NURSING NU270 Capstone

Submission Details Submission Date: 11/9/2014 Submission Time: 11:53 AM Points Awarded: 100 Points Missed: 0 Number of Attempts Allowed: Unlimited Not Scored: 0 Percentage: 100% Questions 1.ID: 283571104 A nurse is working in the emergency department. Which of the following clients should be assessed first? A client with new-onset dizziness A client admitted with a recent ear injury A client who has been experiencing nausea and vomiting for 12 hours A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse’s attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation. Test-Taking Strategy: Use the process of elimination and use the ABCs — airway, breathing, and circulation — to find the correct option. The client experiencing atrial fibrillation is the least stable of the clients identified in the other options. Review the principles of prioritization if you had difficulty with thisquestion. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 1457-1458, 2203). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 2.ID: 283569282 A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items: Within the client’s reach on the left side Within the client’s reach on the right side Correct Just out of the client’s reach on the left side Just out of the client’s reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the client’s unaffected side and by placing the client’s personal care items on the affected side within reach. Placing items out of the client’s reach presents a risk of injury.Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect. With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of the environment. Review care of the client with unilateral neglect if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 1850, 1865). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Awarded 1.0 points out of 1.0 possible points. 3.ID: 283569800 A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though “something ripped.” For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. Bradypnea Severe chest pain Correct Absence of fetal heart tones Correct Increased blood pressure Increased frequency of uterine contractions Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetaloxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety. Test-Taking Strategy: Use the process of elimination, thinking about the manifestations that would be present in the event of uterine rupture. Knowing that bleeding would occur and recalling the signs of shock will assist you in answering correctly. Also, recalling that contractions would cease if rupture occurred will assist you in eliminating the option of increased frequency of uterine contractions. Review the manifestations associated with uterine rupture if you had difficulty with this question. Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 719). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Intrapartum Awarded 1.0 points out of 1.0 possible points. 4.ID: 283570730 A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? Supine Semi-Fowler Correct On the side that has undergone surgery Prone on the side that has undergone surgery Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are allincorrect because they will result in increased edema at the site. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are flat positions. To select from the remaining options, remember that local edema may occur after the trauma of surgery. Use the principles of gravity and measures to prevent accumulation of fluid around the surgical site to direct you to the correct option. If you had difficulty with this question, review care of the client immediately after cataract surgery. References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1094). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 898). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Awarded 1.0 points out of 1.0 possible points. 5.ID: 283572030 A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which of the following interventions does the nurse include in the plan? Placing extra blankets on the client Keeping the room warm Providing a high-calorie, high-protein diet Correct Encouraging frequent ambulation and activities Rationale: Graves disease is characterized by a hypermetabolic state, and the client benefits most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high inprotein. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment. Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., extra blankets and a warm room). To select from the remaining options, recall that Graves disease is characterized by a hypermetabolic state, which will direct you to the correct option. Review care of the client with Graves disease if you had difficulty with this question. Reference: Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical-surgical nursing: Health and illness perspectives (8th ed., p. 1078). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Awarded 1.0 points out of 1.0 possible points. 6.ID: 283570154 A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child’s diet? Rice Correct Wheat cereal Rye crackers Oatmeal biscuits Rationale: Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of grains may betolerated after the ulcerations have healed. Test-Taking Strategy: Use the process of elimination and knowledge regarding the dietary management of celiac disease to answer this question. Recalling that corn and rice are substitutes for gluten- containing foods in this disease will direct you to the correct option. Review dietary management of celiac disease if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 1129). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health – Gastrointestinal Awarded 1.0 points out of 1.0 possible points. 7.ID: 283570704 A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? Assessing the client’s vision Correct Placing ice on the eye Removing the sand par