NYU Adult and Elder 1 Final zzz

A student nurse is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend?

A. Tell the student that temporary confusion is normal and simply requires reorientation

B. Tell the student to increase the patient's fluid intake since the urine is concentrated

C. Tell the student that her assessment findings are normal for an older adult

D. Tell the student that he will notify the physician of the findings

D

The patient may have subtle symptoms of a urinary tract infection, as evidenced by a slight increase in body temperature, development of confusion, and the dark-colored urine. Temporary confusion is not a normal condition in older adults. Increasing the fluid intake is acceptable but not a recommendation for the set of symptoms the patient presents. The presenting set of symptoms is not normal.

A patient's family member is considering having her mother placed in a nursing center. You have talked with the family before and know that this is a difficult decision. Which of the following criteria would you recommend in choosing a nursing center? (Select all that apply.)

A. The center should be clean, and rooms should look like a hospital room.

B. There should be adequate staffing on all shifts.

C. Social activities should be available for all residents.

D. Three meals should be served daily with a set menu and serving schedule.

E. Family involvement in care planning and assisting with physical care is necessary.

B, C, E

Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person's home.

A nurse has conducted an assessment of a new patient who has come to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the nursing history. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:

A. Dementia.

B. Depression.

C. Delirium.

D. Disengagement.

B

Factors that often lead to depression include presence of a chronic disease or a recent change or life event (such as loss). Patients are alert but easily distracted in conversation.

A major life event such as the death of a loved one, a move to a nursing home, or a cancer diagnosis could precipitate:

A. Dementia.

B. Delirium.

C. Depression.

D. Stroke.

C

The onset of depression could be abrupt or gradual, but the usual cause is a major life-altering event in the life of the person experiencing the depression.

Sexuality is maintained throughout our lives. Which answer below best explains sexuality in an older adult?

A. When the sexual partner passes away, the survivor no longer feels sexual.

B. A decrease in an older adult's libido occurs.

C. Any outward expression of sexuality suggests that the older adult is having a developmental problem.

D. All older adults, whether healthy or frail, need to express sexual feelings.

D

Sexuality is normal throughout the life span, and older adults need to be able to express their sexual feelings.

Older adults experience a change in sexual activity. Which best explains this change?

A. The need to touch and be touched is decreased.

B. The sexual preferences of older adults are not as diverse.

C. Physical changes usually do not affect sexual functioning.

D. Frequency and opportunities for sexual activity may decline.

D

As a result of loss of a loved one or a chronic illness in themselves or their partner, opportunities for sexual activity may decline.

You see a 76-year-old woman in the outpatient clinic. Her chief complaint is vision. She states she has really noticed glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. You suspect that she may have:

A. Presbyopia.

B. Disengagement.

C. Cataract(s).

D. Depression.

C

Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of vision. Presbyopia is a common eye condition resulting in a person having difficulty adjusting to near and far vision. The symptoms are not reflective of depression since her vision affects her ability to interact. She has not chosen to avoid her friends. Disengagement is a term referring to aging theory.

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read and has a hearing loss. His family caregiver will be visiting before discharge. What can you do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.)

A. Speak loudly so the patient can hear you.

B. Sit facing the patient so he is able to watch your lip movements and facial expressions.

C. Present one idea or concept at a time.

D. Send a written copy of the instructions home with him and tell him to have the family review them.

E. Include the family caregiver in the teaching session.

B, C, E

Teaching and communication are more effective with older adults when you sit and face the patient and present one idea or concept at a time. This requires planning. Speaking loudly can distort sound. Speak in a normal tone. Sending instructions is helpful but will not directly facilitate the patient's own understanding. Sharing information with a caregiver provides someone to clarify instructions

Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result, the older adult is less able to discern:

A. Spicy and bland foods.

B. Salty, sour, and bitter tastes.

C. Hot and cold food temperatures.

D. Moist and dry food preparations.

B

Often an older adult uses "heavy" spices because of his or her inability to taste the food.

Kyphosis, a change in the musculoskeletal system, leads to:

A. Decreased bone density in the vertebrae and hips.

B. Increased risk for pathological stress fractures in the hips.

C. Changes in the configuration of the spine that affect the lungs and thorax.

D. Calcification of the bony tissues of the long bones such as in the legs and arm.

C

This can also affect the ability of the patient to deep breath and cough effectively.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are your major concerns for this patient? (Select all that apply.)

