The nurse suspects that a child has cardiac disease what does the nurse include in the assessment

ANSWER AND RATIONALE

1. D, F, G, H
Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
 

2. A, B, C
Electronic translation applications, telephone-based interpreters, and agency interpreters are all appropriate to use to communicate with non-English-speaking patients. When no interpreter is available, family members may be considered, but some information that will be needed in an admission assessment may be misunderstood or not shared if a child is used as the interpreter. Gestures are appropriate to use, but an exaggeration of the gestures is not needed.

3. A, B, C, E
The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process.

4. A, B, D, E
National Patient Safety Goals have been established to promote safe delivery of care. The nurse should use at least two reliable ways to identify the patient such as asking the patient's full name and date of birth before medication administration. Other actions that improve patient safety include performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments before administering medications, and giving a list of the current medicines to the patient and caregiver before discharge.

5. D, B, C, A
The order of the nurse's statements follows the SBAR format.

6. C, D, A, B
When assessing the abdomen, the initial action is to inspect the abdomen. Auscultation is done next because percussion and palpation can alter bowel sounds and produce misleading findings.

7. C, D, E
For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient's reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.

8. A, B, C, D
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients' ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

9. A, B

A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

10. B, C, D

The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

11. A, B

Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

12. A, B, C, D

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

13. B, D, E

Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL.

14: B, C, D, G
Chest pain or tightness, shortness of breath, wheezing, and purulent sputum are all symptoms associated with lung cancer. White sputum, weight gain, and recurrent attacks of asthma are not known to be associated with lung cancer.

15. A, C, D
People working in mines, those making pottery, and those working with a brick would be at highest risk to develop silicosis because of the dust generated in these occupations.

16. B, C, E, F
Symptoms of pneumothorax include rapid respiration, reduced breath sounds on the affected side, dyspnea, decreased oxygen saturation, tracheal deviation, and prominence of one side of the chest.

17. B, D, E
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 ml/hr because this could indicate hemorrhage. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

18. B, A, E, C, D
When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow.

19. A, D, E
Aspiration is less likely to occur if the client is well rested. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order. Aspiration may become more likely if the client is urged to swallow faster. Placing the client in a lithotomy position after the meal will not prevent aspiration.

20. D, F, G, H
Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.

21. A, B, C, D
Rationale: Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4 count has dropped or when an infection has occurred.

22. C, A, D, B
Rationale: The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.

23. A, C, D, E, B
A. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained.
C. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased BP. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia.
D. The dressing should be assessed to determine if bleeding is occurring.
E. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the HCP.
B. The HCP should be notified when the nurse has the needed information.

24. A, B, E
A. Assessment and documentation of fluid balance are critical aspects of all postoperative care.

B. Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children.

C. A special diet is not indicated after this surgery.

D. After a laparoscopic appendectomy, there is little drainage and no dressings.

E. Auscultating for bowel sounds and documenting their presence or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery.

25. A,B,D

The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health.

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