A profession is generally distinguished from other kinds of occupations/vocations by: 1.

Requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed usually entrusted to higher education. 2. An orientation of the individual toward service, either to a community or to an organization. 3. The members must be united and identified through their membership and they must be clearly separated from the laypeople or the ordinary congregations. 4. The society which it intends to serve has an indispensable need for such services and which others cannot provide and the society accepts it. 5. The techniques or skills applied are the product of scientifically proven and long experience. 6. REQUIREMENT TO EXERCISE DISCRETION AND JUDGMENT as to the time and manner of the performance of the duty. 7. The presence of common values, cultures, and norms uniquely found among its members which are also being guided by its own code of ethics. 8. The ability to continue its research to expand constantly its body of knowledge. Conceptual Framework - group of related concepts. It can also be viewed as an umbrella under which many theories can exist (Cresia & Parker 1991,p7). Theory- is made up of concepts and propositions; however, a theory accounts for phenomena with much greater specificity. Nightangle's Environmental theory - Florence Nightangle, "the mother of modern nursing" espoused her theory focusing on the environment. She linked health with five environmental factors: " " " " " pure or fresh air pure water efficient drainage cleanliness light

Informed Consent -The patient UNDERSTANDS the reason for the proposed intervention, with its benefits and risks, and agrees to the treatment by affixing his signature in the consent form. It generally contains the following elements: " disclosure " understanding " voluntariness " competence " permission giving Practicing Professional Nurse- a person who is engaged in the practice of nursing profession or is performing acts or activities, whether regularly or occasionally, including one who is employed in a

government office or in a private firm, company or corporation whose duties require knowledge and application of the nursing profession (Rule 1 Sect. 3 (f) IRR RA 9173). Private Duty Nurse - is a registered nurse who independently contracts with a patient; a private duty nurse is responsible for the total nursing care of the patient during the period she is with him. all of the three are bill of rights of the patient except option D. a patient must sign a waiver ( HAMA form) if he wants to leave the hospital against medical advice. BASIC HUMAN RIGHTS ON RESEARCH SUBJECTS: " " " " " Right to informed consent Right to refuse and/or withdrawal from participation Right to privacy Right to confidentiality Right to be protected from harm

RA 9173 Philippine Nursing Act of 2002 RATIONALE: When applying a vest restraint, allow room for movement. Never crisscross the flaps in the back; the client may choke himself. Wrapping the vest tightly may impede respirations. Tying a bowknot, rather than a regular knot, secures the straps but allows for quick release.

RATIONALE: The client has a right to know the medication he's getting and its adverse effects. If the physician has explained the medication to the client, it's the nurse's responsibility to reinforce the explanation. A client has the right to refuse medications. Explanation of medications should be done before the client receives them. RATIONALE: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. RATIONALE: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack. RATIONALE: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.

RATIONALE: One cup of low-fat yogurt contains 415 mg of calcium. One cup of skim milk has 302 mg of calcium. One ounce of cheddar cheese has 20 mg of calcium. One cup of ice cream has 176 mg of calcium. RATIONALE: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture. RATIONALE: Restraints should never be applied for staff convenience. The situations described in options A, B, and D could result in client harm; therefore, it's appropriate to apply restraints in these instances. RATIONALE: Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Clients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching. RATIONALE: Narcotics are contraindicated in trauma cases because of the depressive effect on the respiratory center, which can result in hypoxia and increased ICP. All medications would need to be given with caution if there's no medical history. Nothing specifically makes narcotics more contraindicated than other drugs. Narcotics should be used with caution in diabetic clients, but they aren't flatly contraindicated. This situation in itself wouldn't contraindicate narcotics. RATIONALE: After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Extended time out of refrigeration increases the risk of contamination and growth of bacteria. The client could experience fluid overload if the blood is administered too rapidly. RATIONALE: In later years, socialization allows the individual to provide examples of wisdom and courage. Self-realization is achieved during middle life (between ages 46 and 64); during middle life, individuals may also tend to withdraw from mental activity or overcompensate by trying impossible things. Retirement begins in the early later years (between ages 65 and 79). RATIONALE: Linking health and personal behavior is extremely important to disease prevention. By promoting healthy behaviors, individuals are preventing disease and living longer, more productive lives. This issue affects all individuals, not just health maintenance organizations. The external environment is only one of many factors affecting disease processes. RATIONALE: An increased metabolic rate in hyperthyroidism because of excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss face; not gain face; occurs due to the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat

if a client is dehydrated. RATIONALE: The client should be protected from a chill. Brushing the teeth with the client lying supine may lead to aspiration. Clients with hyperthyroidism experience an increase in appetite face. perspiration. stool. The water temperature should be 110 to 115 F to compensate for evaporative body cooling during and after the bath. or slightly warmer will eventually cool. RATIONALE: The nurse is performing an analysis and formulating a diagnosis by categorizing symptoms or potential health problems. RATIONALE: Daily weight shows trends and can assist medical management by indicating if interventions and medications are effective. RATIONALE: Physical care is an individual's most basic need according to Maslow's hierarchy of needs. slightly cooler. Gait changes are also uncommon. Intake and output aren't affected unless there's nephrotoxicity. but the other answers are incorrect. Water that is 115 to 120 F would be too hot and would put the client at risk for burns or discomfort. other dimensions of care can be addressed. Intake and output is extremely important. not anorexia. a thorough assessment must be done. RATIONALE: Vision changes. but that situation is uncommon. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. some laboratory data can show false elevations. however. which could cause discomfort and increase evaporative body cooling. but matching the two is difficult because fluid is also lost through breathing. Evaluation is an integral part of the nursing process and is usually performed as the last phase. Risk factors could become potential health problems. Before determining an appropriate nursing diagnosis.intolerance and widened pulse pressure do occur. and surgical tubes. such as halos around objects. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with fluid balance problems. Implementation is the initiation of the nursing care plan. Water should always be tested with a bath thermometer. Increasing fluid or food intake may alleviate the nausea. RATIONALE: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. Difficulty breathing along with a sensation that the throat is closing up is a type I reaction . it isn't a common sign of digoxin toxicity. However. RATIONALE: Nausea is a common adverse drug effect. Lemon glycerin can be drying if used for extended periods. Hydrogen peroxide is caustic to tissues and shouldn't be used. Hearing loss can be detected through hearing assessment. are signs of digoxin toxicity. Water that's the same temperature as the body. When physiological needs are met and the client feels comfortable. referring to the client's outcome and goals and determining if they've been met.

Penicillin is used to treat syphilis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. hard. causing localized. and poorly delineated with irregular edges. the nurse should elevate the head of the bed 15 to 30 degrees. is an acute inflammation of the dorsal root ganglia. reduces the amount of bulk ingested with meals. There's no need to restrict the amount of fluids. Duodenal ulcers and hemorrhoids aren't a preexisting condition of colorectal cancer. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. A mobile mass that's soft and easily delineated is most commonly a fluid-filled benign cyst. not gain face. Herpes simplex type 2 primarily affects the genital area. Nothing in this case relates to pain or medication for pain. Small amounts of water are allowable before meals. RATIONALE: Herpes zoster. just the time when the client drinks fluids. RATIONALE: To facilitate venous drainage and avoid jugular compression. may be a sign of cancer. so turning and changing positions should be avoided. colonoscopy aids in the detection of colorectal cancers.(anaphylactic shock). Impaired sense of time would be included in altered perceptions. Nipple retraction face. The room should be kept quiet and dimly lit. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. usually producing cold sores or fever blisters. RATIONALE: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Doxycycline and tetracycline are used to treat Lyme disease. vesicular skin lesions following a dermatome. An itchy rash with blisters is a type IV reaction (cell-mediated hypersensitivity). Turning from side to side increases the risk of jugular compression and rises in ICP. fresh. Abdominal CT scan is used to stage the presence of colorectal cancer. not eversion face. Weight loss face. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes. . or gray skin protrusions. RATIONALE: This client may be at risk for altered perceptions related to an unfamiliar environment. RATIONALE: Breast cancer tumors are fixed. Warts appear as rough. or shingles. RATIONALE: Used to visualize the entire colon. is an indication of colorectal cancer. Also. no information is given regarding the client's cognitive function. RATIONALE: Colorectal polyps are common with colon cancer. and aids in preventing rapid gastric emptying. Achy joints and temperature elevation are type II reactions (cytotoxic). causing painful clusters of small ulcerations. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. RATIONALE: Acyclovir reduces symptoms of herpes and also reduces viral shedding and healing time. Taking fluids between meals allows for adequate hydration.

RATIONALE: Most accidents occur in the home and safety devices are the most important element in minimizing injury. RATIONALE: In osteoarthritis. The other foods are high in potassium. is an acute inflammation of the dorsal root ganglia. An MI would involve chest pain or cardiac compromise. such as furosemide. causing localized. or helping the client to complete the menu doesn't ensure adequate nutritional intake. Protective devices aren't usually necessary for the client to perform exercises. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes. Clients may ambulate during feedings. Antiembolism stockings prevent venostasis and thromboembolism formation. Doing so prevents contamination and bacterial growth. causing painful clusters of small ulcerations. bread. or more frequently if the feeding requires it. Narrowing of joint spaces or margins. The client needs to use proper body mechanics when stooping or picking up objects. reduce total blood volume and circulatory congestion. which is a period of intense fear or discomfort that develops abruptly. and tea are foods that have low potassium content. they most probably signal a panic attack. Allowing privacy during meals. RATIONALE: Eggs. Shoes should be supportive and not too worn. An allergic reaction would have a precipitating cause and may also include a cutaneous reaction or edema. fresh. osteophytes form in joint spaces. . Oxygen administration increases oxygen delivery to the myocardium and other vital organs. and peaks in 10 minutes. cystlike bony deposits in the joints. RATIONALE: Diuretics. RATIONALE: Staying with the client and encouraging him to feed himself will ensure adequate food intake. and long-bone growths at weight-bearing areas are other X-ray findings. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Herpes simplex type 2 primarily affects the genital area. usually producing cold sores or fever blisters. Warts appear as rough. RATIONALE: Tube feeding solutions and tubing should be changed every 24 hours. A client with Alzheimer's disease can forget how to eat. filling out the menu. Anticoagulants prevent clot formation but don't decrease fluid volume excess. vesicular skin lesions following a dermatome. or shingles. Hypoglycemia rarely includes shortness of breath but would need to be differentiated by obtaining the client's blood glucose level.RATIONALE: Considering the circumstances surrounding these symptoms. or gray skin protrusions. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. RATIONALE: Herpes zoster.

inflamed joints rarely occur in osteoarthritis. Tophi are deposits of sodium urate crystals that occur in chronic gout face. the nurse moves each joint through its range of movement. If cramping occurs during irrigation. reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Heberden's nodes. Gastric ulcers rarely become malignant and aren't associated with colorectal cancer. Heberden's nodes are bony growths that occur at the distal interphalangeal joints. and legs each make up 18% of the total body surface.RATIONALE: According to the Rule of Nines. RATIONALE: The breasts are least tender and have fewer nodules 1 week after menstruation starts. Before the onset of menstruation. the client received burns to his back (18%) and one arm (9%). During passive ROM exercises.000 ml of water at a temperature no higher than 105 F (40. Coughing also increases ICP by increasing intrathoracic pressure and reducing venous return. Bouchard's nodes. which relieve pressure on the skin and underlying tissues. A high-fat. RATIONALE: Familial polyposis is a strong risk factor for colorectal cancer. The head. RATIONALE: Clinical findings for osteoarthritis include joint pain. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. the posterior trunk. the irrigation should be stopped and the client told to . totaling 27% of his body. neck. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. RATIONALE: The peak incidence of testicular cancer in men occurs between ages 15 and 40. anterior trunk. RATIONALE: Stool softeners reduce the risk of straining during a bowel movement. breasts may be most tender and nodular. such as genital or breast cancers. adults use 500 to 1. and arms each make up 9% of the total body surface. and tenderness on palpation occur with a sprain injury. As the disease progresses. Examining the breasts every day or after every shower is excessive and unnecessary. Other risk factors for colorectal cancer include inflammatory bowel disease and a history of colorectal cancer. high-calorie diet also increases the risk of colorectal cancer. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. capillaries become occluded. Certain cancers. In addition. Swelling. and enlarged joints. and the perineum makes up 1%. not osteoarthritis. RATIONALE: An irrigation bag should be elevated 18 inch to 20 inch (45 to 50 cm) above the stoma. If pressure isn't relieved. joint pain. Hot. pain may also occur at rest. which can increase ICP by raising intrathoracic pressure and interfering with venous return. The joint pain occurs with movement and is relieved by rest.6 C) to irrigate a colostomy. Bouchard's nodes involve the proximal interphalangeal joints. crepitus. Sensory stimulation and noxious stimuli can increase ICP. In this case. Typically. RATIONALE: The most important intervention to prevent pressure ulcers is frequent position changes. the risk of developing colorectal cancer increases after age 50. are risk factors for colorectal cancer.

occurs with lithium. Constipation can occur with other psychiatric drugs. RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences. Options B and C are incorrect because amphetamines stimulate norepinephrine. such as antipsychotic drugs. The other choices could also be related to stress and anxiety but they don't occur as frequently or as commonly as diarrhea. and medicating as needed. ask. RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. The irrigation can then be resumed. not constipation. "How do you think you would kill yourself?" If the client has a plan. Diarrhea. engage him in reality-based activities. Option a requires a yes-orno response and is self-limiting. challenging the client isn't therapeutic and may increase his anger. RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. turning on a stereo or lights. so option D is incorrect. remaining calm. Not heeding the client's request can agitate him further. RATIONALE: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. RATIONALE: The client needs to be informed of the activity and when it will be done. RATIONALE: Antianxiety drugs provide symptomatic relief. Debating with the client about his emotions isn't therapeutic. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Diarrhea is a common adverse effect. and opening windows may increase the client's anxiety. An overdose increases tension and irritability. When the client is calm. without telling him exactly what's going to happen. the nurse is telling the client what to think and feel. Hand washing reduces the spread of microorganisms. Depressants aren't appropriate for treating panic attacks. Negotiating and . the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. it's more common with sedatives and tricyclic antidepressants.take deep breaths until the cramping stops. In Option b. Barbiturates and amphetamines can precipitate panic attacks. The client shouldn't be touched. such as in taking vital signs. Also. RATIONALE: Diarrhea is a common physiological response to stress and anxiety. Seizures may be a later sign of lithium toxicity. RATIONALE: To determine if a client is at risk for suicide. Leaving the client alone. staying with the client. which increases the heart rate and blood flow. Option d dismisses the client's feelings. False reassurance isn't warranted in this situation. Sexual dysfunction isn't a common adverse effect of lithium. she may be closer to carrying out the act. RATIONALE: If the client tells the nurse to leave. decreasing stimuli.

white blood cell (WBC) counts are necessary weekly. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and. not monthly. the medication must be stopped.preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity. Hypotension may occur in clients taking this medication. In the process of doing play therapy. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. should be considered an emergency. and pill rolling. but that isn't the main goal of therapy. RATIONALE: Focusing on the client's blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. Because of the risk of agranulocytosis. The medication should be continued. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms. The child must also know that he isn't to blame for this situation. a potentially life-threatening complication of clozapine. Blindness and other physical symptoms in a conversion disorder aren't under the client's control and are real to him. along with dystonia. and facial grimacing. RATIONALE: The foundation of any treatment for alcoholism is abstinence. give positive reinforcement for what the client can do. Firm rules and consistency among staff members will help control the client's behavior. RATIONALE: A sore throat and fever are indications of an infection caused by agranulocytosis. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. jerky muscle movements. If the medication must be stopped. even when symptoms have been controlled. Attendance at AA is helpful to some individuals to maintain strict abstinence. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. . difficulty sitting still. and fidgeting. the child can also have fun. Eye exercises won't resolve the client's blindness because no organic pathology is causing the symptoms. If the WBC count drops below 3. It's important for the child to find a way to express internalized feelings. Abstinence requires refraining from social drinking. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. RATIONALE: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness. RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling. rigidity. RATIONALE: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.000/ml. To promote selfesteem.

RATIONALE: By talking about returning to college. RATIONALE: Atropine sulfate is administered approximately 30 minutes before electroconvulsive therapy to reduce oral secretions. the client is demonstrating an interest in making plans for the future. lack of interest in personal appearance. Weight gain & not loss & is typical when taking this medication. therefore. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. any new symptoms reported by a client with hypochondriasis should be reported to the physician. or control nausea and vomiting. and lack of emotion are all symptoms of depression. RATIONALE: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. RATIONALE: Confusion and temporary memory loss are the most common adverse effects of electroconvulsive therapy. RATIONALE: The nurse must tell the client that she'll share information if it affects his safety or his care. RATIONALE: Because of the risk of missing an actual medical problem. with dry mouth being the most common. Anxiety. Atropine also blocks the vagal stimulation of the heart. Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness.RATIONALE: The defining characteristics are those of chronic low self-esteem. Muscle spasms aren't an adverse effect of tricyclic antidepressants. The nurse should continually reorient the client to time and place as he . Atropine sulfate isn't given to make the client feel calm and relaxed nor does it induce sleep. the client doesn't seem to be manipulating those around her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. often followed by an attempt to change it. The nurse also shouldn't encourage the client to withhold information from her. along with negative feelings about self or capabilities. Decreased socialization. RATIONALE: Tricyclic antidepressants can have anticholinergic adverse effects. Hypotension would be expected. The nurse shouldn't promise to ask permission before disclosing information to others. relieve anxiety. The nurse & not the client & should judge what specific information must be shared with others on the health care team. The definition of this diagnosis is negative self-evaluation. the client's mouth would feel dry. rather than hypertension. Based on the information provided. RATIONALE: Benztropine is an anticholinergic medication. which is a sign of recovery from depression. Insight is comprehension of one's own behavior. causing a rise in heart rate (much higher than 48 beats/minute). ineffective denial. and ineffective individual coping all have different sets of defining characteristics. Benztropine doesn't reduce psychotic symptoms. The other interventions are appropriate after the nurse has determined that the client doesn't have a serious medical disorder. which may be directly or indirectly expressed. administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications.

Naloxone is administered for narcotic overdose. It encourages the widest range of client responses. RATIONALE: Chlordiazepoxide and other tranquilizers help reduce the symptoms of alcohol withdrawal. By letting the client know that the nurse doesn't hear the voices. rather than the content of the hallucination. Being alone in his room encourages the client to withdraw and may promote more hallucinations. RATIONALE: Benztropine mesylate is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. emotional immaturity. the nurse is reinforcing the hallucination. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. and a lack of impulse control. thus fostering dependency. a hydantoin drug that reduces the catabolic processes. the nurse conveys acceptance of the client.wakes up from the procedure. severe agitation. By asking the client what the voices are saying. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Asking the client why he drove while intoxicated can make him feel defensive and intimidated. . Magnesium sulfate and other anticonvulsant medications are administered to treat seizures only if they occur during withdrawal. The nurse should focus on the client's feelings. Because of a lack of trust in others. the nurse avoids reinforcing the hallucination. or delirium. Following electroconvulsive therapy. Diazepam. and shows the client that the nurse is interested in his feelings. the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. The client should remain on bed rest until he's fully awake and oriented. miss work repeatedly. is administered to control seizure activity. The nurse shouldn't touch the client with schizophrenia without advance warning. makes the client an active participant in the conversation. clients with antisocial personality disorder commonly have difficulty developing stable. a potentially fatal adverse effect of antipsychotic drugs. By giving advice. and quit work without plans for other employment. RATIONALE: By acknowledging that the client hears voices. close relationships. is administered to alleviate the symptoms of neuroleptic malignant syndrome. A judgmental approach isn't therapeutic. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. The nurse should provide an activity to distract the client. They commonly have a history of unemployment. a benzodiazepine drug that depresses the CNS. the nurse suggests that the client isn't capable of making decisions. RATIONALE: An open-ended statement or question is the most therapeutic response. They also display a lack of responsibility for the outcome of their actions. RATIONALE: Clients with an antisocial personality disorder exhibit a low tolerance for frustration. Clonazepam. Dantrolene. They don't feel guilt about their behavior and commonly perceive themselves as victims. is administered to reduce anxiety. a benzodiazepine drug. Haloperidol may be given to treat clients with psychosis.

The other options leave open the interpretation that attendance is suggested but not mandatory. clear. RATIONALE: The nurse should look for consistency in subjective and objective data. but the client's danger to himself or others takes priority. Measuring urine output isn't crucial. but the nurse needs more data than any one of these options provides. Telling the client he will feel better soon is a vague promise that may create unrealistic expectations in the client. Telling the client to calm down is a placating response. RATIONALE: The nurse's open-ended response encourages exploration. Assessing pupillary responses isn't relevant to the situation. Falling asleep. at least. The nurse should use the least restrictive form of treatment at all times. The other options are important assessments. Option A ignores what the client said and violates the client's right to the least restrictive environment. Dosages of MAO inhibitors can vary widely. Option B assumes that the client is hallucinating. The words "You'll be expected to attend" are concise and concrete and convey precisely what behavior is expected. Facing off with the client and demanding quiet is challenging. Option C fails to address what the client said. RATIONALE: This response acknowledges that the client is important to the nurse and preserves the client's dignity with minimal restriction. Option A is placating the client. RATIONALE: The nurse must check extremities for signs of circulatory impairment. and leave little room for misinterpretation. RATIONALE: MAO inhibitors. Option C assumes that the client is afraid. cessation of verbal threats. A client with antisocial personality disorder tends to disregard rules and authority and be socially irresponsible. Option B is threatening or. which will likely increase the client's anxiety. The client doesn't need to be escorted to his room at this point. assessment for circulation takes priority over respiratory pattern. he hasn't yet been given a chance to go on his own. and saying that he's okay may indicate that restraints are no longer needed. Although the nurse should check vital signs every 15 minutes for 1 hour. the client may void into a urinal as necessary. .RATIONALE: Rules and explanations must be brief. RATIONALE: A voluntary client who poses a danger to himself or others may be denied permission to leave the hospital. RATIONALE: This question aims to clarify the client's remark. too restrictive because the client hasn't exhibited dangerous behavior. may take up to 4 weeks before improving the client's mood. The client's suicidal state and his allergy to cheese are irrelevant to the choice of drug or timing of administration. Consulting the physician is premature. RATIONALE: Administering these two medications within a short time frame increases the risk of hypertension and hyperpyrexia. such as tranylcypromine.

but they don't relate directly to the clients' understanding of medications. how the care is furnished. religious and spiritual beliefs. The ANA Standards of Professional Performance describes a competent level of behavior in the professional nurse's role. Madeleine Leininger's conceptual model of nursing (1978) has a key emphasis that caring is universal and varies transculturally. Some components of cultural assessment that provide insight into the type of information that may be useful in planning and delivering care are heritage and ethnohistory. The physiology of pain includes four processes. gating mechanisms can be found in substantia gelatinosa cells within the dorsal horn of the spinal cord and the thalamus. is the root of biases and prejudices comprising beliefs and attitudes associating negative permanent characteristics with persons who are perceived to be different from the valued group. restorative. primary. Under the managed care system. tertiary. and communication patterns. a tendency to place one's own way of life as superior to others.RATIONALE: A client taking an MAO inhibitor must avoid tyramine-rich foods to prevent a hypertensive or hyperpyretic crisis. transmission. potential for self-harm. and facilitative because it fits the valued life patterns of the client. In the "gate control" theory of pain. and standards of care. and who receives compensation. The point at which a person becomes aware of pain is perception. supportive. the nurse makes clinical judgments about the client's care based on fact. experience. when providing nursing care. and level of anxiety are important assessment areas. Ethnocentrism. These are transduction. secondary. Fluid intake. the organization that pays for health care has the capacity to influence who provides client care. According to Alfaro-Lefevre (1955). and continuing care. The federally funded national health insurance program in the United States for persons older than age 65 is Medicare. . and modulation. The six levels of the health care system are preventive. Culturally congruent care is meaningful. perception.

The longest segment of the digestive tract is the small intestine. The patellar reflex is elicited by the examiner striking the patellar tendon just below the patella. snail-shaped bony tube that forms a portion of the inner ear and contains the transducer for hearing is the cochlea. Core temperature measurement sites include rectum. There are 206 bones in the human body. move the client's feet and legs to the edge of the bed. acute prolonged seizure activity that occurs without full recovery of consciousness between attacks. The primary functions of the liver are to break down and store many biological molecules. and formal operations) and recognizes that children move through these specific periods at different rates but in the same sequence. When assisting a client out of bed. The middle ear contains the three smallest bones in the body. An involuntary response to temperature differences in the body that can increase heat production four to five times greater than normal is shivering. restoration of health. Comprehensive client education includes three important purposes: Health maintenance and promotion of health and illness prevention. . and irregular bones. incus. They are categorized as long bones. and destroy poisons that enter the body. preoperational. and urinary bladder. destroy old blood cells. and stapes. tighten the muscles in the back.the malleus. The largest organ system of the body is the skin. is a medical emergency and is considered the major complication of seizures. store vitamins and iron. The winding. short bones.Jean Piaget's theory of cognitive development includes four periods (sensorimotor. flat bones. and coping with impaired functioning. tympanic membrane. the nurse should move the client's head and shoulders to the edge of the bed. place both arms well under the client's hips. produce bile to aid digestion. A nosocomial infection is one that is acquired in the hospital. Status epilepticus. concrete operation. The federal agency responsible for monitoring endemic and epidemic disease is the CDC. and straighten the back while moving the client.

the only one that is an antiseizure medication is lamotrigine (Lamictal). Adventitious or additional breath sounds. noncontinuous. In a client with metabolic alkalosis. the nurse should expect to find low pH. Chest pain may occur in clients with pneumonia. In a client with respiratory acidosis. and protecting the client's head. . In complex partial seizures. low or normal HCO?. Epilepsy is defined as a group of syndromes characterized by recurring seizures. Approximately 1 in 5 people in the United States have some form of disability. a very subtle finding heard only in the presence of dense consolidation of the lungs due to enhanced transmission of high-frequency components of sound is whispered pectoriloquy. On assessment. noncontinuous breath sound that results from delayed reopening of deflated airways. and pleurisy. are categorized as discrete. the nurse should expect to find a high pH. the nurse should expect to find a high pH. After a seizure has begun. easing the client to the floor if possible. In a client with respiratory alkalosis. and a low PaCO?. and continuous. caused by abnormal conditions that affect the bronchial tree and alveoli. Although the listed drugs have similar sounding names. the nurse should expect that the client will remain motionless or move inappropriately for time and place and that the client will not remember the episode. The International Classification of Seizures differentiates between two main types: Partial and generalized seizures. high HCO?. pulmonary embolism. It is commonly a late symptom of bronchogenic carcinoma. and a high PaCO?. Crackles (formerly called rales) are considered a discrete. this is a PRN medication order.If a prescriber orders a medication to be taken by the client when required. Inspiratory and expiratory breath sounds that are about equal and are often heard in the first and second interspaces anteriorly and between the scapula are bronchovesicular sounds. and a high or normal PaCO?. the primary steps the nurse should take include providing privacy. high or normal HCO?.

the nurse notices a flapping tremor of the hands and documents this as asterixis. Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors used to treat type 2 diabetes mellitus. blood glucose monitoring. but the mortality rate is approximately 10%. slightly fecal odor of the client's breath known as fetor hepaticus. An example of an exocrine gland is the sweat glands. The two most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Five components of diabetes mellitus management are nutritional management. pharmacologic therapy. . The percentage of the end-diastolic volume that is ejected with each stroke is called ejection fraction. Most people who contract hepatitis B develop antibodies to the infection and recover in about 6 months. The type of diabetes mellitus previously referred to as non-insulin-dependent diabetes mellitus is type 2 diabetes mellitus. exercise. Both Addison's disease and Cushing's syndrome result from an imbalance of cortisol and aldosterone. and coma is hepatic encephalopathy. and client education. When assessing a severely ill client with liver dysfunction. and hyperglycemic hyperosmolar nonketotic coma or HHNS. DKA.The client is the key member of a rehabilitation team. The primary mode of transmission for hepatitis A is the fecal-oral route. the nurse detects a sweet. Three major acute complications of diabetes mellitus are hypoglycemia. The highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin is ketone. A life-threatening central nervous system dysfunction resulting from liver disease and frequently associated with elevated ammonia levels that produce changes in mental status. severe anorexia is an early symptom and is thought to be caused by release of a toxin from the damaged liver or by failure of the damaged liver cells to detoxify an abnormal product. altered level of consciousness. When assessing a severely ill client with liver dysfunction. In hepatitis A.

Clients with decreased calcium regulation and metabolism are at risk for osteoporosis and pathologic bone fractures due to weakened bone tissue. . leading to refractive error in which light rays are spread over a diffuse area rather than sharply focused on the retina is astigmatism. muscle. phosphorus. and fluoride. and bone. In the renin-angiotensin system. sometimes subcutaneous tissue. entire dermis. the stimuli for renin secretion are decreased renal perfusion pressure and/or decreased salt delivery to the kidney tubules. A full-thickness burn is described as one that involves the epidermis. The test for cerebellar dysfunction that requires the client to stand with feet together. The term that refers to the body's specific protective response to an invading foreign agent or organism is immunity One function of the spleen is to destroy old and injured red blood cells. In a client with a urinary tract infection. two sugar cubes. shellfish. and possibly connective tissue. The bone matrix stores calcium. An important nursing action in preparing a client for urologic testing with a contrast agent is to obtain the client's allergy history. and arms extended is the Romberg test. Legionnaires' disease is describes as a multisystem illness that usually includes pneumonia and is caused by the gram-negative bacteria Legionella pneumophila.Giving a client with acute hypoglycemia approximately 20 g of a simple carbohydrate is approximately equal to 4 ounces of orange or grapefruit juice. a fetid urine odor is commonly associated with Escherichia coli. The nurse should expect that the major symptom in the B. An eye condition caused by differences in the curvature of the cornea and lens. magnesium. and other seafood. In all types of acute renal failure. or seven Life Savers. especially to iodine. eyes closed. The nurse should never clamp a client's nephrostomy tube. because many contrast agents contain iodine.and T-lymphocyte disorder Wiskott-Aldrich syndrome is thrombocytopenia. the client's serum creatinine level is increased.

A person's unique genetic constitution is made up of 30.000 genes and is called a genotype. pain that is inadequately treated as harmful has harmful . include helping to control mood and sleep and inhibiting pain pathways. An Anesthetist is a member of the nonsterile team who administers anesthetics during the surgical procedure OPTIONS A. OPTION C: The surgeon is responsible in performing the surgical procedure safely and correctly. Cerebral edema is abnormal accumulation of water or fluid in the intracellular space. OPTION B: The anesthesiologist is the person that administers the anesthetic to the patient. Nonsterile team are perioperative caregivers who provide direct care from the pheripery of the sterile field and environment. Sterile team are perioperative caregivers who provide direct care within the sterile field. Martocchio (1982). OPTION C: Dextrose may lead to clumping of red blood cells and hemolysis. are cytokines.000 to 40.C. During transplantation rejection. or both associated with an increase in brain tissue volume. Non-antibody proteins that act as intracellular mediators especially in immune responses. such as Ringer's lactate may cause clotting. extracellular space. The originator of this framework is B. the nurse should ask about use of ototoxic drugs. a major neurotransmitter. Also he/she is responsible for the opening of the outer wrapper of sterile supplies that will be used during the operative procedure. The preferred method of taking a temperature of an unconscious client is rectal or tympanic if not contraindicated. RATIONALE: Regardless of its source. OPTION D: The nursing aide is not a part of the surgical team. and diuretics such as furosemide (Lasix). the cellular response dominates. One framework for understanding the individuality of the dying process describes the patterns of living while dying. RATIONALE: The circulating nurse is responsible for the overall running of the OR before. during and after the operative procedure. RATIONALE:Anesthetist is the answer. When assessing a client with an ear disorder.Actions of dopamine. such as aminoglycoside antibiotics. Most immune responses to antigens involve a specific type of response. antimalarials. B & D: Sterile members of the surgical team RATIONALE:Normal saline solution is the only solution compatible for blood transfusion OPTION A: is not for blood transfusion OPTION B: Solutions containing calcium.

RATIONALE: fentanyl (sublimaze) is a narcotic agonist analgesic (Other name: Neuroleptanalgesic) It is 75-100 times more potent than morphine! In very high doses it can cause respiratory depression. OPTION D: Medications should never be left at the bedside for the patient to take later. hypothermia. By providing an explanation such as this. anaphylaxis. RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. decreased mucocilliary clearance. airway patency is the priority during postoperative pneumonectomy OPTIONS B. resulting in increased pulse and BP and a distressed appearance. RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery. 434). hypoxia. Assess respiratory rate to monitor impending signs of respiratory depression. and can initiate the stress response. an accidental removal of airway is negligent. malignant hyperthermia and disseminated intravascular coagulation and assisting with their management is an important factor (Smeltzer. Being alert to and reporting changes in vital signs and symptoms of nausea and vomiting. The anesthesia provider functions as the guardian of the patient throughout the entire care period. 51). Maintaining the patency of airway is the responsibility of the anesthesia provider. RATIONALE: Using ABC. as well as physiologic changes in the cardiovascular and immune systems. RATIONALE: It is the responsibility of the surgeon and the anesthetist or anesthesiologist to monitor and manage complications. helping reduce the potential for adverse effect associated with smoking such as increased airway reactivity. . a nurse plays an important role. and the surgical site maximizes patient safety and allows for early identification and intervention if any discrepancies are identified. the nurse can help the patient to accept the drugs needed to relieve pain. Unrelieved pain affects various body systems. C & D: correct intervention but airway patency is still the priority RATIONALE: Patient safety in the preoperative area is a priority. Using process to verify patient identification. OPTION A: Patients have the right to refuse therapy. However. OPTION C: A general principle for administering analgesics is to administer them before pain increases in severity.effects beyond the discomforts it causes. the surgical procedure. the anesthesia provider manage the patient's physiology using the principle of aseptic technique (Phillips. The nurse can play an important role in determining the reason for refusal and should first make that attempt before accepting refusal. Research suggest that counseling has a positive effect on the patient's smoking behavior 24 hors preceding surgery. These patients should be counseled to stop smoking at least 24 hours prior to surgery. including the cardiovascular system.

RATIONALE: Following breast reconstruction. The nurse would also document the findings once the physician is notified. and capillary refill. temperature. the flap is inspected for color. or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. There is a reduced PaO2 and an initial respiratory alkalosis. OPTIONS B & C: are incorrect actions. Quick-acting beta-adrenergic medications are first used to prompt relief of airflow obstruction. and dressings are designed so this area can be observed.08 seconds after the end of the QRS. A ventilationperfusion abnormality results in hypoxemia and respiratory alkalosis initially. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells. Assessment of the nipple areola is made. purple. dyspepsia and dysphagia are cardinal symptoms. RATIONALE:The QRS is normally less than 0. As the area of injury becomes ischemic. RATIONALE: QRS complex represents ventricular muscle depolarization OPTION B: T wave represents ventricular muscle repolarization OPTION D:P wave represents atrial muscle depolarization RATIONALE: GERD is the backflow of gastric or duodenal contents into the esophagus caused by incompetent lower esophageal sphincter. RATIONALE: Asthma exacerbations are best managed by early treatment and education of the patient. The basic characteristic of asthma decreases the diameter of the bronchi and is apparent in status asthmaticus. As status asthmaticus worsens. myocardial repolarization is altered and delayed. An areola that is deep red. The ischemic region may remain depolarized while adjacent areas of the myocardium return to resting state. The attacks last longer than 24 hours. with a decreased PaCO2 and an increased pH.12 seconds in duration . followed by respiratory acidosis. RATIONALE: The first ECG signs of acute MI are from myocardial ischemia and injury. Pyrosis or heartburn. the PaCO2 increases and pH falls. reflecting respiratory acidosis. Myocardial injury causes a T wave to become enlarged and symmetric. causing the T wave to invert. Myocardial injury also causes ST-segment changes. dusky. causing the ST segment to rise at least 1 mm above the isoelectric line (area between the T wave and the next P wave is used as a reference for isoelectric line) when measured 0. OPTION A: This is not a priority OPTION B: Should only be at 2L/min OPTION C: Suctioning the client increases respiratory distress RATIONALE: Status asthmaticus is severe persistent asthma that does not respond to conventional therapy.

Teaching the patient measures that will help to reduce odor will be most beneficial. also known as judgmental sampling OPTION C: Snowball sampling is the selection of participants through referrals from other participants. RATIONALE: The surgeon is the head of the surgical team and is the one making decisions about the surgery. skin strips.the odor does not gradually become less noticeable unless steps are taken to reduce it.While it is important to help the patient ventilate. also known as network sampling OPTION D: Quota sampling . Ulcers due to over secretion of HCl. Probanthine exerts benefits for treatment of severe diaphoresis. OPTION A . interrupted suture. such as placing charcoal in the ileostomy bag. retention suture and buried suture. PANCREATITS [Please take note] and other conditions of over . RATIONALE: Convenience sampling .RATIONALE: When difficulty of swallowing is accompanied with pain this is now referred as odynophagia OPTION D . RATIONALE: The surgical wound may be closed with sutures.Dysphagia is difficulty of swallowing alone. RATIONALE: There are techniques that the nurse can use to reduce odor of the ileostomy.This statement is not necessarily true. clamp off the tubing and allow the patient to rest before progressing. The charcoal will absorb the odor in the bag. OPTION A: Purposive sampling .selection of the most readily available persons as participants in the study. 1000.a non-probability sampling method in which the researcher selects participants based on personal judgment about which one will be most representative or informative. Others may be offended by the odor. Painful cramps are often caused by too rapid flow or by too much solution. staples and other materials or may be left open to heal by secondary intention. also known as accidental sampling. 300 ml of fluid maybe all that is needed to stimulate evacuation. or 1500ml as needed by the patient for effective results.a nonrandom selection of participants in which the researcher prespecifies characteristics of the sample to increase its representative RATIONALE: Random sampling is a selection of the sample such that each member of the population has an equal probability of being included. Volume may be increased with subsequent irrigation to 500. OPTION D . Common skin closures are the following: continuous suture. Spasms. not approved by the FDA for treatment with various disorders. OPTION B . RATIONALE: If cramping occurs. staples. RATIONALE: Probanthine reduces glandular secretion of the different organs of the body. this response does not answer the issue of the odor. It is an anticholinergic/antispasmodic drug and still.

RATIONALE: Deliberate attempt to lose weight during the early phase of burn therapy would keep the patient in a state of negative nitrogen balance (catabolism). RATIONALE: Probanthine on its own already cause severe dizziness and drowsiness. OPTION B: Chlorinated pool is discouraged for patients undergoing skin radiation for skin cancer to prevent breakdown. which develops as intracellular and interstitial fluid shift back into the intravascular compartment. RATIONALE: A decrease serum sodium level usually indicates dilutional hyponatremia. RATIONALE: The patient with hypothyroidism has intolerance to cold so a warm environment should be provided.secretion. The nurse should provide psychological support for the patient. RATIONALE: Plasma to interstitial fluid shift usually occurs during the initial stage of burn injury. After the initial stage. It requires a doctor's order. OPTIONS A. Infection control is necessary to help ensure proper healing. . which usually lasts approximately 36 hours. predisposing the patient to circulatory overload. potassium is released into the extracellular space. large amounts of potassium are excreted in the urine because of the increased intravascular volume. catabolism. this would further complicate the patient's condition because he needs to rebuild tissue. Aldosterone. which reabsorbs sodium and excretes potassium. Fluid and electrolyte replacement helps prevent weight loss. The other laboratory values do not reflect changes in water balance. or water excess. this causes leakage through the capillaries. burns commonly have negative effect on the patient's body image. Pain is controlled using probanthine and meperidine (Demerol) in cases of acute pancreatitis. RATIONALE: Probanthine alters the ability of the body to secrete sweat. causing hyperkalemia. OPTIONS C & D: Limiting fluid intake and avoiding cold weather are unecessary teachings. Telling the client to avoid hot weathers to prevent heat stroke is appropriate. at the same time. resulting in edema. Because of cellular trauma. B & C are not contraindicated when taking probanthine EXCEPT when the disease entity itself do not permit intake of such drugs like in Pancreatitis. the body starts to shift fluid back into the intravascular space. NSAID is not use. Addition of alcohol will further depress the CNS and might lead to potentiation of the side effects of probanthine. OPTION A: inappropriate OPTION B: administering medication is a dependent nursing intervention. and the effects of fluid and electrolyte imbalances. the patient's water intake should be restricted to allow the kidneys to excrete the excess water. is released in large quantities in response to dilutional hyponatremia.

If possible. In hypothyroidism there is constipation not diarrhea RATIONALE: Lying prone with the head of the bed lowered 15-30 degrees will make the fluid settle on the upper areas of the lungs by gravity. OPTION D: Appropriate nursing diagnosis for hyperthyroidism. Levothyroxine is given when the thyroid does not produce enough of this hormone on its own. RATIONALE: Clients with hypothyroidism must receive a lifelong thyroid replacement therapy such as (levothyroxine) Synthroid.OPTION D: weight gain develops in hypothyroidism due to a slowed metabolic rate and eventually leads to edema formation. OPTION B: An anesthetic agent OPTION C: Antilipidic agent OPTION D: A dopaminergic agent RATIONALE: A client with hypothyroidism usually feels fatigued which commonly leads to the nursing diagnosis activity intolerance related to weakness and apathy secondary to a decreased metabolic rate and resulting in an increased heart rate and shortness of breath with activity OPTION B: Appropriate nursing diagnosis for hyperthyroidism. RATIONALE: The use of side rails has been a routine practice with the rationale that the side rails serve as a safe and effective means of preventing clients from falling out of bed. In hypothyroidism there is hypometabolism not hypermetabolism. In thoracentesis. Encouraging drinking 6-8 glasses of water may further aggravate existing edema. Does not address safety. OPTION A: inappropriate because the patient is going to sleep. place the patient upright or in one of the following positions: Sitting on the edge of the bed with the feet supported and arms ad on a padded over-the bed table Straddling a chair with arms and head resting on the back of the chair lying on the unaffected side with the bed elevated 30 degrees to 45 degrees if unable to assume a sitting position The upright position facilitates the removal of fluid that that usually localized at the base of the chest. Levothyroxine is a replacement for a hormone that is normally produced by your thyroid gland to regulate the body's energy and metabolism. position the patient comfortably with adequate supports. OPTION C: Does not answer safety in bed concern OPTION D: Locking the door does not provide bed safety RATIONALE: The nurse's immediate response is to ensure compliance with currently ordered . Exophthalmus is seen in hyperthyroidism OPTION C: Appropriate nursing diagnosis for hyperthyroidism. A position of comfort helps the patient to relax.

the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx All other options are incorrect RATIONALE: The creatinine clearance test is a blood and timed urine specimen that evaluates kidney function. OPTIONS A. the person is placed in dorsal recumbent. the procedure is usually done with the person in a sitting position (more common with adults).intravenous fluids. Monitor signs of hemorrhage (frequent swallowing may indicate hemorrhage) OPTION A: Milk and milk products (ice cream and yogurt) may be restricted because they make removal of secretions difficult. Blood is drawn at the start of the test and the morning of the day that the 24-hour urine specimen collection is complete. OPTION B: In the immediate post operative period. rash. Some patients experience a flush of warmth. RATIONALE: The iodine-based dye used in IVP can cause allergic reactions such as itching. RATIONALE: The IVP is a painless procedure. a tight feeling in the throat. You will feel a minor sting as the iodine is injected into your arm. . shortness of breath. assessment is the priority RATIONALE: Post IVP interventions: Monitor vital signs. a mild itching sensation and a metallic taste in their mouth as the iodine begins to circulate throughout their body. it is not a priority RATIONALE: The procedure may be under either local or general anesthesia. If general anesthesia is used. Assessing for allergies is a priority. Assess the venipuncture site for bleeding Monitor urinary output. Monitor for signs of a possible allergic reaction to the dye used during the test. If a local anesthetic is used. the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx OPTION C: may mask bleeding RATIONALE: In the immediate post operative period. hives. Instruct the client to drink atleast 1L of fluid unless contraindicated. RATIONALE: Continuous nursing intervention is required in the immediate postoperative and recovery period because of significant risk of hemorrhage. OPTIONS A & B: are wrong actions OPTION D: Although an unusual occurrence should be filed. B & D . and bronchospasm.Address implementation.

OPTION B: 50% of patients with pancreatitis have interference with insulin release from the beta cells. Not all patients exhibit hyperglycemia. and the outcome of the situation. OPTION D: TPN does not interfere with the production of insulin. incidents. Hyperkalemia result from severe burns for the 1st 24 hours. C. Giving additional insulin would not be the correct intervention. Options B. The goal of therapy is to reduce the secretion of pancreatic enzymes. Based on the information provided in the question. and D are interpretations of the situation and not factual data as observed by the nurse. which may cause hyperglycemia. The report should contain a factual description of the incident. 50% of the patients have a transient hyperglycemia due to the damage to the beta cells. Since most of the potassium in the body is contained in muscle. the patient would experience hypoglycemia. RATIONALE: Insulin is released after ingestion and absorption of carbohydrates SOURCE: RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues. a selected part of the lesion is removed. Rationale: Incisional biopsy. This form of biopsy is commonly completed During endoscopic examination. The Frozen Method procedure is used to assess for malignant cells from tissue samples. The situation and the error presented in the question are not a reason for notifying the board of nursing. Glucose is used to supply energy and caloric needs and usually accounts for 50 . The use of TPN meets the patient's nutritional needs while the patient is taking nothing by mouth. and accidents and the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present.70% of the nutrient prescription OPTION A: In pancreatitis. age. If the pancreas were producing too much insulin. Hyponatremia in burns occur due to low plasma osmolarity. Frozen sections are used for rapid microscopic . RATIONALE: Documentation of unusual occurrences. any injury experienced by those involved. a severe trauma that crushes muscle cells results in an immediate increase in the concentration of potassium in the blood. which stops the inflammatory process. the nurse's error will not result in suspension nor will it be documented in the personnel file.RATIONALE: TPN is used to maintain nutritional status and prevent malnutrition when the patient is unable to be fed orally or by tube feeding. RATIONALE: The incident report should contain the client's name. Option A is the only option that describes the facts as observed by the nurse. and diagnosis.

The client first should be taught how to examine the stoma. The pathologist can determine whether malignancy is present and whether the entire tumor has been removed by looking for a margin of tumor-free tissue. Teach the client how to apply the pouch to the stoma correctly. . RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug. or flat. as prescribed to decrease the bacterial content of the colon to reduce the risk of infection from the surgical procedure. Ascending colon tumor: Diarrhea. RATIONALE: Carefully assess the client's physical condition. emotional and mental attitudes toward the colostomy before attempting to teach ostomy self-care. Increasing fiber in the diet may reduce exposure to carcinogens by speeding stool transit through the intestines. anorexia. kanamycin sulfate. Pace the teaching to the client's level of acceptance of the colostomy and ability to manage it. Descending Colon tumor: constipation or some diarrhea. thus raising the probability that cancer will develop. malaise. A thin slice of tissue is cut from the frozen specimen and examined. RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the development of cancer of the large bowel. Sulfasuxidine and other antiseptics and antibiotics. Some researchers propose that metabolic and bacterial end products are carcinogenic and that constipation allows a longer contact with the bowel wall. erythromycin. abnormal stools. abdominal mass (a late sign). RATIONALE: Symptoms include the following: Blood in stools. & succinylsulfathiazole (Sulfasuxidine) are used preoperatively to reduce bacterial number in the GI tract. Rectal Tumor: alternating constipation and diarrhea. guarding or abdominal distention. Studies on bulk in stool and the rate of transit of fecal matter have so far given mixed results. vomiting. Anemia. A healthy stoma and abdominal incision is a very good indicator that client is now ready for ostomy care teaching.diagnosis. ribbon-like stool resulting from a partial obstruction. primarily for the treatment of asymptomatic mengococcal carrier. Cachexia (a late sign). The procedure requires 10-15 minutes. and weight loss. can be used as alternative for penicillin in rheumatic fever. Neomycin.

Allow tepid fluid to enter the colon slowly. Green beans. Irrigation should be performed at the same time each day. Cheese. Raw fruits. Prune juice. Rice. Whole grains. Spinach.RATIONALE: A suitable time for the irrigation is selected that is compatible with the patient's posthospital pattern of activity (preferably after a meal). Foods causing odor: Cabbage. Apple juice. Food resulting in soft stools (High Fiber): Red wine. Raw carrots. highly spicy food. Raw onions. Cabbage and Milk. 500 mL as needed by the patient for effective results. Corn. Coffee. Grape juice. Spinach. Turnip. Still certain foods you need to avoid or include in your diet so as to maintain a good health after Ostomy. Legumes. and Pretzels. Fish. Prune juice. Seeds and Skins. The main point is that you should be able to tolerate the food you are eating. Fresh vegetables. or blunt trauma. including gas gangrene. Subcutaneous emphysema occurs when air gets into tissues under the skin covering the chest wall or neck. Beans. Cabbage. Potato skins. Beer. it produces an unusual crackling sensation as the gas is pushed through the tissue. Raisins. Subcutaneous emphysema can often be seen as a smooth bulging of the skin. Beans. other penetrations. Volume may be increased with subsequent irrigations to 500. RATIONALE: As such there is no specific diet plan for Ostomy patients. Asparagus. . Broccoli. When a health care provider feels (palpates) the skin. It may also be an indication for a chest tube complication known as subcutaneous emphysema. Tapioca. Peanut butter. iced beverages and Chewing gums. Bananas. Milk. Foods causing diarrhea: Fried foods. Cabbage. Beer. Popcorn. Air can also be found in between skin layers on the arms and legs during certain infections. If cramping occurs. 1000. Foods causing gas: Raw apple. Fruits and Food with high fiber content. clamp off the tubing and allow the patient to rest before progressing. RATIONALE: Assessment actions to check for signs of extended pneumothorax or hemothorax should be performed such as palpating surrounding areas for crepitus. Pineapple. Onions. boiled milk. Below is the list of food you need to keep in consideration: Food resulting in thickened stools (Low-Fiber): Applesauce. Chinese vegetables. Garlic. Water should flow in over 5 to 10 minute period. Eggs. Nuts. Celery. Onions. Coconut. Corn. Raw fruits. RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate evacuation. Alcohol and Vitamins. This can happen due to stabbing. gun shot wounds. Carbonated beverages. up to 1. Foods resulting in incomplete digestion: Broccoli. Nuts.

RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall as a result of the inflammation of the vessel wall. It is very important to seek treatment for respiratory infections existing to stop the progress of the disease. RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM. palpable thrombus that feels bumpy and hard. and Pelvic. OPTION D: Avoiding physical activity is also an intervention for Glomerulonephritis. microorganisms can easily find its way to enter the body through the bloodstream. furthermore. It has 3 Types: Superficial. or who have chronic liver disease. However a specific vaccine had been developed for Hepatitis A which is the inactivated hepatitis A vaccine (active). Also includes the following symptoms: warm and pinkish red color over the thrombus area. elevated WBC count. Assessment findings for a developing Superficial Thrombophlebitis are tenderness and pain in the affected lower extremity. IgD. OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is more of an intervention rather than a preventive measure for recurrence. erythema or drainage at the insertion site. RATIONALE: It is most important to watch out for signs of infection because a patient in TPN is most prone to infection because of an open venous access that can be easily contaminated. which is a medium for bacterial growth. Household and personal contacts of clients with HAV should be given immune globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and after exposure. A strict aseptic technique must be used because the TPN solution has a high concentration of glucose. Assess IV site for . and fever. and IgE. Signs of an infection are as follows: Chills. OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria from entering the urethra. RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or tonsillitis 2 .3 weeks before symptoms. however is indicated for UTI. Usually a streptococcal infection may precede it. which are essential in the body's defense against microorganisms. who are at risk because of foreign travel. IgA. IgG. Femoral. which is given two doses of at least 6 months apart for persons who reside in a community that has a high rate of hepatitis A virus infection. And it is usually with untreated respiratory infections (Group A ?-hemolytic streptococcus) that this sequelae develop.

swelling. and other materials needed for dealing with the disaster . p. or drainage. (Frances Fischbach's A manual of Laboratory and Diagnostic Tests 7th edition. nurse must move close to the client and speak slowly and clearly. Infectious diseases or processes can be diagnosed by detection of an immunologic response specific to an infecting agent in a patient's serum. older clients. and care of disaster victims Includes plans for training disaster personnel and gathering resources. talking in lower tones is advised as shouting may not help and may only disturb other clients inside the unit. the disabled. thus determining the type of medication to be given to the patient. and environmental health and stability to the community Response: Involves putting disaster-planning services into action and enumerating the actions needed to save lives and prevent further damage. Normal humans produce both IgM ( first-response antibodies) and IgG (antibodies that may persist long after an infection) to most pathogens. the following must be done: IV line must be removed and restarted at a different site Remove the tip of the IV catheter and send it to the laboratory for culture Prepare the client for blood cultures RATIONALE: The Gram-Stain is the most important of all bacteriologic differential stains to diagnose a wound infection. evacuation. 500) RATIONALE: It is important to get the attention of the client before beginning to speak despite it's inability to respond or to react. RATIONALE: Mitigation .actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of one Involves determining community hazards and risks (actual and potential threats) for the occurrence of a disaster Involves identifying available community resources and community-health personnel Involves determining the resources available for care of infants. Source: Saunders Comprehensive Review for the NCLEX-RN exam. tenderness.and Gram + organisms. equipment. and those with chronic health problems Recovery: Includes actions taken to return to normal after the disaster. It divides bacteria into two physiologic groups: Gram . If signs of infection occur at the site. Includes prevention of debilitating effects and restoration of personal. Change IV tubing every 24 hours or according to agency protocol.redness. 3rd Edition. economic. Primary concerns include the safety and physical and mental health of both the victims and the members of the disaster-response team Preparedness: Includes plans for rescue.

Gloves shall be worn when cleaning up blood spills or other bodily fluid spills. and is often the disinfectant of choice in cleaning surfaces in hospitals. OPTION C: Black Tag: They are so severely injured that they will die of their injuries. clothing. lethal radiation dose). A 1 in 5 dilution of household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria and some viruses.Includes identification of specific responsibilities for various disaster-response personnel Establishes a community disaster plan and an effective public-communication system Involves setting up an emergency medical system and a plan for its activation Includes checking proper functioning of emergency equipment Involves making anticipatory provisions and setting up a location for distribution of food. OPTION B: Red Tag: They require immediate surgery or other life-saving intervention. severe trauma. shelter. they "cannot wait" but are likely to survive with immediate treatment. These spills shall be disinfected with a ten percent bleach solution or an approved cleansing solution. after more critical injuries have been treated. water. septic shock. or in lifethreatening medical crisis that they are unlikely to survive given the care available (cardiac arrest. Option A:Yellow Tag: Their condition is stable for the moment but requires watching by trained persons and frequent re-triage. other supplies. so the bleach disinfection is sometimes followed . and needs to be thoroughly removed afterwards. and have first priority for surgical teams or transport to advanced facilities. RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated cautiously. possibly in hours or days (large-body burns. will need hospital care (and would receive immediate priority care under "normal" circumstances). severe head or chest wounds). many soft tissue injuries). they are composed of various chemical components one of which is Sodium Hypochlorite. They will require a doctor's care in several hours or days but not immediately. and medicine Includes checking supplies on a regular basis and replenishing those that have become outdated Includes practicing community disaster plans (mock-disaster drills) RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical care at some point. Bleach primarily is used to disinfect blood spills on various surfaces. they should be taken to a holding area and given painkillers as required to reduce suffering. The solution is corrosive. may wait for a number of hours or be told to go home and come back the next day (examples: broken bones without compound fractures.

you should be able to understand the consequences of the disease and the treatment. The family is the primary system to which a person belongs. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. avoidable or unavoidable. OPTIONS: A . A comprehensive assessment of learning needs incorporates data from the nursing history and physical assessment and addresses the client's support system. OPTIONS A. motivation to learn. it is the most powerful system to which a person may ever belong. It also considers client characteristics that may influence the learning process: readiness to learn. puberty. RATIONALE: The nurse may feel conflict because the nurse wants the client to share important information but is unsure about making such promise.Wrong delegation B & C . The family can be the source of love or hate. for example. Birth. and can be caused by a variety of things. RATIONALE: In this age the patient is aware that death will soon occur. pride or shame. and in most cases. marriage. . and death are all considered to be family experiences.by an ethanol disinfection.Destructors Situation 12 . RATIONALE: Learning need is a desire or a requirement to know something that is presently unknown to the learner. RATIONALE: Variances are actual deviations or detours from the critical paths. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. RATIONALE: Bowel softener promotes bowel evacuation without straining / Valsalva's maneuver because it increases ICP. Look at the statement. Negative variance occurs when untoward events prevent a timely discharge. OPTION D may be done at later part of learning. Let the client decide whether to share the information or not.Let the client decide whether to share the information or not. Variances can be positive or negative.B and C . security or insecurity. movement in bed or moving bowels increases ICP. and reading or comprehension level. Assessment of learning need is done first before developing a teaching plan. whether malignant or benign. has serious management implications nurse. The information may be important to the health or safety of the client or others. Straining during coughing.Brain tumor.

The risk of infectious tuberculosis is much higher for persons who are .Noise and frequent interruptions may decrease needed sleep and alter ability to cope. movement in bed.OPTION B . OPTION B . a hypocarbic (low carbon dioxide) blood level is created.Facilitates venous drainage from the brain.for informed consent to be valid. OPTION C . leading to decreased blood flow thus decreased ICP.Coughing increases ICP. Thus reduces cerebral edema. OPTION B . RATIONALE: Straining during coughing. OPTION C . moving bowels or Valsalva Maneuver increases ICP. RATIONALE: The infectious stage of tuberculosis declines immediately after effective chemotherapy. not describe the procedure.Positioning the client with his head towards the side of the tumor increases pressure on the tumor and increases or produces pain. RATIONALE: In order for an informed consent to be valid. A partial pressure of C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels. it must be obtained before the administration of the patient's preoperative medication. and the patient must be competent to understand the information and alternatives. OPTION D . OPTION D . The patient's decision must be voluntary.Hyperventilation had been recommended as the primary treatment of head injured clients because carbon dioxide causes cerebral blood vessels to dilate. 2089) OPTION A . creating diuresis over the following hours. Black and Hawks. pp. Mannitol has a delayed effect of creating an osmotic gradient and pulls fluid out of the cells.The patient needs only to understand the information and alternatives.Osmotic diuretics such as Mannitol.Making a voluntary decision to have a procedure performed is only part of an informed consent. ( SOURCE: Medical Surgical Nursing 7th editon. is used to expand immediately the volume of plasma that increases blood flow and oxygen delivery. By manually hyperventilating or increasing the ventilator settings to cause hyperventilation. the patient must be informed. three basic criteria must be met. The registered nurse's signature as a witness indicates these criteria were met. OPTION C .

Rectal discharge manifestation of ureteral obstruction and heavy aching abdominal pain. A Mantoux test identifies individuals exposed to Mycobacterium tuberculosis. heavy and prolonged alcohol use. OPTION C . Other factors are Low socioeconomic status. pp. inflammation. Trauma. RATIONALE: Lymphedema develops in clients with missing or impaired lymphatic system.Pain is late manifestation. OPTION C . and the normal bicarbonate level is 24 . bladder or both. However. Untreated chronic cervicitis. . OPTIONS B. However. OPTION A .For a definite diagnosis of TB.The nurse should be aware of what the patient has eaten prior to admission since food may slow down the absorption of alcohol and thereby delay withdrawal. OPTION B . the nurse can anticipate withdrawal symptoms and intervene inappropriately. RATIONALE: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. Short term use of antibiotics is not effective chemotherapy. OPTION D . the normal pCO2 is 38-42 mmHg.Late manifestations. By knowing when the patient had her last drink. This test does not differentiate between active and dormant infection. the most essential assessment for the nurse to make is determining when the patient had her last drink. surgical excisions. OPTION C . It usually becomes a difficult problem with the onset of cachexia. because tuberculosis is spread by droplets. OPTION A .This arterial blood gas indicates metabolic acidosis. it will be much more difficult for her to quit. If the patient has a husband who enables her drinking. OPTION D .This information will be use when the individual begins counseling. neoplasms.BCG strengthens the body's immune system.Knowing how old the patient was when she started drinking provides information on the length of her addiction. RATIONALE: Alcohol withdrawal begins within four to six hours of cessation of.STD's and Having a sexual partner with a history of penile or prostate cancer. The normal blood pH is 7.26 mEq /L.45. filariasis.35 . Together with pressure on the bowel.This is a normal arterial blood gas OPTION D . a positive sputum culture is necessary.Antimycobacterial therapy is usually prescribed for six to nine months. or high doses of radiation are factors that develops lymphedema. Bladder iiritation. (SOURCE: CGFNS guide 5th edition.7. 59) OPTION B .are all risk factors of cervical cancer. OPTION B . C & D .This arterial blood gas indicates respiratory acidosis.immunosuppressed. RATIONALE: Not included among the risk factors. or general wasting syndrome. Human papilloma virus (HPV) is the leading cause of cervical cancer. Patients need to be taught to cover their mouth when coughing. it is not a question that needs to be asked immediately. or reduction in.

the patient on Melphalan (Alkeran) therapy would probably have a reduced WBC count. because melphalan affects bone marrow production of blood cells. OPTION A . The cast may be too tight if the patient is unable to move his / her toes.Inability to move the toes indicates compression.Forcing fluids typically causes a feeling of fullness. OPTION B .Temporary alopecia and mild thrombophlebitis at the infusion site are adverse effects of melphalan therapy. OPTION A & C . pp 324) OPTION B . OPTION . RATIONALE: The first step a nurse should take when a blood lithium level is 1. pp 323) syndrome.6 mEq/ dL . This is a dangerous practice because of the possibility of breakage and / or skin irritation. OPTION D .Elevation prevents dependent edema.Skin pigmentation is governed by melanocytes. Pakyaw's loss of appetite causes him to eat less than normal. RATIONALE: Complications of fractures include infection.Heat increases itching due to vasodilation. which are controlled by pituitary gland. Guided imagery is a way to help patients distract themselves from their pain and may produce relaxation response. OPTIONs A & C . The patient may be tempted to slip an object under the cast to scratch. Vaginal discharges and bleeding especially after intercourse are late manifestations Because Mr. the drug would cause skin pigmentation changes. RATIONALE: Pancytopenia refers to depression in all the blood's cellular elements.OPTION C as well. compartment venous thrombosis and fat embolism. OPTION D . which commonly cause a metallic taste in the patient receiving radiation therapy.He should avoid hot meat dishes. RATIONALE: Itching under the cast can be extremely uncomfortable.moderate activity increases persons appetite. (Source: CGFNS study guide th 5 edition. OPTION C . this would further reduce the patients appetite and nutritional intake.Disuse Syndrome may occur late into the post fracture period but is not seen immediately. (Source: CGFNS study guide 5th edition. he should make every mouthful count by eating high calorie foods.Electrolyte imbalance and fluid volume deficit may occur post-surgery but they are not evident in the immediate post-fracture period. OPTION B . but they are not related to pancytopenia.

(Source: CGFNS study guide 5 edition.The nurse should recheck the lithium level after withholding the dose of lithium. which can cause an increase in lithium levels. OPTION C . OPTION D .The physician should be called to re-evaluate the dose after the nurse has the results of a redrawn lithium level.above is to withhold the lithium dose. .Vital signs may be helpful in assessing if the patient is dehydrated. However this should be the initial action by the nurse. pp 324) OPTION A .

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