infection that may cause genital warts. Genital warts are not malignant; however, infection with other types of HPV increases the risk of cervical, oral, and certain other genital cancers (eg, vaginal, penile) (Option 3). Contact with oral, genital, or perineal areas not covered by a condom or other physical barrier method can transmit HPV. Physical barrier methods (eg, condoms, dental dams) can reduce the risk of transmission when compared to unprotected sexual contact (Option 5). However, as with other sexually transmitted infections, the only definitive way to prevent infection is to abstain from intimate contact with anyone who has infection. Women should be screened (eg, Pap testing) regularly for cervical cancer, as recommended by the health care provider, usually starting at age 21 (Option 2). (Option 1) The HPV vaccine does not treat active HPV; rather, it protects against HPV infection. Current immunization guidelines suggest that teens and young adults be vaccinated, ideally before becoming sexually active. (Option 4) Genital warts can be treated (eg, podophyllin, cryotherapy, laser surgery). However, they may return at any time, especially within the first few months following treatment. Educational objective: Because human papillomavirus (HPV) increases the risk of cervical cancer, teens and young adults should be vaccinated with the HPV vaccine and women should be screened (eg, Pap tests) regularly for cervical cancer. Barrier methods (eg, condoms) can reduce transmission; however, uncovered areas are still vulnerable.

Cardiac glycosides (digoxin [Lanoxin]) improve cardiac output and efficiency in clients with heart failure by increasing cardiac contractility and decreasing heart rate. A client experiencing weight gain and orthopnea is likely experiencing a heart failure exacerbation. The nurse should assess the client's entire medication regimen to determine why digoxin may not be working effectively (eg, possible drug interactions). Sucralfate (Carafate) is used to coat and protect the mucosal lining in clients with ulcers; therefore, drug absorption will be altered. Sucralfate should be taken at least 2 hours after digoxin administration, as taking these medications at the same time can result in decreased digoxin absorption (Option 3). (Option 1) Exercise is an important part of maintaining cardiac health. A client with heart failure should exercise as tolerated with frequent periods of rest. However, this is not the priority assessment for a client with a heart failure exacerbation. (Option 2) Checking the heart rate prior to taking digoxin is recommended to assess for signs of digoxin toxicity (eg, bradycardia). However, this is not the priority teaching for a client with a heart failure exacerbation. (Option 4) Information about the client's last visit to the primary care clinic might be helpful but would not be beneficial to the assessment of symptoms. Educational objective: Cardiac glycosides (digoxin [Lanoxin]) improve cardiac output and efficiency in clients with heart failure. Sucralfate (Carafate) taken at the same time as digoxin can decrease absorption of the latter, thereby increasing symptoms of heart failure. Clients should take sucralfate at least 2 hours after digoxin.

Clients who have had a stroke can experience cognitive dysfunction (eg, confusion), neglect on one side, deficits in spatial perception, and paralysis (hemiplegia), all of which increase the risk for injury (eg, falls). The nurse should see this client first to ensure that safety precautions (eg, bed alarm, nonslip socks) are in place to prevent injury (Option 1). The least restrictive measures (eg, orienting the client, room assignment near the nursing station) should be implemented prior to initiating restraints. (Option 2) Albuterol is a beta-adrenergic agonist that stimulates the sympathetic nervous system to cause bronchodilation and relieve asthma symptoms. Expected side effects include tachycardia, palpitations, and tremors. (Option 3) The nurse should administer the prescribed dose of insulin for a client with a blood glucose of 290 mg/dL (16.1 mmol/L). However, a client with a high risk of injury is the priority. (Option 4) Anesthetics and sedating analgesics may exacerbate symptoms of obstructive sleep apnea. Although oxygen saturation is below 95%, the client is stable on room air. Educational objective: Clients who have suffered a stroke can experience cognitive dysfunction (eg, confusion) and hemiplegia, resulting in a high risk for injury (eg, falls). The nurse should ensure that safety precautions (eg, bed alarm, nonslip socks) are in place.

Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. (Option 1) Vomiting with oral intake may indicate infection (viral or bacterial). Most serious abdominal processes (eg, obstruction, intussusception, appendicitis) also have abdominal pain. This client may require IV fluids and antiemetics but is not a priority. (Option 2) Tympanostomy tubes placed for recurrent otitis media may fall out of the ear canal. This child should be evaluated for the presence of infection and the need for possible tube reinsertion, but this is a common occurrence and can wait to be addressed. (Option 4) Increasing pain at skeletal pin sites after surgical fracture repair may indicate infection or displacement of the pins. Pin displacement may compromise blood flow to the leg. The nurse should assess the neurovascular status of the limb, but this does not take priority over a basilar skull fracture. Educational objective: A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway, breathing, and circulation support.

Constipation is a symptom of many disease processes (eg, Parkinson disease, diabetic neuropathy, depression), procedures (eg, abdominal surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids). Immobility, low-fiber diets, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. When caring for a hospitalized client, the nurse should include these interventions to prevent constipation: Have the client ambulate as often as tolerated as movement stimulates peristalsis and defecation (Option 1). Provide the client with high-fiber foods such as fruits, vegetables, whole grains, nuts, seeds, and legumes (Option 2). Fiber softens stool and increases bulk. Encourage the client to drink 2-3 L of fluids each day (unless contraindicated). Provide privacy for the client during restroom use; privacy is important to many clients and influences the ability to defecate. The nurse should leave the client alone and provide a call button in case assistance is required (Option 3). Encourage a healthy bowel regimen, including avoiding delay of defecation when the urge is felt, defecating at the same time each day, and tracking bowel movements to identify if there is a change in patterns. (Option 4) The client should avoid caffeinated beverages (eg, coffee, colas) as they promote diuresis, which may lead to dehydration and worsen constipation. Educational objective: Ambulation, fiber consumption, privacy, and creation of a bowel regimen (eg, avoiding delay of defecation, defecating at the same time each day) are important practices that prevent constipation. Clients should avoid caffeinated beverages, which cause diuresis.

An automated external defibrillator (AED) should be used as soon as it is available, as evidence shows early defibrillation is associated with improved cardiopulmonary resuscitation outcomes. For an AED to work appropriately, the pads must be placed correctly as incorrect placement interferes with appropriate conduction. The anterolateral position is the most common, with one pad below the right collarbone and the other pad a few inches below the left armpit. Additional steps are needed in special circumstances; these include: Moving the client out of large bodies of water Drying the chest area - Water conducts electricity; therefore, it is important to quickly wipe the chest dry before applying pads so that AED energy is appropriately transferred. Removing transdermal medication patches and wiping the chest of medication residue before applying AED pads (Option 1) The AED is used as soon as it is available; its use should not be delayed. (Option 2) The entire body does not need to be completely dry; the chest should be quickly wiped, as this is where the electrical current travels. The AED can still be used if the client is damp or lying in a small puddle of water. (Option 4) AED pads should not be placed over medication patches as this interferes with conduction and can burn the skin. Educational objective: An automated external defibrillator (AED) is used as soon as possible for improved outcomes. The chest should be clean and dry, and any medication patches should be removed before applying the AED pads.

Assault is an act that threatens the client and causes the client to fear harm but without the client being touched (Option 1). False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is not a threat to self or others) (Option 3). Invasion of privacy includes disclosing medical information to others without client consent. A client's information regarding medical treatment is private and cannot be released without the client's permission (Option 5). (Option 2) Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). Lying to a client would violate the ethical principle of veracity (ie, being truthful). (Option 4) An emancipated minor is someone under the age of legal responsibility who has been legally freed from parental control through a court order (eg, due to enlistment in the military, marriage). Emancipated minors have the right to be informed of risks and benefits of procedures prior to care and to give informed consent without asking the clients' parents. Educational objective: Clients have the right to privacy and to give informed consent prior to medical care. Assault is an act that threatens the client, causing the client to fear harm without the client being touched. Battery is physical contact with the client without the client's permission. False imprisonment includes restraining a competent client against the client's will or without legal justification.

Petechiae are a reddish or purple pinpoint rash that occurs due to bleeding from capillaries just beneath the skin. Petechiae usually occur due to blood vessel injury or bleeding disorders (eg, idiopathic thrombocytopenic purpura, disseminated intravascular coagulation). Petechiae and similar skin conditions are often challenging to detect in dark-skinned clients as dark pigmentation makes it difficult to assess skin color changes. In dark-skinned clients, petechiae can best be assessed in the conjunctivae of the eyes and the buccal mucosae. (Option 2) The nail bed of the finger is the best location to assess dark-skinned clients for cyanosis, a blue discoloration that may occur with hypoxemia (ie, decreased blood oxygen). Petechiae generally do not occur in the nail bed. (Option 3) The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client. (Option 4) Over the sacrum and behind the heels are common locations for pressure injury formation; skin here typically appears dark, especially in dark-skinned clients. Educational objective: Skin assessment of dark-skinned clients can be challenging as dark pigmentation makes it difficult to detect color changes. To best assess for petechiae in a dark-skinned client, the nurse should observe the buccal mucosae or conjunctivae.

Varicose veins are tortuous, distended veins, usually accompanied by discomfort (eg, heavy feeling, aching, pruritus). They occur frequently in clients with a family history, certain chronic conditions (eg, heart disease, obesity), or jobs that require prolonged sitting, standing, or heavy lifting. Over time, increased pressure on the legs leads to weakening and dilation of healthy veins. To promote improved venous return and prevent further complications (eg, rupture of the vein, venous stasis ulcer), the nurse should encourage the 3 Es: Elevation: Gravity promotes venous return (Option 4) Low-impact Exercise: Muscles pump blood back to the heart more effectively (Option 5) Graduated Elastic compression hose: Maintenance of venous tone, preventing the backflow of blood (Option 2) Weight reduction should be encouraged to improve mobility and decrease pressure on the legs. Clients should be instructed not to cross the legs when sitting, as this increases pressure on the legs and prevents venous return (Option 1). (Option 3) Prolonged sitting may be as damaging for varicose veins as prolonged standing, as venous return is decreased due to lack of movement. Clients with desk jobs should flex the ankles periodically, elevate the legs when able, and get up and walk whenever possible. Educational objective: Varicose veins (tortuous, distended veins) occur frequently in clients with a family history, certain chronic conditions, or jobs requiring prolonged sitting, standing, or heavy lifting. To improve venous return, the client should follow the 3 Es: elevation, exercise, and elastic compression hose, and should maintain an appropriate weight.

Sleep hygiene refers to a group of practices that promote regular, restful sleep. Components of sleep hygiene include: Keep a consistent sleep schedule, even on nonworking days. Avoid daytime naps; if needed, they should be brief (less than 20-30 min). Go to bed early enough to get at least 7 hours of sleep. Get out of bed if sleep does not occur after 20 minutes (Option 3). Engage in regular, relaxing activities (eg, warm bath, reading) before bedtime. Sleep in a cool, quiet, dark room (Option 4). Avoid brain-stimulating substances or activities at least 4 hours before bedtime (eg, caffeine, computer usage, exercise) (Option 1). Reduce fluid intake before bedtime to prevent nocturia. Use sleeping pills cautiously or avoid them as they may affect daytime functioning, and rebound insomnia may occur on withdrawal. (Option 2) Alcohol may help to induce sleepiness at bedtime; however, it can cause early awakening and fragmented sleep. (Option 5) Clients should not watch television at bedtime as it is stimulating and produces ambient light. The bed should be used only for sleep and sex. Educational objective: Practices to promote sleep hygiene include establishing a regular sleep routine; sleeping in a cool, quiet, comfortable environment; avoiding caffeine and alcohol and reducing fluid intake before bedtime; and limiting stimulating light (eg, computer, television) before bedtime. A client unable to sleep after 20 minutes should get out of bed.

