Medical Surgical Nursing Patient Centered Collaborative Care, 8th Edition by Donna D. Ignatavicius Test Bank

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Medical Surgical Nursing Patient Centered Collaborative Care, 8th Edition by Donna D. Ignatavicius Test Bank

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WITH ANSWERS
Medical Surgical Nursing Patient Centered Collaborative Care, 8th Edition by Donna D. Ignatavicius Test Bank

Chapter 2: Common Health Problems of Older Adults
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nursing faculty member working with students explains that the fastest growing subset of the older population is which group?
a.
Elite old
b.
Middle old
c.
Old old
d.
Young old
ANS: C
The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.
DIF: Remembering/Knowledge REF: 9
KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
2. A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal?
a.
Exercise program to improve physical function
b.
Financial planning seminar series for older adults
c.
Social events such as dances and group dinners
d.
Workshop on prevention from becoming an abuse victim
ANS: A
All activities would be beneficial for the older population in the community. However, failure in performing ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.
DIF: Applying/Application REF: 12
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Psychosocial Integrity
3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?
a.
Auscultate bowel sounds.
b.
Check skin turgor.
c.
Perform an oral assessment.
d.
Weigh the client.
ANS: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the clients food preferences as they relate to constipation.
DIF: Applying/Application REF: 10
KEY: Nutrition| dentures| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
a.
Barley soup
b.
Black beans
c.
White rice
d.
Whole wheat bread
ANS: C
Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.
DIF: Applying/Application REF: 11
KEY: Nutrition| fiber| older adult
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
a.
Cut some sodium out of your diet.
b.
Dehydration can cause incontinence.
c.
Have something to drink every 1 to 2 hours.
d.
Take your diuretic in the morning.
ANS: C
Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.
DIF: Applying/Application REF: 11
KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?
a.
Building strength and flexibility
b.
Improving exercise endurance
c.
Increasing aerobic capacity
d.
Providing personal training
ANS: A
This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the clients functional abilities.
DIF: Applying/Application REF: 12
KEY: Exercise| functional ability| older adult
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority?
a.
History of previous depression
b.
Previous stressful events
c.
Role of work in the adults life
d.
Usual leisure time activities
ANS: C
Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the role that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.
DIF: Applying/Application REF: 12
KEY: Depression| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping?
a.
I have had the same best friend for decades.
b.
I think I am coping very well on my own.
c.
My kids come to see me every weekend.
d.
Oh, I have lots of friends at the senior center.
ANS: A
Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.
DIF: Remembering/Knowledge REF: 12
KEY: Coping| relationships| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
9. A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?
a.
Have the client use a walker or cane on the steps.
b.
Install contrasting color strips at the edge of each step.
c.
Instruct the client to use the garage door instead.
d.
Tell the client to use a two-footed gait on the steps.
ANS: B
As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.
DIF: Applying/Application REF: 13
KEY: Safety| falls| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?
a.
Assess for orthostatic hypotension.
b.
Determine if there are new medications.
c.
Evaluate the client for gait abnormalities.
d.
Perform a delirium screening test.
ANS: B
Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the clients condition.
DIF: Applying/Application REF: 13
KEY: Medications| medication safety| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those are for old people. What action by the nurse would be most helpful?
a.
Arrange medications by time in a drawer.
b.
Encourage the client to use easy-open tops.
c.
Put color-coded stickers on the bottle caps.
d.
Write a list of when to take each medication.
ANS: C
Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.
DIF: Applying/Application REF: 14
KEY: Medications| medication safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?
a.
Keep the light on in the bathroom at night.
b.
Order a bedside commode for the client.
c.
Put the client on a toileting schedule.
d.
Use siderails to keep the client in bed.
ANS: A
Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion.
DIF: Applying/Application REF: 21
KEY: Falls| safety| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine?
a.
Cyclobenzaprine (Flexeril)
b.
Hydromorphone hydrochloride (Dilaudid)
c.
Ketorolac (Toradol)
d.
Meperidine (Demerol)
ANS: B
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.
DIF: Remembering/Knowledge REF: 16
KEY: Medications| Beers list| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate?
a.
Ask the family how these problems occurred.
b.
Call the police department and file a report.
c.
Notify Adult Protective Services.
d.
Report the findings as per agency policy.
ANS: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.
DIF: Applying/Application REF: 19 KEY: Abuse| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best?
a.
Call Adult Protective Services.
b.
Discuss concerns with the health care team.
c.
Do not allow the client to sign the consent.
d.
Have the clients family sign the consent.
ANS: B
In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the clients ability to provide consent.
DIF: Applying/Application REF: 16
KEY: Competence| autonomy| older adult
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.)
a.
Dementia
b.
Exhaustion
c.
Slowed physical activity
d.
Weakness
e.
Weight gain
ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.
DIF: Remembering/Knowledge REF: 9
KEY: Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.)
a.
1% milk
b.
Carrots
c.
Lean ground beef
d.
Oranges
e.
Vitamin D supplements
ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.
DIF: Applying/Application REF: 10
KEY: Nutrition| nutritional requirements| older adults
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.)
a.
Constipation
b.
Dehydration
c.
Mania
d.
Urinary incontinence
e.
Weakness
ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.
DIF: Remembering/Knowledge REF: 14
KEY: Medications| adverse effects
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.)
a.
Confusion
b.
Evidence of abuse
c.
Incontinence
d.
Problems with behavior
e.
Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.
DIF: Remembering/Knowledge REF: 20
KEY: SPICES| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.)
a.
Assess the clients ability to drive or transportation alternatives.
b.
Determine if the client has dentures that fit appropriately.
c.
Encourage the client to continue the current exercise plan.
d.
Have the client complete a 3-day diet recall diary.
e.
Teach the client about proper nutrition in the older population.
ANS: A, B, D
Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.
DIF: Applying/Application REF: 10
KEY: Nutrition| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a.
Assess skin redness when turning.
b.
Document Braden Scale results.
c.
Keep the clients skin dry.
d.
Obtain a pressure-relieving mattress.
e.
Turn the client every 2 hours.
ANS: C, D, E
The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be directed to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility as the RN is the one who performs that assessment.
DIF: Applying/Application REF: 22
KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnel
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.)
a.
Contact Adult Protective Services or hospital social work.
b.
Notify the provider that the client needs a tube feeding.
c.
Perform and document results of a Braden Scale assessment.
d.
Request a dietary consultation from the health care provider.
e.
Suggest a high-protein oral supplement between meals.
ANS: C, D, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.
DIF: Applying/Application REF: 20
KEY: Nutrition| malnutrition| older adult| Braden Scale
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
a.
14%
b.
21%
c.
28%
d.
31%
ANS: B
Room air is 21% oxygen.
DIF: Remembering/Knowledge REF: 514
KEY: Oxygen| physiology
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a.
Administer prescribed anxiolytic medication.
b.
Ensure informed consent is on the chart.
c.
Reinforce any teaching done previously.
d.
Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.
DIF: Applying/Application REF: 522
KEY: Informed consent| autonomy
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
a.
Assess the clients oxygen saturation.
b.
Notify the Rapid Response Team.
c.
Oxygenate the client with a bag-valve-mask.
d.
Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
DIF: Applying/Application REF: 523
KEY: Oxygenation| tracheostomy| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
a.
Elevate the head of the clients bed.
b.
Measure and compare cuff pressures.
c.
Place the client on NPO status.
d.
Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.
DIF: Analyzing/Analysis REF: 523
KEY: Tracheostomy| patient safety| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a.
Assess the clients lung sounds.
b.
Assign a different UAP to the client.
c.
Report the UAP to the manager.
d.
Request thicker liquids for meals.
ANS: A
The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.
DIF: Applying/Application REF: 524
KEY: Delegation| aspiration| tracheostomy| nursing assessment| unlicensed assistive personnel (UAP) MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?
a.
Holding the device securely when changing ties
b.
Suctioning the client first if secretions are present
c.
Tying a square knot at the back of the neck
d.
Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate.
DIF: Applying/Application REF: 527
KEY: Tracheostomy| tracheostomy care| patient safety| supervision
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
a.
Applying suction while inserting the catheter
b.
Preoxygenating the client prior to suctioning
c.
Suctioning for a total of three times if needed
d.
Suctioning for only 10 to 15 seconds each time
ANS: A
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
DIF: Remembering/Knowledge REF: 525
KEY: Tracheostomy| tracheostomy care| suctioning| supervision
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?
a.
100% of meals being eaten by the client
b.
Intact skin behind the ears
c.
The client understanding the need for oxygen
d.
Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.
DIF: Evaluating/Synthesis REF: 515
KEY: Oxygen| skin integrity| nursing diagnosis| oxygen therapy
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
a.
Call the operating room to inform them of a pending emergency case.
b.
No action is needed at this time; this is a normal finding in some clients.
c.
Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d.
Stay with the client and have someone else call the provider immediately.
ANS: D
This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.
DIF: Applying/Application REF: 523
KEY: Tracheostomy| medical emergencies| communication
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
a.
The client demonstrates good understanding of stoma care.
b.
The client has joined a book club that meets at the library.
c.
Family members take turns assisting with stoma care.
d.
Skin around the stoma is intact without signs of infection.
ANS: B
The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.
DIF: Evaluating/Synthesis REF: 528
KEY: Tracheostomy| nursing evaluation| psychosocial response
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Psychosocial Integrity
11. A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
a.
Apply water-soluble ointment to nares and lips.
b.
Periodically turn the oxygen down or off.
c.
Remove the tubing from the clients nose.
d.
Turn the client every 2 hours or as needed.
ANS: A
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.
DIF: Applying/Application REF: 515
KEY: Oxygen| comfort measures| oral care| skin care| delegation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
12. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
a.
Assess the clients oxygen saturation and, if normal, turn off the oxygen.
b.
Determine if the client can switch to a nasal cannula during the meal.
c.
Have the client lift the mask off the face when taking bites of food.
d.
Turn the oxygen off while the client eats the meal and then restart it.
ANS: B
Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.
DIF: Applying/Application REF: 517
KEY: Oxygen therapy| oxygen
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. The nurse assesses the client using the device pictured below to deliver 50% O2:
The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?
a.
Assess the clients oxygen saturation.
b.
Document these findings in the chart.
c.
Immediately increase the flow rate.
d.
Turn the flow rate down to 2 L/min.
ANS: C
For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.
DIF: Analyzing/Analysis REF: 519
KEY: Oxygen| patient safety| oxygen therapy
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)
a.
The client does not allow smoking in the house.
b.
Electrical cords are in good working order.
c.
Flammable liquids are stored in the garage.
d.
Household light bulbs are the fluorescent type.
e.
The client does not have pets inside the home.
ANS: A, B, C
Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.
DIF: Understanding/Comprehension REF: 515
KEY: Patient safety| fire| oxygen| home safety| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
a.
Applying water-soluble lip balm to the clients lips
b.
Ensuring the humidification provided is adequate
c.
Performing oral care with alcohol-based mouthwash
d.
Reminding the client to cough and deep breathe often
e.
Suctioning excess secretions through the tracheostomy
ANS: A, D
The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.
DIF: Applying/Application REF: 515
KEY: Tracheostomy| oral care| delegation| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)
a.
Create a communication system.
b.
Dont go out in public alone.
c.
Find hobbies to enjoy at home.
d.
Try loose-fitting shirts with collars.
e.
Wear fashionable scarves.
ANS: A, D, E
The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.
DIF: Understanding/Comprehension REF: 528
KEY: Tracheostomy| psychosocial response| patient education
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)
a.
Cognition
b.
Dexterity
c.
Hydration
d.
Range of motion
e.
Vision
ANS: A, B, D, E
The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.
DIF: Understanding/Comprehension REF: 529
KEY: Older adult| tracheostomy| patient education
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)
a.
Absorptive atelectasis
b.
Combustion
c.
Dried mucous membranes
d.
Oxygen-induced hyperventilation
e.
Toxicity
ANS: A, B, C, E
Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.
DIF: Understanding/Comprehension REF: 515
KEY: Respiratory system| oxygen therapy| home safety| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Chapter 42: Care of Patients with Problems of the Central Nervous System: The Brain
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching?
a.
Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.
b.
Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
c.
This drug will relieve the pain during the aura phase soon after a headache has started.
d.
This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.
ANS: B
Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
DIF: Applying/Application REF: 856
KEY: Medication safety| beta blocker| migraine
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?
a.
Vertigo
b.
Lethargy
c.
Visual disturbances
d.
Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.
DIF: Understanding/Comprehension REF: 854
KEY: Migraine| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?
a.
Bronchial asthma
b.
Prinzmetals angina
c.
Diabetes mellitus
d.
Chronic kidney disease
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions would not affect the clients treatment.
DIF: Applying/Application REF: 856
KEY: Medication safety| migraine
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?
a.
Atonic seizure
b.
Tonic-clonic seizure
c.
Myoclonic seizure
d.
Absence seizure
ANS: B
Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.
DIF: Understanding/Comprehension REF: 858 KEY: Seizure
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?
a.
Start fluids via a large-bore catheter.
b.
Turn the clients head to the side.
c.
Administer IV push diazepam.
d.
Prepare to intubate the client.
ANS: B
The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
DIF: Applying/Application REF: 861
KEY: Seizure| aspiration precautions
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
a.
Atenolol (Tenormin)
b.
Lorazepam (Ativan)
c.
Phenytoin (Dilantin)
d.
Lisinopril (Prinivil)
ANS: B
Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.
DIF: Applying/Application REF: 861
KEY: Seizure| benzodiazepine| medication safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
a.
To prevent complications, I will drink at least 2 liters of water daily.
b.
This medication will stop me from getting an aura before a seizure.
c.
I will not drive a motor vehicle while taking this medication.
d.
Even when my seizures stop, I will continue to take this drug.
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
DIF: Applying/Application REF: 861
KEY: Medication safety| seizure| antiepileptic
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
8. After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
a.
I will wear my medical alert bracelet at all times.
b.
While taking my epilepsy medications, I will not drink any alcoholic beverages.
c.
I will tell my doctor about my prescription and over-the-counter medications.
d.
If I am nauseated, I will not take my epilepsy medication.
ANS: D
The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.
DIF: Applying/Application REF: 860
KEY: Seizure| medication safety| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
9. A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
a.
Do you live in a crowded residence?
b.
When was your last tetanus vaccination?
c.
Have you had any viral infections recently?
d.
Have you traveled out of the country in the last month?
ANS: A
Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.
DIF: Applying/Application REF: 863
KEY: Meningitis| infection control
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
10. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?
a.
His masklike face makes it difficult to communicate, so I will use a white board.
b.
He should not socialize outside of the house due to uncontrollable drooling.
c.
This disease is associated with anxiety causing increased perspiration.
d.
He may have trouble chewing, so I will offer bite-sized portions.
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.
DIF: Applying/Application REF: 868 KEY: Parkinson disease
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
11. A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?
a.
Ambulate the client in the hallway twice a day.
b.
Ensure a fluid intake of at least 3 liters per day.
c.
Teach the client pursed-lip breathing techniques.
d.
Keep the head of the bed at 30 degrees or greater.
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.
DIF: Applying/Application REF: 870
KEY: Parkinson disease| aspiration precautions
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
12. A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
a.
It will allow your mother to live independently for several more years.
b.
It is used to halt the advancement of Alzheimers disease but will not cure it.
c.
It will not improve her dementia but can help control emotional responses.
d.
It is used to improve short-term memory but will not improve problem solving.
ANS: C
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimers disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.
DIF: Applying/Application REF: 877
KEY: Alzheimers disease| safety
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
a.
Assess religious and spiritual needs while in the hospital.
b.
Identify the clients ability to perform self-care activities.
c.
Evaluate the clients reaction to a change of environment.
d.
Ask the client about relationships with family members.
ANS: C
As Alzheimers disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the clients reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the clients reaction to environmental change.
DIF: Applying/Application REF: 875
KEY: Alzheimers disease| psychosocial response
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity
14. A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
a.
I see you are still hungry. I will get you some toast.
b.
You ate your breakfast 30 minutes ago.
c.
It appears you are confused this morning.
d.
Your family will be here soon. Lets get you dressed.
ANS: A
Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the clients concerns.
DIF: Applying/Application REF: 876
KEY: Alzheimers disease| patient-centered care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Psychosocial Integrity
15. A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
a.
Serum electrolyte levels
b.
Kidney function tests
c.
Complete blood cell count
d.
Antinuclear antibodies
ANS: B
Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.
DIF: Applying/Application REF: 860
KEY: Medication safety| seizure| antiepileptic
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
16. A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
a.
This is a sign of fatigue. The client would benefit from a daily nap.
b.
Engage the client in scheduled activities throughout the day.
c.
It sounds like this is difficult for you. I will consult the social worker.
d.
The provider can prescribe a mild sedative for restlessness.
ANS: B
Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregivers concern.
DIF: Applying/Application REF: 878
KEY: Alzheimers disease| patient safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
17. A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?
a.
Allow the client to rest most of the day.
b.
Place a padded throw rug at the bedside.
c.
Install deadbolt locks on all outside doors.
d.
Provide a high-calorie and high-protein diet.
ANS: C
Clients with Alzheimers disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.
DIF: Applying/Application REF: 879
KEY: Alzheimers disease| patient-centered care
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
18. A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client?
a.
Shuffling gait
b.
Jerky hand movements
c.
Continuous chewing motions
d.
Tremors of the hands
ANS: B
An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson disease.
DIF: Remembering/Knowledge REF: 881
KEY: Huntington disease
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
19. A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurses best response?
a.
Most clients with the Huntington gene do not pass on Huntington disease to their children.
b.
I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease.
c.
The need for family planning is limited because one of the hallmarks of Huntington disease is infertility.
d.
Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.
ANS: D
The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogacy options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other statements are not accurate.
DIF: Applying/Application REF: 881
KEY: Huntington disease| genetic counseling
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
20. A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching?
a.
Place a warm compress on your forehead at the onset of the headache.
b.
Wear dark sunglasses when you are in brightly lit spaces.
c.
Lie down in a darkened room when you experience a headache.
d.
Set your alarm to ensure you do not sleep longer than 6 hours at one time.
ANS: C
At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.
DIF: Applying/Application REF: 856
KEY: Migraine| complementary/alternative medications
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
21. A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
a.
Allow the client to be as independent as possible with activities.
b.
Assist the client with frequent and meticulous oral care.
c.
Assess the clients ability to eat and swallow before each meal.
d.
Schedule appointments early in the morning to ensure rest in the afternoon.
ANS: A
Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.
DIF: Applying/Application REF: 869
KEY: Parkinson disease| delegation| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
22. A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
a.
If she is confused, play along and pretend that everything is okay.
b.
Remove the clock from her room so that she doesnt get confused.
c.
Reorient the client to the day, time, and environment with each contact.
d.
Use validation therapy to recognize and acknowledge the clients concerns.
ANS: C
Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.
DIF: Applying/Application REF: 876
KEY: Alzheimers disease| delegation| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
a.
Have suction equipment at the bedside.
b.
Place a padded tongue blade at the bedside.
c.
Permit only clear oral fluids.
d.
Keep bed rails up at all times.
e.
Maintain the client on strict bedrest.
f.
Ensure that the client has IV access.
ANS: A, D, F
Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.
DIF: Applying/Application REF: 861
KEY: Seizure| patient safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.)
a.
Increase your intake of caffeinated beverages.
b.
Incorporate physical exercise into your daily routine.
c.
Avoid all alcoholic beverages.
d.
Participate in a smoking cessation program.
e.
Increase your intake of fruits and vegetables.
ANS: B, D, E
Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.
DIF: Applying/Application REF: 857
KEY: Migraine| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
3. A nurse evalua

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