Nokea
The nurse in the mental health unit is preparing to admit a severely depressed client. Which findings on assessment support the diagnosis of this client? Select all that apply.
- A. Insomnia
- B. Flat affect
- C. Hypersomnia
- D. Substantial weight loss
- E. Weight gain since onset of depression
- F. Reports, 'I don't have any more tears to cry.'
Correct Answer: A,B,D,F
Rationale: In the severely depressed client, loss of weight is typical, whereas the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way, with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying. A flat affect may be associated with depression.
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A nursing childbirth educator tells a class of expectant parents that it is standard routine to instill the ophthalmic ointment form of which medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum?
- A. Penicillin
- B. Neomycin
- C. Vitamin K
- D. Erythromycin
Correct Answer: D
Rationale: Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered in an injectable form to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X. Options 1 and 2 are incorrect and are not medications routinely used in the newborn.
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety?
- A. Use the right arm blood pressure measurement.
- B. Use the fistula for all venipunctures and intravenous infusions.
- C. Ensure that small clamps are attached to the AV fistula dressing.
- D. Assess the fistula for the presence of a bruit and thrill every 4 hours.
Correct Answer: D
Rationale: AV fistulas are created by anastomosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the risk of clotting, infection, or damage to the fistula. The fistula is not used for venipunctures or intravenous infusions for the same reason. Clamps may be needed for an external device such as an AV shunt, but the AV fistula is internal.
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the child's risk for condition-related injury?
- A. Check the anterior fontanel for bulging and the sutures for widening each day.
- B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration.
- C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.
- D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air.
Correct Answer: C
Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV.
A client diagnosed with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field when the client makes which statement?
- A. I'll be able to wash the ink marks off my skin after the initial treatment.
- B. Direct sunlight is something I'll have to really avoid exposing my skin to.
- C. I'll have my family bring me some unscented lotion to keep my skin soft.
- D. Wearing snug fitting clothing over the skin site will help provide good support.
Correct Answer: B
Rationale: The client undergoing radiation therapy must keep the affected skin protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). The client should wash the site using mild soap and warm or cool water and pat the area dry. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. No lotions, creams, alcohol, perfumes, or deodorants should be placed on the skin over the treatment site. The client should wear cotton clothing over the skin site and guard against irritation from tight or rough clothing such as belts or bras.
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
- A. Dependent edema
- B. Diminished distal pulse
- C. Coolness and pallor of the skin
- D. Presence of warm areas on the cast
Correct Answer: D
Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.