Unlicensed assistive personnel (UAP) are assigned routine tasks with predictable outcomes by the licensed practical nurse (LPN), who coordinates overall client care. UAP can perform active and passive range-of-motion exercises (Option 5). Under the direction of the LPN, UAP can apply protective (ie, barrier) ointment after providing perineal care for a client (Option 1). UAP may obtain and document objective data (eg, height, weight) but must also convey these data to the LPN; the LPN evaluates the data and compares them to expected outcomes (Option 3). (Option 2) UAP can collect data (eg, numeric pain score), but the LPN is responsible for evaluating whether pain relief is adequate. Determining the adequacy of pain relief is an evaluation of treatment and not part of the UAP's scope of practice. The LPN considers additional, subjective signs of pain (eg, facial grimacing, restlessness) when making such evaluations, especially in a nonverbal client. (Option 4) A client with a stroke is not considered stable until approximately 48 hours have passed without changes. The client's risk of losing the gag reflex is still high as the stroke could still be evolving. UAP should feed only stable clients with no risk for aspiration (eg, no dysphagia). Educational objective: Unlicensed assistive personnel (UAP) can perform passive range-of-motion exercises, apply protective ointment, and obtain objective data for stable clients under the direction of a licensed practical nurse. However, UAP cannot feed clients with potential dysphagia or make evaluations about treatment effectiveness.

Septic arthritis (infectious arthritis) is acute joint inflammation due to an infection. Pathogens may enter the joint from the bloodstream (eg, current infection elsewhere in the body), direct penetration (eg, intraarticular injection), or infected adjacent tissue (eg, osteomyelitis). Septic arthritis can lead to irreversible joint damage if not treated promptly. Clinical manifestations of septic arthritis include: Severe, pulsating pain, usually with sudden onset and exacerbated by movement Erythema, warmth, effusion (ie, excess synovial fluid) Limited range of motion due to swelling in the joint Systemic immune response to the joint infection (eg, fever) (may not be present in elderly or immunocompromised clients) The goal of treatment is to limit joint destruction and promote pain relief. Management may include aspirating synovial fluid; immobilizing the joint; restricting weight bearing; and administering antibiotics, analgesics, and antipyretics. (Option 5) Numbness in the lower extremity related to spinal nerve compression can be associated with arthritic diseases (eg, spinal stenosis) but is not characteristic of septic arthritis. Educational objective: Septic arthritis can lead to irreversible joint damage if not treated promptly. Characteristic manifestations include severe pain of sudden onset, erythema, warmth, swelling, limited range of motion, and fever.

Perform hand hygiene, and remove the outer glove package (Option 2). Place the inner glove package on a clean, dry surface. Open the inner package by carefully folding back the edges (Option 1). Use the nondominant hand to grasp the cuff of the dominant glove. Touch only the inside surface of the glove (Option 6). Pull on the dominant hand glove (Option 4). Place the fingers of the gloved dominant hand under the cuff of the nondominant glove. Keep the gloved thumb pulled away to prevent contact with the skin of the nondominant hand (Option 3). Pull on the nondominant hand glove (Option 5).

Permanent pacemakers consist of a generator that is implanted subcutaneously in the chest and lead wires that terminate in the heart. Infection of the incision site can easily travel down the pacemaker lead wires into the heart, causing myocarditis and/or endocarditis. Infection may disrupt pacemaker function and result in failure to sense or pace that causes decreased cardiac output and life-threatening arrhythmias. Signs and symptoms of pacemaker malfunction (eg, hypotension, bradycardia, dizziness) and infection (eg, redness, fever, purulent drainage) should be assessed immediately (Option 3). (Option 1) Redness at the umbilicus with fever may indicate infection due to a retained umbilical cord. This requires parent teaching on proper care and an antibiotic but is not the priority. (Option 2) Post-tussive emesis (vomiting after coughing) can occur in children during frequent or severe coughing spells. A respiratory rate of 27/min is slightly elevated for a 2-year-old (normal: 25/min). This child should be assessed for the cause of the cough (eg, respiratory infection) but is not the priority. (Option 4) This client needs to be evaluated second for possible concussion or hemorrhage; however, the client is currently alert and responsive. Educational objective: Infection of a pacemaker incision site can travel down the lead wires to the heart, causing myocarditis and/or endocarditis. Infection may disrupt pacemaker function, resulting in failure to sense or pace that causes decreased cardiac output and life-threatening arrhythmias. Signs and symptoms of pacemaker malfunction (eg, dizziness) and infection (eg, purulent drainage at incision site) should be assessed immediately.

Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible (Option 1). To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes (Option 3). Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in (Option 5). A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 4). Place a pillow under the head to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client's belongings to a family member or send with the body. (Option 2) This client's death was expected. It is not necessary to contact the medical examiner for autopsy. Educational objective: Postmortem care involves preparing the body for presentation to the family and includes hygiene (removing soiled linens and dressings, cleaning the body and room) and positioning (head on pillow, pad under perineum, mouth and eyes closed).

Priority assessment of the pregnant client during the third trimester emphasizes early identification of complications and differentiation from normal physiologic changes and discomforts of pregnancy. Leukorrhea (ie, whitish, mucoid vaginal discharge) increases dramatically during pregnancy. However, copious, clear vaginal discharge that is thin or watery could indicate leaking of amniotic fluid, especially in the third trimester. Assessing for rupture of membranes should be a priority (Option 1). Frequent urination throughout pregnancy may be caused by uterine enlargement, hormonal influences, increased blood volume, and changes in glomerular filtration rate. However, dysuria, cloudy urine, or flank pain should not be present and may indicate infection (Option 2). Headache, right upper quadrant pain, and visual changes could indicate preeclampsia and need priority assessment (Option 4). (Option 3) During pregnancy, total blood volume increases by 30%-50%, and estrogen contributes to increased vascularity of the mucous membranes. These physiologic changes cause capillary engorgement and hyperemia, which may lead to nasal stuffiness and a sense of fullness in the ears. (Option 5) Colostrum, a precursor to breast milk, is yellow-orange in color and may be seen leaking from the nipples during the second and third trimesters. Educational objective: Common physiologic changes in pregnancy include nasal stuffiness, ear fullness, and colostrum secretion. Findings warranting further investigation and evaluation include dysuria; flank pain; headache with blurred vision; and copious amounts of watery, clear vaginal discharge.

Barium, a contrast medium, aids in the visualization of tumors, obstructions, polyps, and other abnormalities. Barium can be administered rectally (ie, enema) to fill the lower gastrointestinal tract and facilitate clear x-ray images of the large intestine. After the procedure, clients should increase fluid intake and consume foods high in fiber to facilitate removal of the barium. Retention of barium can cause fecal impaction or bowel obstruction, resulting in severe complications such as bowel perforation and peritonitis. Reports of constipation should be assessed further as intervention (eg, laxatives, suppositories) may be needed to help evacuate the barium and prevent complications. (Option 2) A bowel obstruction causes gas and fluid to accumulate, stretching the lumen. Flatulence is an expected finding after the obstruction is cleared and the bowels are decompressed. (Option 3) Clients with irritable bowel syndrome may experience diarrhea, constipation, or both. This client may need fluid and electrolyte replacement from loss through stools, but it is not a priority. (Option 4) Bloody diarrhea is an expected finding in clients with ulcerative colitis; fewer than 4 stools a day indicates mild disease. Although this client should be assessed, the client with a potential bowel obstruction related to barium is higher priority. Educational objective: After a barium enema, evacuation of the barium through bowel movements is crucial for preventing impaction or obstruction. Reports of constipation after the procedure should be assessed to prevent the development of severe complications (eg, bowel perforation).

Atypical presentation of a myocardial infarction (MI) refers to a client who is having characteristic symptoms (eg, sweating, nausea, dyspnea) with no chest pain. Although any client may have atypical symptoms during an MI, certain factors increase the risk of atypical presentation. Clients with advanced age or female gender have a greater risk for atypical presentation during an MI (Option 1). Clients with diabetes or neuropathy may have impaired pain perception due to nerve dysfunction, which makes them more likely to have an atypical presentation, or a silent MI (ie, asymptomatic). (Options 2, 3, and 4) Hyperlipidemia, hypertension, and smoking increase the risk of MI, but these factors do not specifically increase the risk of atypical presentation. Educational objective: Atypical presentation of a myocardial infarction involves associated symptoms (eg, sweating, nausea, dyspnea) with no chest pain. Women, older adults, and clients with diabetes or neuropathy are more likely to have an atypical presentation.

Malfunctioning health care equipment must be taken out of service to prevent client injury. If an automatic, noninvasive blood pressure (BP) machine malfunctions (eg, overinflates, displays error message), it may cause an inaccurate reading and pain and bruising to the client. The nurse should tag any malfunctioning piece of equipment and take it out of service until it can be checked by maintenance personnel (Option 4). The nurse should take the client's BP with a manual cuff so that the maximum inflation can be controlled. A BP cuff needs to be inflated only approximately 30 mm Hg above the pressure at which the client's brachial pulse disappears. (Option 1) Placing a washcloth under the cuff can make the blood pressure measurement less accurate and does not address malfunctioning equipment. (Option 2) If the nurse suspects that health care equipment is malfunctioning, it should not be used. Troubleshooting malfunctioning equipment on the client may harm the client. (Option 3) BP cuffs that are too small or too large for a client will affect the accuracy of the BP measurement, so the nurse should always verify that the correct size of cuff is being used. Educational objective: Malfunctioning health care equipment, such as an automatic, noninvasive blood pressure machine that is overinflating and displaying an error message, must be taken out of service to prevent client injury. The nurse should verify the correct cuff size and take a manual blood pressure.

Administration of a placebo (a substance with no therapeutic effect) outside of a consented research trial is unethical and deceitful. Clients with a history of drug abuse and increased opioid tolerance often require a higher-dose analgesic or stronger opioid (eg, hydromorphone) to achieve pain relief. The most appropriate action by the charge nurse at this time is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine to alleviate uncontrolled pain (Option 3). (Options 1 and 2) Any documentation or reporting (eg, variance or incident report) should be completed after addressing the issue with the nurse, to ensure the client receives the appropriate medications for pain relief. (Option 4) A hospital ethics committee examines the overall plan of care for clients with complex, often life- or limb-threatening conditions. A scenario such as this client's should be resolved by unit management and not be escalated to the ethics committee unless it becomes a pervasive issue or a pattern of behavior among nursing staff. Educational objective: Administration of a placebo outside of a consented research trial is unethical and deceitful. When faced with an ethical dilemma, the nurse should address the client's needs prior to reporting or documenting the unethical behavior.

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (eg, >5.0 mEq/L [5.0 mmol/L]) may progress to lethal dysrhythmias (eg, ventricular fibrillation) Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation Hyperphosphatemia (eg, >4.4 mg/dL [>1.42 mmol/L]) can cause acute kidney injury and dysrhythmias TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia. (Option 1) Superior vena cava (SVC) syndrome (eg, dyspnea, facial and upper body edema, engorged upper body blood vessels) is an oncologic emergency caused by SVC compression (eg, tumors). Radiation or chemotherapy may relieve SVC compression. (Option 2) Syndrome of inappropriate antidiuretic hormone (SIADH) (eg, edema, dilutional hyponatremia) often occurs with central nervous system involvement of cancer. Effective cancer treatment corrects SIADH. (Option 4) Neutropenia from cancer treatment puts clients at high risk for infection and sepsis (eg, hypotension, elevated lactic acid). Fluid resuscitation should be promptly initiated, blood cultures drawn, and IV antibiotics started. Educational objective: Tumor lysis syndrome, an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components into the bloodstream (eg, hyperkalemia, hyperphosphatemia). Released nucleic acids degrade into uric acid and cause hyperuricemia, leading to possible kidney injury.

Singed facial hair may indicate a smoke inhalation injury from close proximity to a fire. Inhaled smoke causes injury to the airway and lung tissue, which may result in life-threatening pulmonary or tracheal edema. The nurse should assess for any indications of inhalation injury (eg, singed facial hair, hoarse voice, burned clothing around the chest and neck) and prepare for emergent intubation to protect the airway. (Option 1) A child who has a headache after a head trauma may have a concussion and will require a neurologic examination. This client is alert enough to verbalize pain and will likely be discharged with instructions to the parents to observe for changes in neurologic status. (Option 2) A client who is unable to raise an injured arm above the head may have a rotator cuff tear. This client will require joint rest, application of ice or heat, and analgesia with nonsteroidal anti-inflammatory drugs but is not the priority. (Option 4) An elderly client with severe diarrhea is at risk for dehydration. The client may require IV fluids and further workup, but this treatment may be delayed until treatment of higher-priority clients. Educational objective: Smoke inhalation injuries may cause life-threatening pulmonary or tracheal edema. The nurse should assess for any indications of inhalation injury (eg, singed facial hair, hoarse voice, burned clothing around the chest and neck) and prepare for emergent intubation to protect the airway.

Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option 1). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge them or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options 2 and 4) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider. Educational objective: Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements should be monitored and stool softeners administered as prescribed. Additional nursing measures include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen; and placing clients in a side-lying position or assisting with ambulation.

Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and damage to the endothelium from surgeries or IV catheter placement. VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) (Option 3) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. Educational objective: Hospitalized clients have many risk factors for venous thromboembolism (VTE), including immobility and damage to the endothelium from surgeries or IV catheter placement. VTE prophylaxis measures include anticoagulation, compression devices, ambulation, leg exercises, and prevention of pressure behind the knees (eg, crossing legs).

For clients with increased intracranial pressure (ICP), the goal is to reduce ICP while managing the client's basic needs; however, many nursing activities increase client ICP. Nursing interventions to decrease ICP include: Position head of bed at 30 degrees to promote venous return from the head, which decreases cerebral edema. Elevating the head >30 degrees decreases blood pressure, which can decrease cerebral perfusion pressure (CPP); therefore, position the client to balance ICP and CPP. Keep head and body midline and avoid hip or neck flexion, as this impedes venous return (Option 4). Administer stool softeners to prevent straining during defecation (Option 1). Straining and coughing increase intrathoracic and intra-abdominal pressure, increasing ICP. Keep client in a calm environment; minimize noise and disturbances (eg, dim lights, limit visitors) (Option 2). Reduce metabolic demands (eg, pain, hypoxia, fever). Treat fever aggressively (eg, acetaminophen) and avoid shivering. (Option 3) For clients with increased ICP, elevating the head of the bed is preferred over using pillows. Elevating the head with pillows may flex the neck, therefore decreasing venous drainage and increasing ICP. (Option 5) Suctioning is uncomfortable, increases ICP, and should be performed only when needed to maintain airway and for ≤10 seconds per pass. Educational objective: For clients with increased intracranial pressure, reduce metabolic demands (eg, treat fever and/or pain), promote venous return (eg, keep head midline at 30 degrees), limit stimulation (eg, from suctioning, noise), and administer stool softeners to prevent straining during defecation.

A pregnant nurse does not have a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) if appropriate infection precautions are used (Option 3). The nurse should carefully follow contact precautions, including wearing gloves and a gown and performing strict hand hygiene. Even if the pregnant nurse were to contract MRSA, there are few known harmful effects to the fetus. TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health care workers. (Option 1) Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, nurses limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. Pregnant health care workers should not care for these clients if possible as fetal radiation exposure is teratogenic. (Option 2) Herpes zoster (ie, shingles, varicella-zoster virus infection) is a TORCH infection, and pregnant health care workers should avoid caring for these clients. (Option 4) Zika virus may be transmitted through mosquito bites, infected body fluids, and sexual contact. Using standard precautions should provide protection; however, because Zika is known to cause birth defects, pregnant health care workers should not care for a client exposed to it if at all possible. Educational objective: Pregnant health care workers can safely care for clients with methicillin-resistant Staphylococcus aureus by using contact precautions. Clients receiving radioactive therapy or with infections known to be teratogenic should not be assigned to pregnant health care workers.

Clients may use complementary and alternative medicine (CAM) with conventional medicine. Generally, CAM is categorized into 5 groups: Biologically based medicine: Aromatherapy, whole-food diets Complete medical systems: Homeopathy Energy-based medicine: Acupuncture, Reiki, magnet therapy Osteopathic or body-based practices: Chiropractic, massage Mind-body therapies: Biofeedback, meditation/prayer, hypnosis CAM modalities are often low risk when used appropriately, but some practices may cause adverse interactions or place the client at risk for injury. Clients on anticoagulants (eg, apixaban, rivaroxaban, edoxaban) or with a bleeding disorder (eg, hemophilia) should not undergo acupuncture (thin needle insertion) without first consulting their health care provider as it increases the risk for bleeding (Option 1). (Option 2) The use of garlic supplements has been shown to slightly reduce cholesterol levels, and there is no known interaction with statin medications (eg, atorvastatin). (Options 3 and 4) Massage and biofeedback are low-risk CAM modalities that can be used for a variety of conditions. However, massage should be avoided in clients with unstable orthopedic conditions. Biofeedback, learning to control physiological responses (eg, muscle tension, heart rate) by monitoring and feedback, has not been correlated with significant adverse effects. Biofeedback therapy can assist with strengthening pelvic floor muscles after birth. Educational objective: Clients taking anticoagulants or with bleeding disorders should not use acupuncture due to the risk for bleeding.

Sepsis is a life-threatening condition that occurs when a known or suspected infection triggers systemic inflammatory response syndrome (SIRS). A client with symptoms of infection (eg, urinary tract infection) displaying two or more SIRS criteria (eg, fever, tachypnea) requires immediate intervention (eg, fluids, antibiotics). This overwhelming inflammatory response can progress rapidly to hemodynamic instability, respiratory failure, and end-organ dysfunction. (Option 1) Addressing postoperative pain and nausea is important but a lower priority than addressing and treating possible sepsis. (Option 2) A client with diabetes who is hyperglycemic is not as much a life-threatening concern as a client with impending sepsis. (Option 4) This client's total intake and output and recent electrolyte levels should be assessed, but this client is not at immediate risk because fluids and electrolytes are being repleted. Educational objective: A client with a suspected infection and vital sign changes indicative of systemic inflammatory response syndrome (eg, fever, tachypnea) requires immediate treatment with IV fluids and antibiotics.

A PRN (ie, as needed) medication prescription must state the name, dose, route, and purpose of the medication (eg, pain, nausea, sleep) and the time interval between doses. The nurse should administer a PRN medication for its prescribed purpose only. If the client requires medication for a different purpose, the nurse should contact the health care provider (HCP) to either clarify the current prescription or request a new prescription. If a client requests a sleep aid and does not have a prescription for sleep medication, the nurse should contact the HCP to request a prescription (Option 4). (Option 1) If diphenhydramine (Benadryl) is prescribed every 8 hours PRN and the previous dose was at 11:00 AM, it would be appropriate to administer a dose at 9:00 PM; however, diphenhydramine that is prescribed for itching may be administered only for itching. (Option 2) Lorazepam that is prescribed for anxiety may be administered only for anxiety. (Option 3) Informing a client that there is no prescribed medication that can be administered for sleep does not resolve a client's request for help with sleep. The nurse should implement actions to address the client's difficulty sleeping. Educational objective: A PRN prescription states the name, dose, route, and purpose of the medication (eg, for pain, nausea, sleep) and the time interval between doses. A nurse must administer a PRN medication for its prescribed purpose only.

Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure. The skin is assessed at the bleb administration site 48-72 hours after placement. Positive results include an induration of ≥15 mm in healthy individuals, ≥5 mm in high-risk populations and ≥10 mm in clients with potential risk or mild immunosuppression. Redness without induration is a negative reaction. This immigrant client has a positive purified protein derivative test (>10-mm induration). The bacille Calmette-Guérin vaccine improves TB resistance in high-risk countries but produces false-positive tuberculin skin test results. Knowing this information and documenting it is important (Options 1 and 2). Positive results warrant further testing. Chest x-ray helps identify clients who do not have symptoms but still have active disease. Sputum cultures can be used for diagnosis if the client is symptomatic (Option 4). (Options 3 and 5) Clients with active TB are placed under airborne isolation precautions in single-occupancy, negative-pressure rooms. Staff/visitors must wear N95 particulate respirators when in the room. Surgical masks are not protective against TB. Regardless, this client has no symptoms, and unless chest x-ray or sputum culture is positive, the client has only latent TB (exposure). Educational objective: Prior administration of the bacille Calmette-Guérin vaccine can produce a false positive tuberculin skin test (purified protein derivative [PPD] reaction). Positive PPD reactions in clients who are asymptomatic need further evaluation with chest x-ray.