Question Of The Day: Neurosensory Disorders

Q. A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

A. gather assessment data and notify the physician of the change in the client's status.

B. ask the physician to order an antipsychotic medication for the client.

C. consult with the social worker about the possibility of discharging the client from the facility.

D. tell the client that she'll punish him if he doesn't behave.

Correct Answer: A

Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

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Question Of The Day: Endocrine and Metabolic Disorders

Q. Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?

A. Verbalizing an understanding of blood glucose meter use

B. Documenting a normal blood glucose level

C. Providing documentation of previous certification

D. Demonstrating correct technique

Correct Answer: D

Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.

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Question Of The Day: Gastrointestinal Disorders

Q. A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:

A. the client requires an antiviral agent.

B. enteric precautions must be continued.

C. enteric precautions can be discontinued.

D. the client's infection may be caused by droplet transmission.

Correct Answer: B

Reason: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

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Question Of The Day: Cardiovascular Disorders

Q. When assessing a client for early septic shock, the nurse should assess the client for which of the following?

A. Cool, clammy skin.

B. Warm, flushed skin.

C. Increased blood pressure.

D. Hemorrhage.

Correct Answer: B

Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

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Question Of The Day: The Neonate

Q. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

A. Rewarm the neonate gradually.

B. Rewarm the neonate rapidly.

C. Observe the neonate hourly.

D. Notify the physician when the neonate's temperature is normal.

Correct Answer: A

Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

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Question Of The Day: Postpartum Period

Q. A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision?

A. Inserting an indwelling urinary catheter

B. Fundal massage

C. Administration of oxytocics

D. Pad count

Correct Answer: D

Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.

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Question Of The Day: Antepartum Period

Q. A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

A. 7 weeks' gestation

B. 11 weeks' gestation

C. 17 weeks' gestation

D. 21 weeks' gestation

Correct Answer: B

Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.

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Question Of The Day: Mood, Adjustment, and Dementia Disorders

Q. Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

A. flight of ideas and inflated self-esteem.

B. increased sleep and greater distractibility.

C. decreased self-esteem and increased physical restlessness.

D. obsession with following rules and maintaining order.

Correct Answer: A

Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.

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Question Of The Day: Toddler

Q. When performing a physical assessment on an 18-month-old child, which of the following would be best?

A. Have a parent hold the toddler.

B. Assess the ears and mouth first.

C. Carry out the assessment from head to toe.

D. Assess motor function by having the child run and walk.

Correct Answer: A

Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

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Question Of The Day: Basic Physical Care

Q. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

A. Have the client wear eyeglasses at all times.

B. Lightly tape the eyelid shut.

C. Instill artificial tears once every shift.

D. Clean the eyelid with a washcloth every shift.

Correct Answer: B

Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

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Question Of The Day: Neurosensory Disorders

Q. A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

A. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician.

B. Ask the nursing assistant to notify the physician of the low pulse oximetry level.

C. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

D. Complete the assessment of the new client before attending to the client who underwent laminectomy.

Correct Answer: C

Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

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Question Of The Day: Oncologic Disorders

Q. A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy?

A. "Most impotence resolves in a couple of months."

B. "You could have early ejaculation with this type of surgery."

C. "We will refer you to a sex therapist because you will probably notice erectile dysfunction."

D. "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."

Correct Answer: D

Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.

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Question Of The Day: Cardiovascular Disorders

Q. Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?

A. "Take an extra dose of digoxin if you miss one dose."

B. "Call the physician if your heart rate is above 90 beats/minute."

C. "Call the physician if your pulse drops below 80 beats/minute."

D. "Take digoxin with meals."

Correct Answer: B

Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

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Question Of The Day: The Neonate

Q. The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:

A. peripheral acrocyanosis.

B. bradycardia.

C. lethargy.

D. jaundice.

Correct Answer: C

Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

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Question Of The Day: Postpartum Period

Q. The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?

A. Firm fundus at the symphysis.

B. White, thick vaginal discharge.

C. Striae that are silver in color.

D. Soft breasts without milk.

Correct Answer: A

Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).

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Question Of The Day: Psychotic Disorders

Q. A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

A. Dismantling the showerhead and showing the client that there is nothing in it

B. Explaining that other clients are complaining about the client's body odor

C. Asking a security officer to assist in giving the client a shower

D. Accepting these fears and allowing the client to take a sponge bath

Correct Answer: D

Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.

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Question Of The Day: Foundations of Psychiatric Nursing

Q. A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

A. "I can still eat my favorite salty foods."

B. "When my moods fluctuate, I'll increase my dose of lithium."

C. "A good blood level of the drug means the drug concentration has stabilized."

D. "Eating too much watermelon will affect my lithium level."

Correct Answer: B

Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.

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