A. The loss of his work role

B. The risk of social isolation

C. A determination if the wife will need to start working

D. How the wife expects household tasks to be divided in the home in retirement

E. The age the patient chose to retire

A, D

The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time, nor is the age of the patient.

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings places him at risk for an adverse drug event? (Select all that apply.)

A. Taking two medications for hypertension

B. Taking a total of eight different medications during the day.

C. Having one physician who reviews all medications

D. Patient's health history

E. Involvement of the caregiver in assisting with medication administration

B

The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

You are caring for an 80-year-old man who recently lost his wife. He shares with you that he has been drinking more than he ever did in the past and feels hopeless without his wife. He reports that he rarely sees his children and feels isolated and alone. This patient is at risk for:

A. Dementia.

B. Liver failure.

C. Dehydration.

D. Suicide.

D

The patient is sharing that he is depressed. Key concepts include recent loss of his wife, excessive drinking, hopelessness, and isolation, making him at risk for suicide.

You are working with an older adult after an acute hospitalization. Your goal is to help this person be more in touch with time, place, and person. What might you try?

A. Reminiscence

B. Validation therapy

C. Reality orientation

D. Body image interventions

C

Reality orientation is a communication technique that can help restore a sense of reality, improve level of awareness, promote socialization, elevate independent functioning, and minimize confusion.

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable around 130/70. The patient does not exercise regularly and complains of weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)

A. Presence of a chronic disease

B. Impaired vision

C. Residence design

D. Blood pressure

E. Leg weakness

F. Exercise history

B,E,F

Risk factors for falling include sensory changes such as visual loss, musculoskeletal conditions affecting mobility (in this case weakness), and deconditioning (from lack of exercise). The mere presence of a chronic disease is not a risk factor unless it is a condition such as a neurological disorder that alters mobility or cognitive function. The patient's blood pressure is stable, and there is no report of orthostatic hypotension. A one-floor residence should not pose risks

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:

A. Inference.

B. Diagnostic reasoning.

C. Competency.

D. Problem solving.

D

This is an example of problem solving. The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient's IV and not on solving the patient's health problem; thus this is not the diagnostic reasoning process.

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:

A. Diagnostic reasoning.

B. Competency.

C. Inference.

D. Problem solving.

A

In this example the nurse collects information about the patient, sees patterns in the data collected, and makes a nursing diagnosis. This is an example of the diagnostic process.

A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are:

A. Problem solving.

B. Showing humility.

C. Conducting reflective practice.

D. Exercising responsibility.

C

Reflective practice is a conscious process of thinking, analyzing, and learning from previous work situations. The staff may discuss problems that occurred, but in this case they are reflecting on them to learn for future patient situations.

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.)

A. Experience

B. Ethical

C. Analyticity

D. Self-confidence

E. Risk taking

C,D

Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering additional findings, and sensing a problem), and self-confidence (calling the physician, which shows trust in his own reasoning). The nurse's experience would have influenced the familiarity of patient symptoms, but in this text experience is considered a component of the critical thinking model and not a concept. Acting ethically is a critical thinking standard

A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.)

A. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction.

B. Think about past experience with patients who develop postoperative complications.

C. Decide which activities can be combined for patients B and C.

D. Carefully gather any assessment information and identify patient problems.

C

Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of clinical decision making for groups of patients. Thinking about past experience with patients is an example of reflection, an approach to strengthen critical thinking skills. Gathering assessment information is part of the process of diagnostic reasoning, which should be applied to each patient.

The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?

A. Deep

B. Relevant

C. Consistent

D. Significant

C

Use of the same pain scale for assessing pain acuity is an example of being consistent.

During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?"

A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."

B. "I see that you're uncomfortable. I'll call your doctor to decide the next step."

C. "Show me exactly where your pain is and rate it for me on a scale

A

The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of integrity. In calling the doctor for the next step, the nurse does not reinforce the importance of exercises, which is likely the standard of care for this type of patient. In asking the location and strength of the pain the nurse is interpreting further to determine if any other physical problems are developing. In attempting to learn if any other underlying problems exist, the nurse is showing curiosity.

The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.)

