Flashcards in Exam 4 Deck (488)
A client is scheduled to have a fundoplication. What statement by the client indicates a need to review
a. After the operation I can eat anything I want.
b. I will have to eat smaller, more frequent meals.
c. I will take stool softeners for several weeks.
d. This surgery may not totally control my
Nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. The other statements show good understanding.
The best way for the nurse to promote and support the maternal-infant bonding process is to:
a. help the mother identify her positive feelings toward the newborn.
b. encourage the mother to provide all newborn care.
c. assist the family with rooming-in.
d. return the newborn to the nursery during sleep periods.
Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. Having the mother express her feelings is important; however, it is not the best way to promote bonding. The mother needs time to rest and recuperate; she should not be expected to do all of the care. The patient needs to observe the infant during all stages so she will be aware of what to anticipate when they go home.
What is used to treat moderate-to-severe inflammatory bowel disease?
d. Antidiarrheal medications
Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.
Which type of dehydration results from water loss in excess of electrolyte loss?
a. Isotonic dehydration
b. Isosmotic dehydration
c. Hypotonic dehydration
d. Hypertonic dehydration
Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.
What are modes of heat loss in the newborn? (Select all that apply.)
ANS: B, C, D
Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.
Which antacid is likely to cause acid rebound?
a. Aluminum hydroxide
b. Calcium carbonate
c. Magnesium hydroxide
d. Magnesium trisilicate
While calcium carbonate is most effective in neutralizing acid, a significant amount can be systemically
absorbed and can cause acid rebound. The other antacids do not have significant systemic absorption.
a. occurs when, in multiple births, one child dies, and the other or others live.
b. is a state in which the parents are ambivalent, as with an abortion.
c. is an extremely intense grief reaction that persists for a long time.
d. is felt by the family of adolescent mothers who lose their babies.
Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, but this is not complicated bereavement. Abortion can generate complicated emotional responses, but they do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but this is not complicated bereavement.
A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling
urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red
blood in the NG tube. What action should the nurse take first?
a. Document the findings in the
b. Notify the surgeon immediately.
c. Reassess the drainage in 1 hour.
d. Take a full set of vital signs.
The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood
indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an
additional hour to reassess.
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________.
a. disseminated intravascular coagulation; asking for laboratory tests
b. von Willebrand disease; noting whether bleeding times have been extended
c. thrombophlebitis; using real-time and color Doppler ultrasound
d. coagulopathies; drawing blood for laboratory analysis
Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. Doppler ultrasound is a common noninvasive way to confirm diagnosis.
Which maternal event is abnormal in the early after birth period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.
Bismuth subsalicylate may be prescribed for a child with a peptic ulcer to effect what result?
a. Eradicate Helicobacter pylori
b. Coat gastric mucosa
c. Treat epigastric pain
d. Reduce gastric acid production
This combination of drug therapy is effective in the treatment and eradication of H. pylori. It does not bring about any of the results.
A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention
should the nurse indicate as the priority action in this clients plan of care?
a. Low-fiber diet
b. Skin protection
c. Antibiotic administration
d. Intravenous glucocorticoids
Protecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid
enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of
care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:
c. hip dysplasia.
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.
As related to the normal functioning of the renal system in newborns, nurses should be aware that:
a. the pediatrician should be notified if the newborn has not voided in 24 hours.
b. breastfed infants likely will void more often during the first days after birth.
c. “Brick dust” or blood on a diaper is always a cause to notify the physician.
d. weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother’s breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain.
To initiate the milk ejection reflex (MER), the mother should be advised to:
a. wear a firm-fitting bra.
b. drink plenty of fluids.
c. place the infant to the breast.
d. apply cool packs to her breast.
Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but this alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.
A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. determine which pad is best.
c. demonstrate that other nurses usually underestimate blood loss.
d. reveal to the nurse supervisor that one of them needs some time off.
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.
The nurse is teaching a patient who is about to take a long car trip about using dimenhydrinate (Dramamine)
to prevent motion sickness. What information is important to include when teaching this patient?
a. Do not drive while taking this medication.
b. Dry mouth is a sign of toxicity with this mediation.
c. Take the medication 1 to 2 hours prior to beginning the trip.
d. Take 100 mg up to 6 times daily for best effect.
Drowsiness is a common side effect of dimenhydrinate, so patients should be cautioned against driving while
taking this drug. Dry mouth is a common side effect and not a sign of toxicity. The drug should be taken 30
minutes prior to travel. The maximum recommended dose is 400 mg per day
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much
worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when
standing was 98/52 mm Hg. What action by the nurse is most appropriate?
a. Administer ibuprofen (Motrin).
b. Call the Rapid Response Team.
c. Start a large-bore IV with normal saline.
d. Tell the client to remain lying down
This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a
large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not
needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is
not the priority.
A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them:
a. “Infants can see very little until about 3 months of age.”
b. “Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns.”
c. “The infant’s eyes must be protected. Infants enjoy looking at brightly colored stripes.”
d. “It’s important to shield the newborn’s eyes. Overhead lights help them see better.”
“Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns” is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:
a. pouring water from a squeeze bottle over the woman’s perineum.
b. placing oil of peppermint in a bedpan under the woman.
c. asking the physician to prescribe analgesics.
d. inserting a sterile catheter.
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.
A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:
a. uterine atony.
b. lacerations of the genital tract.
c. perineal hematoma.
d. infection of the uterus.
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.
If the patient’s white blood cell (WBC) count is 25,000/mm on her second after birth day, the nurse should:
a. tell the physician immediately.
b. have the laboratory draw blood for reanalysis.
c. recognize that this is an acceptable range at this point after birth.
d. begin antibiotic therapy immediately.
During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.
Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients
record because I just have to know how much she weighs! What action by the clients nurse is most
a. Make an anonymous report to the charge nurse.
b. State That is a violation of client confidentiality.
c. Tell the nurse Dont look; Ill tell you her weight.
d. Walk away and ignore the other nurses behavior.
Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client
confidentiality rules. The other responses do not address this concern.
A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How
should the nurse respond?
a. Bile salts accumulate in the skin and cause the itching.
b. Toxins released from an inflamed gallbladder lead to itching.
c. Itching is caused by the release of calcium into the skin.
d. Itching is caused by a hypersensitivity reaction.
In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to
accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she:
a. waves her arms in the air.
b. makes sucking motions.
c. has hiccups.
d. stretches her legs out straight.
Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues.
A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.)
a. White rice
c. Whole grain breads
d. Bran pancakes
e. Raw carrots
ANS: C, D, E
High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find?
(Select all that apply.)
a. Distended abdomen
b. Inability to pass flatus
d. Hyperactive bowel sounds
e. Decreased urine output
ANS: A, B, E
A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass
flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive
bowel sounds are not associated with peritonitis.
A nurse has conducted a community screening event for oral cancer. What client is the highest priority for
referral to a dentist?
a. Client who has poor oral hygiene practices
b. Client who smokes and drinks daily
c. Client who tans for an upcoming vacation
d. Client who occasionally uses illicit drugs
Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology
of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not
have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers.