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The nurse has just administered a purified protein derivative (PPD) tuberculin skin test (Mantoux test) to a client who is at low risk for developing tuberculosis. The nurse determines that the test is positive if which occurs?

• An induration of 15 mm

• The presence of a wheal

• A large area of erythema

• Itching at the injection site

Answer explanation

An induration of 10 mm or more is considered positive for clients in low-risk groups. The presence of a wheal would indicate that the skin test was administered appropriately. Erythema or itching at the site is not indicative of a positive reaction.

The nurse caring for a client diagnosed with a stroke is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item would the nurse eliminate from this client's diet?

• Spinach

• Custard

• Scrambled Eggs

• Mashed Potatoes

Answer explanation

Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.

The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item would be offered to the child?

• Green Jell-o

• Cold soda pop

• Butterscotch pudding

• cool cherry flavored kool-aide

Answer explanation

After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.

A client at risk for respiratory failure is receiving oxygen via nasal cannula at 6 L/min. Arterial blood gas (ABG) results indicate pH 7.29, Pco2 49 mm Hg, Po2 58 mm Hg, and HCO3 18 mEq/L. What intervention would the nurse anticipate that the primary health care provider will prescribe for respiratory support for this client?

• Intubating for mechanical ventilation

• Keeping the oxygen at 6 L/min via nasal cannula

• Lowering the oxygen to 4 L/min via nasal cannula

• Adding a partial rebreather mask to the current prescription

Answer explanation

If respiratory failure occurs and supplemental oxygen cannot maintain acceptable Pao2 and Paco2 levels, endotracheal intubation and mechanical ventilation are necessary. The client is exhibiting respiratory acidosis, metabolic acidosis, and hypoxemia. Lowering or keeping the oxygen at the same liter flow will not improve the client's condition. A partial rebreather mask will raise CO2 levels even further.

The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?

• Note the child's physical symptoms.

• Prepare the child for hydrostatic reduction.

• Prepare the child and parents for the possibility of surgery.

• Report the passage of a normal brown stool to the primary health care provider.

Answer explanation

Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.

The nurse is caring for an infant with jaundice and notes that the serum bilirubin levels have been increasing over the past 48 hours. The nurse anticipates that the serum level today will be at a level appropriate to institute phototherapy. After explaining phototherapy to the parents, which statement indicates the need for further teaching?

• "Our baby will have eye patches on."

• "We will be available for feedings every 2 to 3 hours."

• "We understand that home phototherapy is an option."

• "We will bring in clean clothes for our baby to wear today."

Answer explanation

A common treatment for jaundice is phototherapy. During phototherapy, bilirubin in the skin absorbs the light and changes into water-soluble products (photobilirubin and lumirubin). These do not require conjugation by the liver and can be excreted in the bile and urine. During phototherapy, clothes are not needed, because the infant will be wearing only a diaper to facilitate the benefit of the phototherapy. Eye patches will be placed on the infant's eyes. Feedings will be provided every 2 to 3 hours. Phototherapy can be performed at home.

The clinic nurse is providing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

• "I should keep an extra battery available at all times."

• "I should not wear the hearing aid if I have an ear infection."

• "I should turn the hearing aid off after removing it from my ear."

• "I should wash the ear mold frequently with mild soap and water."

Answer explanation

Nurses would have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should not wear the hearing aid if an ear infection is present. The client should wash the ear mold frequently with mild soap and water with the use of a pipe cleaner to cleanse the cannula.

The registered nurse (RN) reviews a plan of care developed by a nursing student for a client with a history of schizophrenia demonstrating paranoia and notes that the client demonstrates suspicion and mistrust of others. The RN determines that the student needs additional teaching if which intervention is documented?

• Sits with the client and holds the client's hand

• Avoids a warm approach when working with the client

• Uses simple and clear language when speaking to the client

• Defuses angry and hostile verbal attacks with a nondefensive stand

Answer explanation

When caring for a paranoid client, the nurse must avoid any physical contact and should not touch the client. The nurse should ask the client's permission if touch is necessary because touch may be interpreted as a physical or sexual assault. A warm approach is avoided because it can be frightening to a person who needs emotional distance. A matter-of-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a nondefensive stand. The nurse would use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse's intent and actions. The anger that a paranoid client expresses is often displaced, and when a staff member becomes defensive, the anger of both the client and the staff member escalates. A nondefensive and nonjudgmental attitude provides an atmosphere in which feelings can be explored more easily.

A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief would the nurse monitor the client for? Select all that apply.

• Stating a fear of the future and unknown

• Engaging in periods of weeping or raging

• Expressing anger at the medical professionals

• Stating that he knows all he needs to know about his condition

• Expressing a desire to run away from the situation

Answer explanation

Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.

The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?

• Tissue Hypoxia

• Chronic HTN

• Delayed Physical Growth

• Destruction of bone marrow

Answer explanation

Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia. Options 2, 3, and 4 do not cause clubbing.