A. Data entry of time of day, who was present, and condition of the child

B. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response

C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death

D. A description of what the nurse said to the mother, the mother's response, and how the nurse might a

B,C,D

The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate.

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is:

A. Commitment.

B. Scientific method.

C. Basic critical thinking.

D. Complex critical thinking.

C

This is an example of basic critical thinking, in which the nurse trusts that experts have the right answers for how to insert the Foley catheter and thus goes to the procedure manual. Thinking is concrete and based on a set of rules or principles.

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:

A. Planning.

B. Evaluation.

C. Intervention.

D. Diagnosis.

B

The patient's baseline for wound drainage was 40 mL, representing the initial assessment of the patient's wound condition. In this example the nurse is evaluating to determine if there is a change in the amount of drainage, which indicates the progress of wound healing.

The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is:

A. Experience.

B. Problem solving.

C. Knowledge application.

D. Clinical decision making.

C

The nurse reviewed knowledge that pertained to the patient's clinical situation, allowing him to apply critical thinking in the patient's care.

A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.)

A. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations.

B. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead.

C. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early.

D. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.

E. The

A

Successful delegation is represented by good communication, showing respect, and showing initiative. The example in answer 2 shows a lack of initiative on the part of the nurse

Which of the following is unique to the commitment level of critical thinking?

A. Weighs benefits and risks when making a decision.

B. Analyzes and examine choices more independently.

C. Concrete thinking.

D. Anticipates when to make choices without others' assistance.

D

Anticipating when to make choices during decision making is unique to the commitment level of critical thinking. Thinking concretely is basic critical thinking. Analyzing and examining choices and weighing benefits and risks are characteristic of complex critical thinking.

In which of the following examples is the nurse not applying critical thinking skills in practice?

A. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance.

B. The nurse uses a fall risk inventory scale to determine a patient's fall risk.

C. The nurse observes a change in a patient's behavior and considers which problem is likely developing.

D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

D

The nurse is explaining how to provide care on the basis of knowledge. Considering personal experience is self-regulation through reflection. Determining a patient's fall risk is evaluation, using a criteria-based screening scale. Observing a change in the patient's behavior and considering likely developments is inference, in which the nurse looks for a relationship in findings.

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?

A. Setting the stage

B. Gathering information about the patient's chief concerns

C. Collecting the assessment

D. Termination

C

The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history.

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.)

A. Active listening

B. Open-ended questioning

C. Closed-ended questioning

D. Problem-oriented questioning

C,D

The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.)

A. Active listening

B. Back channeling

C. Validating

D. Use of open-ended questions

E. Use of closed-ended questions

A, D

Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling

The nurse's first action after discovering an electrical fire in a patient's room is to:

A. Activate the fire alarm.

B. Confine the fire by closing all doors and windows.

C. Remove all patients in immediate danger.

D. Extinguish the fire by using the nearest fire extinguisher.

C

Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

A. Activity intolerance

B. Impaired bed mobility

C. Acute pain

D. Risk for falls

D

For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)

A. Insert a urinary catheter.

B. Leave a night light on in the bathroom.

C. Ask the physician to order a restraint.

D. Keep the bed in low position with upper and lower side rails up.

E. Assign a staff member to stay with the patient.

F. Provide scheduled toileting during the night shift.

G. Keep the pathway from the bed to the bathroom clear.

B,F,G

Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.)

A. Contact the nursing supervisor.

B. Restrict the family's visiting privileges.

C. Ask the family to stay with the patient.

D. Inform the family of the risks associated with side-rail use.

E. Thank the family for being conscientious and put the four rails up.

F. Discuss alternatives with the family that are appropriate for this patient.

D,F

The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that:

A. A safe environment promotes patient activity.

B. Assessment focuses on environmental factors only.

C. Teaching home safety is difficult to do in the hospital setting.

D. Most accidents in the older adult are caused by lifestyle factors.

A

Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to:

A. Place a bed alarm device on the bed.

B. Place the patient in a belt restraint.

C. Provide one-on-one observation of the patient.

D. Apply wrist restraints.

A

Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

How does the nurse support a culture of safety? (Select all that apply.)

A. Completing incident reports when appropriate

B. Completing incident reports for a near miss

C. Communicating product concerns to an immediate supervisor

D. Identifying the person responsible for an incident

A, B, C

Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.)

A. Smokes a pack a day

B. Used a cane to walk at home

C. Takes antihypertensive and diuretics

D. History of recent fall

E. Neglect, spatial and perceptual abilities, impulsive

F. Requires assistance with activity, unsteady gait

G. IV line, urinary catheter

D,E,F,G

Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)

A. B/P = 128/84

B. Respirations 26 per minute on room air

C. HR 114

D. Crackles heard on auscultation

E. Pain reported as 3 on scale of 0 to 10 after medication

B,D

Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur

A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to:

A. Call the health care provider to report this change in condition.

B. Give the patient a paper bag to breathe into to decrease her anxiety.

C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. Correct

D. Explain that this is normal after such trauma and administer the ordered pain medication.

C

These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to:

A. Prevent varicose veins.

B. Prevent muscular atrophy.

C. Ensure joint mobility and prevent contractures.

D. Promote venous return to the heart.

D

Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.

A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.)

A. The rubber mat in the walk-in shower

B. The three-legged stool on wheels in the kitchen

C. The braided throw rugs in the entry hallway and between the bedroom and bathroom

D. The night-lights in the hallways, bedroom, and bathroom

E. The cordless phone next to the patient's bed

B,C

Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.

A patient of any age can develop a contracture of a joint when:

A. The adductors muscles are weakened as a result of immobility.

B. The muscle fibers become shortened because of disuse.

C. The calcium-to-phosphorus ratio becomes disrupted.

D. There is a deficiency in vitamin D.

B

The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

A. Stage I

B. Stage II

C. Stage III

D. Stage IV

A

A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

A. Necrotic tissue

B. Wound drainage

C. Drainage on the dressing

D. Wound after it has first been cleaned with normal saline

D

Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

Which description best fits that of serous drainage from a wound?

A. Fresh bleeding

B. Thick and yellow

C. Clear, watery plasma

D. Beige to brown and foul smelling

C

Serous fluid generally is serum and presents as light red, almost clear fluid.

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

A. Keeping the buttocks exposed to air at all times

B. Using a large absorbent diaper, changing when saturated

C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment

D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

C

Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.

What does SPICE in Fulmer's SPICES framework stand for?

Sleep disorders

Problems with eating or feeding

Incontinence

Confusion

Evidence of falls

The use of critical thinking skills during the assessment phase of the nursing process ensures

that the nurse

a. Completes a comprehensive database.

b. Identifies pertinent nursing diagnoses.

c. Intervenes based on patient goals and priorities of care.

d. Determines whether outcomes have been achieved.

A

The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes

have been achieved takes place during the evaluation phase of the nursing process

A nurse using the problem-oriented approach to data collection will first

a. Complete an observational overview.

b. Disregard cues and complete the database questions in chronological order.

c. Focus on the patient's presenting situation.

d. Make accurate interpretations of the data.

C

A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask?

a. "Is there anything that you are stressed about right now?"

b. "What reasons do you think are contributing to your fatigue?"

c. "What are your normal work hours?"

d. "Are you sleeping 8 hours a night?"

B

The question asking the patient what factors might be contributing to her fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal works hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on her complaints of daytime fatigue nor ask about the contributing reasons.

Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions

a. Result in decreased energy expenditure.

b. Are always desirable regardless of patient condition.

c. Are necessary for the active movement of muscles.

d. Result in increased energy expenditure.

D

Although isometric contractions do not result in muscle shortening, energy expenditure increases. It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses. Isometric contractions increase muscle tension but not active movement of the muscle.

Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by:

a. Maintaining a narrow base of support.

b. Creating a high center of gravity.

c. Disregarding body posture.

d. Keeping a low center of gravity.

D

Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.

Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that:

a. Breaks in skin integrity are easy to heal.

b. Preventing a pressure ulcer is more expensive than treating one.

c. Immobilized patients can develop skin breakdown within 3 hours.

d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

C

Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Immobilized patients frequently have hypercalcemia, placing them at risk for:

a. Osteoporosis.

b. Renal calculi.

c. Pressure ulcers.

d. Thrombus formation.

B

Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel

The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should:

a. Encourage the patient to perform as many self-care activities as possible.

b. Provide a complete bed bath to promote patient comfort.

c. Place the patient on bed rest to prevent fatigue.

d. Understand that the patient will not eat owing to a decreased energy need.

A

Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.

Of the following nursing goals, which is the most appropriate for a patient who has had a total hip replacement?

a. The patient will walk 1000 feet using her walker by the time of discharge.

b. The patient will ambulate by the time of discharge.

c. The patient will ambulate briskly on the treadmill by the time of discharge.

d. The nurse will assist the patient to ambulate in the hall.

A

"The patient will walk 1000 feet using her walker by the time of discharge" is individualized, realistic, and measurable. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far. "Ambulating briskly on a treadmill" is not realistic for this patient. The last option focuses on the nurse, not the patient, and is not measurable.

The nurse needs to reposition a 300-lb patient. Which of the following strategies is most likely to prevent back injury?

a. Turn the patient alone using the lift pad and applying pillows.

b. Put the bed in Trendelenburg and pull from the head of the bed.

c. Assess and obtain the number of people needed to help.

d. Bend at the waist and pull the lift pad using the arms.

C

Assess and determine the number of people needed; to prevent injury, do not start until the task can be completed safely. Assess the situation and do not turn the patient alone if this cannot be done safely. The trunk should be erect and the knees bent, so that multiple muscle groups (not just the arms) work together in a coordinated manner. This is not a one-person task: DO NOT PULL FROM THE HEAD OF THE BED.

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse?

A) Set up the follow-up appointments with the physician for the patient.

B) Ensure that someone will provide housekeeping for the patient at home.

C) Ensure that the home care agency is aware of medication and health teaching needs.

D) Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.

C

A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

All of these clients are being cared for on the intensive care step-down unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit?

A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask

B. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour.

C. Client with emphysema who requires instruction about correct use of oxygen at home.

D. Client with lung cancer who has just been transferred from the ICU after having a left lower lobectomy the previous day.

A

Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.

The RN and the nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant?

A. Auscultate for improvement in breath sounds in a client who has had a right lower lobectomy.

B. Document discharge instructions for a client being discharged with new asthma medications.

C. Monitor the effectiveness of oxygen therapy for a client admitted with chronic bronchitis.

D. Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.

D

Client education is an RN level skill, but reinforcement of previously taught material can be delegated to unlicensed personnel who are caring for the client.

A client has just been admitted to the intensive care unit (ICU) after having a left lower lobectomy with a video-assisted thoracoscopic surgery (VATS). Which of these requests will the nurse implement first?

A. Adjust oxygen flow rate to keep O2 saturation at 93% to 100%.

B. Administer 2 g of cephalothin (Keflin) IV now.

C. Give morphine sulfate 4 to 6 mg IV for pain.

D. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours

A

Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with Respiratory Therapy will be important.

The change-of-shift report has just been completed on the medical-surgical unit. Which of the following clients will the oncoming nurse plan to assess first?

A. Client with COPD who is ready for discharge but is not able to pay for prescribed home medications.

B. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38.

C. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%.

D. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

B

The client with cystic fibrosis, an elevated temperature, and an elevated respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first.

Your client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client?

A. Mucolytics decrease secretion production.

B. Mucolytics increase gas exchange in the lower airways.

C. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease (COPD).

D. Mucolytics thin secretions, making them easier to expectorate.

D

The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin and make them easier to be expectorated. This is important for a client with chronic bronchitis.

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler?

A. Corticosteroids

B. Long-acting beta agonists

C. NSAIDs

D. Short-acting beta agonists

D

Short-acting beta agonist medications have a rapid onset and cause bronchodilation. These medications would be excellent for marathon running because some types of asthma may be exercise induced.

A client has been diagnosed with asthma. Which statement below indicates that he correctly understands how to use an inhaler with a spacer correctly?

A. "I don't have to wait between the two puffs if I use a spacer."

B. "If the spacer makes a whistling sound, I am breathing in too rapidly."

C. "I should rinse my mouth and then swallow the water to get all of the medicine."

D. "Shake the inhaler only if you want to see whether it is empty."

B

Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used.

What does the nurse do first when setting up a safe environment for the new client on oxygen?

A. Ensures that staff wear protective clothing

B. Ensures that no combustion hazards are present in the room

C. Sets the oxygen delivery to maintain no fewer than 16 breaths per minute

D. Uses a pulse oximetry unit

B

Oxygen is highly flammable. The nurse needs to ensure that no open flames or combustion hazards are present in a room where oxygen is in use.

For relief of hypoxemia in the newly admitted client with chronic obstructive pulmonary disease (COPD), what does the client most likely need?

A. Oxygen flow rate of 1 to 2 L/min via nasal cannula

B. Oxygen flow rate of 2 to 4 L/min via nasal cannula

C. Oxygen flow rate of up to 60% via Venturi mask

D. 100% non-rebreather mask

A

The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula. A low arterial oxygen level is this client's primary drive for breathing.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates understanding of the nurse's instructions?

A. "Asthma drugs help everybody breathe better."

B. "I must carry my emergency inhaler only when activity is anticipated."

C. "I must have my emergency inhaler with me at all times."

D. "Preventive drugs can stop an attack."

C

Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (SABA) like albuterol (Proventil).

Which statement by the client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction?

A. "I don't need to use my oxygen all the time."

B. "I don't need to get the flu shot."

C. "I need to eat more protein."

D. "It is normal to feel more tired than I use to."

B

An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered since pneumonia is one of the most common complications of COPD.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders?

A. It affects only young people.

B. The client has dyspnea.

C. The client is coughing.

D. The client is symptom free between exacerbations.

D

The client may be completely symptom free between exacerbations.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success?

A. Peak flowmeter readings that are yellow after the third reading

B. Productive cough

C. SpO2 level of 92% after ambulating 50 feet

D. Stable arterial blood gases (ABGs)

C

Maintaining a baseline Spo2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective.

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first?

A. Assesses airway, breathing, and circulation

B. Calls for the Rapid Response Team

C. Checks the patency of the chest tubes

D. Listens for breath sounds

A

Assessing the ABCs is the priority to determine possible causes of burning in the client's chest.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

A. "Do you have trouble affording your medications?"

B. "You are lucky; most people get severe morning headaches."

C. "You need to take your medicine or you will get kidney failure."

D. "Most people with hypertension do not have symptoms."

D

Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

A. Assess the client's support system.

B. Assist in finding one change the client can control

C. Determine what stressors the client faces in daily life.

D. Inquire about delegating some of the client's obligations.

B

All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control.

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

A. "Do you walk mostly uphill, downhill, or on flat surfaces?"

B. "How much pain medication do you take each day?"

C. "Could you walk further than that a few months ago?"

D. "Have you ever considered swimming instead of walking?"

C

As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?

A. "I nearly always wear comfy sweatpants and house shoes."

B. "My hands shake when I try to do things requiring coordination."

C. "My daughter makes sure I have plenty of lotion for my feet."

D. "I'm glad I get energy assistance so my house isn't so cold."

B

Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A nursing student is caring for a client with an abdominal aortic aneurysm. What action by the student requires the registered nurse to intervene?

A. Measures the abdominal girth

B. Auscultates over abdominal bruit

C. Palpates the abdomen in four quadrants

D. Assesses the client for back pain

C

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?

A. Verbalizing non-modifiable risk factors.

B. Ambulates with unsteady gait.

C. Oxygen saturation of 98%.

D. Pain of 6/10 after medication.

C

A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?

A. Ask the client's exercise regimen.

B. Review client's breakfast intake.

C. Implement a high-protein, high-fiber diet.

D. Measure for new thrombo-embolic compression stockings.

D

Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best?

A. Tell the client drugs are safer today than before.

B. Assess the reason behind the client's fear.

C. Remind the client about laboratory monitoring.

D. Warn the client about consequences of noncompliance.

B

The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

A. "I will go out and buy some warm, heavy socks to wear."

B. "I can use a heating pad on my legs if it's set on low."

C. "It's going to be really hard but I will stop smoking."

D. "I should not cross my legs when sitting or lying down."

B

Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply) .

A. "I will see my podiatrist if I have problems with my feet."

B. "Lotion is important to keep my feet smooth and soft."

C. "A good abrasive pumice stone will keep my feet soft."

D. "I will keep my feet dry, especially between the toes."

E. "Washing my feet in room-temperature water is best."

A,B,D,E

Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and won't offer much protection against injury.

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply) .

A. Assess the client for support systems and family.

B. Offer to stay with the client if he or she desires.

C. Ask the client to describe his or her current emotions.

D. Relate how smoking contributed to this situation.

E. Tell the client that many people have amputations.

A,B,C

When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client's feelings.

A student nurse asks what "essential hypertension" is. What response by the registered nurse is best?

A. "It is hypertension with no specific cause."

B. "It means it is 'essential' that it be treated."

C. "It refers to severe and life-threatening hypertension."

D. "It means it is caused by another disease."

A

Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

An exercise program is prescribed for a patient with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?

A. Giving the client a written exercise program.

B. Tailoring a program to the client's needs and abilities.

C. Explaining the exercise program to the client's spouse who has been the client's number one coach.

D. Reassuring the client that he or she can do the exercise program.

B

Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.

The most important long-term goal for a client with hypertension would be to:

A. Learn how to avoid stress.

B. Explore a job change or early retirement.

C. Make a commitment to a long-term lifestyle change.

D. Lose weight.

C

Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.

The nurse is providing community education about prevention of atherosclerosis-related diseases. Which risk factors should the nurse include in the presentation? Select all that apply.

A. LDL cholesterol of 160 mg

B. Smoking

C. Aspirin (ASA) consumption

D. Type 2 diabetes

E. Vegetarian diet

A,B,D

Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), client is advised to modify diet and exercise.Smoking is a modifiable risk factor and should be avoided or terminated. Diabetes is a risk factor for atherosclerotic disease.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply.

A. Has maintained a low-sodium, no-added-salt diet

B. Has lost 3 pounds since last seen in the clinic

C. Cooks food in palm oil to save money

D. Exercises once weekly

E. Has cut down on caffeine

A,B,E

Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). For which symptoms should the nurse assess?

A. Reproducible leg pain with exercise

B. Unilateral swelling of affected leg Incorrect

C. Decreased pain when legs are elevated

D. Pulse oximetry reading of 90%

A

Claudication, leg pain with ambulation due to ischemia, is reproducible in similar circumstances.

The client with peripheral arterial occlusive disease has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?

A. Ankle-brachial index (ABI)

B. Dye allergy

C. Pedal pulses

D. Gag reflex

C

Distal pulses must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).

Which teaching should the nurse include for a client with peripheral arterial disease (PAD)?

A. Elevate your legs above heart level to prevent swelling.

B. Inspect your legs daily for brownish discoloration around the ankle.

C. Walk to the point of leg pain, then rest, resuming when pain stops.

D. Apply a heating pad to the legs if they feel cold.

C

Exercise may improve arterial blood flow by building collateral circulation; walk until the point of claudication, stop and rest, and then walk a little farther.

The nurse suspects that the client has developed an acute arterial occlusion of the right lower extremity based on which of the following? Select all that apply.

A. Hypertension

B. Tachycardia

C. Bounding right pedal pulses

D. Cold right foot

E. Numbness and tingling of right foot

F. Mottling of right foot and lower leg

D,E,F

Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic?

A. "Are you afraid you will not be able to work?"

B. "If you control your diabetes, you can avoid amputation."

C. "Your concerns are valid; we can review some steps to limit disease progression."

D. "What about the situation concerns you most?"

C

This option validates the client's concern and offers needed information.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which of these problems identified by the nursing student correctly identifies the client at risk for secondary hypertension?

A. Psychiatric disturbance

B. High sodium intake

C. Physical inactivity

D. Renal failure

D

Secondary hypertension can be related to renal failure.

Which symptom reported by the client who has had a total hip replacement requires emergency action?

A. Localized swelling of one of the lower extremities

B. Positive Homans' sign

C. Shortness of breath and chest pain

D. Tenderness and redness at the IV site

C

Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for DVT and PE.

The nurse is teaching the young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching?

A. "I must stop taking my birth control pills."

B. "I should drink lots of water so I don't get dehydrated."

C. "I should exercise my legs when I have been sitting or standing for a long time."

D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D

Wearing the thromboembolism disease (TED) stockings is a prevention specific to the hospital setting. It is designed to prevent blood clots, unlike regular pantyhose.

Which vascular assessment technique by the student nurse requires intervention by the supervising nurse?

A. Measuring capillary refill in the fingertips

B. Assessing pedal pulses by Doppler

C. Measuring blood pressure in both arms

D. Simultaneously palpating the bilateral carotids

D

Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion.