Question 1

The nurse instructs an older adult client with arthritis on the side effects of nonsteroidal anti-inflammatory drug (NSAID)therapy. Which client statement would indicate that this teaching has been effective?

Accepted Answer

A)Older adult clients are at risk for increased bleeding with NSAID therapy. Thus, the client should be taught to report any abnormal bruising, which may indicate bleeding. Older adult clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. Also, there is no reason for avoiding use of caffeine while using an NSAID.
B)Older adult clients are at risk for increased bleeding with NSAID therapy. Thus, the client should be taught to report any abnormal bruising, which may indicate bleeding. Older adult clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. Also, there is no reason for avoiding use of caffeine while using an NSAID.
C)Older adult clients are at risk for increased bleeding with NSAID therapy. Thus, the client should be taught to report any abnormal bruising, which may indicate bleeding. Older adult clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. Also, there is no reason for avoiding use of caffeine while using an NSAID.
D)Older adult clients are at risk for increased bleeding with NSAID therapy. Thus, the client should be taught to report any abnormal bruising, which may indicate bleeding. Older adult clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. Also, there is no reason for avoiding use of caffeine while using an NSAID.

Question 2

A client with acute abdominal pain is scheduled for an appendectomy in 3 hours. While waiting for the surgery, the client reports that the pain has subsided. In this scenario, what is the priority action by the nurse?

Accepted Answer

A)The pain relief being experienced by the client is consistent with rupture of the appendix. In the case of suspected rupture, the healthcare provider should be notified immediately, because if the appendix has ruptured, the client's risk for peritonitis will increase. The next time the client can be medicated for pain is not relevant in this situation. Notification of the surgery department and the nursing supervisor should not be completed before contacting the healthcare provider.
B)The pain relief being experienced by the client is consistent with rupture of the appendix. In the case of suspected rupture, the healthcare provider should be notified immediately, because if the appendix has ruptured, the client's risk for peritonitis will increase. The next time the client can be medicated for pain is not relevant in this situation. Notification of the surgery department and the nursing supervisor should not be completed before contacting the healthcare provider.
C)The pain relief being experienced by the client is consistent with rupture of the appendix. In the case of suspected rupture, the healthcare provider should be notified immediately, because if the appendix has ruptured, the client's risk for peritonitis will increase. The next time the client can be medicated for pain is not relevant in this situation. Notification of the surgery department and the nursing supervisor should not be completed before contacting the healthcare provider.
D)The pain relief being experienced by the client is consistent with rupture of the appendix. In the case of suspected rupture, the healthcare provider should be notified immediately, because if the appendix has ruptured, the client's risk for peritonitis will increase. The next time the client can be medicated for pain is not relevant in this situation. Notification of the surgery department and the nursing supervisor should not be completed before contacting the healthcare provider.

Question 3

The nurse is caring for a pediatric client recovering from surgery for a perforated appendix. Which nursing diagnosis should the nurse use to guide this client's care during the immediate postoperative period?

Accepted Answer

A)Because the client is recovering from an appendectomy, the client will most likely have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for infection, specifically peritonitis.
B)Because the client is recovering from an appendectomy, the client will most likely have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for infection, specifically peritonitis.
C)Because the client is recovering from an appendectomy, the client will most likely have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for infection, specifically peritonitis.
D)Because the client is recovering from an appendectomy, the client will most likely have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for infection, specifically peritonitis.

Question 4

A client with appendicitis is highly agitated and states that she is experiencing a great deal of pain. Which intervention will help decrease this client's anxiety?

Accepted Answer

A)The extreme pain caused by appendicitis is the source of the client's anxiety. Assessing the client's pain level every 2 hours and administering medications before the pain gets intense is the best intervention to help decrease the client's anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is often appropriate for those with chronic pain.
B)The extreme pain caused by appendicitis is the source of the client's anxiety. Assessing the client's pain level every 2 hours and administering medications before the pain gets intense is the best intervention to help decrease the client's anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is often appropriate for those with chronic pain.
C)The extreme pain caused by appendicitis is the source of the client's anxiety. Assessing the client's pain level every 2 hours and administering medications before the pain gets intense is the best intervention to help decrease the client's anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is often appropriate for those with chronic pain.
D)The extreme pain caused by appendicitis is the source of the client's anxiety. Assessing the client's pain level every 2 hours and administering medications before the pain gets intense is the best intervention to help decrease the client's anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is often appropriate for those with chronic pain.

Question 5

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus. Given this information, which action is most appropriate by the nurse?

Accepted Answer

A)After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake of both food and fluids must be withheld during this time.
B)After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake of both food and fluids must be withheld during this time.
C)After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake of both food and fluids must be withheld during this time.
D)After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake of both food and fluids must be withheld during this time.

Question 6

The nurse, caring for an older school-age client recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which nonpharmacologic nursing strategy would be most appropriate for this client?

Accepted Answer

A)A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.
B)A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.
C)A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.
D)A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.

Question 7

The nurse is providing care to a client who experiences chronic inflammation due to arthritis. For which collaborative intervention should the nurse plan when providing care to this client?

Accepted Answer

A)Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis. Opioid medication is not usually indicated to treat a chronic inflammatory process. Antibiotics would be ordered for an infection, not for chronic inflammation. Finally, diuretics are not used to treat the inflammatory process.
B)Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis. Opioid medication is not usually indicated to treat a chronic inflammatory process. Antibiotics would be ordered for an infection, not for chronic inflammation. Finally, diuretics are not used to treat the inflammatory process.
C)Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis. Opioid medication is not usually indicated to treat a chronic inflammatory process. Antibiotics would be ordered for an infection, not for chronic inflammation. Finally, diuretics are not used to treat the inflammatory process.
D)Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis. Opioid medication is not usually indicated to treat a chronic inflammatory process. Antibiotics would be ordered for an infection, not for chronic inflammation. Finally, diuretics are not used to treat the inflammatory process.

Question 8

A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate?

Accepted Answer

A)The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis, so the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.
B)The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis, so the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.
C)The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis, so the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.
D)The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis, so the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.

Question 9

An adult female client develops signs and symptoms of appendicitis during the night. The client is brought to the emergency department by her family. Which nursing intervention is the most culturally sensitive for this client?

Accepted Answer

A)Culturally competent care means collaborating with the client to determine his or her preferences for medical care. The nurse should not assume that a client will want a male or female doctor. Asking the healthcare provider to decide does not include the client's wishes.
B)Culturally competent care means collaborating with the client to determine his or her preferences for medical care. The nurse should not assume that a client will want a male or female doctor. Asking the healthcare provider to decide does not include the client's wishes.
C)Culturally competent care means collaborating with the client to determine his or her preferences for medical care. The nurse should not assume that a client will want a male or female doctor. Asking the healthcare provider to decide does not include the client's wishes.
D)Culturally competent care means collaborating with the client to determine his or her preferences for medical care. The nurse should not assume that a client will want a male or female doctor. Asking the healthcare provider to decide does not include the client's wishes.

Question 10

A client is admitted to the hospital with airway edema, bronchoconstriction, and increased mucus production after being exposed to an allergen. Which nursing interventions are appropriate to address this inflammation to the client's respiratory system? Select all that apply.

Accepted Answer

A)Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity but not to address respiratory inflammation. In contrast, monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would all be appropriate care for a client who is experiencing inflammation of the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.
B)Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity but not to address respiratory inflammation. In contrast, monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would all be appropriate care for a client who is experiencing inflammation of the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.
C)Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity but not to address respiratory inflammation. In contrast, monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would all be appropriate care for a client who is experiencing inflammation of the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.
D)Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity but not to address respiratory inflammation. In contrast, monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would all be appropriate care for a client who is experiencing inflammation of the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.
E)Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity but not to address respiratory inflammation. In contrast, monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would all be appropriate care for a client who is experiencing inflammation of the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.

Question 11

The warmth and redness that accompany inflammation result from which of the following steps in the inflammatory process?

Accepted Answer

A)Immediately after injury or infection, the damaged tissues release histamines, kinins, and prostaglandins. These substances serve as chemical mediators to dilate blood vessels, causing more blood to flow to the injured area. This increase in blood supply is called hyperemia and is responsible for the characteristic signs of redness and heat that accompany inflammation. Margination refers to the process by which leukocytes aggregate along the inner surface of blood vessels in an injured area. Exudate production occurs later in the inflammatory process and involves the release of fluid, dead cells, and cellular products from the injured area. Cellular regeneration occurs during the last stage of the inflammatory process and does not cause redness or warmth.
B)Immediately after injury or infection, the damaged tissues release histamines, kinins, and prostaglandins. These substances serve as chemical mediators to dilate blood vessels, causing more blood to flow to the injured area. This increase in blood supply is called hyperemia and is responsible for the characteristic signs of redness and heat that accompany inflammation. Margination refers to the process by which leukocytes aggregate along the inner surface of blood vessels in an injured area. Exudate production occurs later in the inflammatory process and involves the release of fluid, dead cells, and cellular products from the injured area. Cellular regeneration occurs during the last stage of the inflammatory process and does not cause redness or warmth.
C)Immediately after injury or infection, the damaged tissues release histamines, kinins, and prostaglandins. These substances serve as chemical mediators to dilate blood vessels, causing more blood to flow to the injured area. This increase in blood supply is called hyperemia and is responsible for the characteristic signs of redness and heat that accompany inflammation. Margination refers to the process by which leukocytes aggregate along the inner surface of blood vessels in an injured area. Exudate production occurs later in the inflammatory process and involves the release of fluid, dead cells, and cellular products from the injured area. Cellular regeneration occurs during the last stage of the inflammatory process and does not cause redness or warmth.
D)Immediately after injury or infection, the damaged tissues release histamines, kinins, and prostaglandins. These substances serve as chemical mediators to dilate blood vessels, causing more blood to flow to the injured area. This increase in blood supply is called hyperemia and is responsible for the characteristic signs of redness and heat that accompany inflammation. Margination refers to the process by which leukocytes aggregate along the inner surface of blood vessels in an injured area. Exudate production occurs later in the inflammatory process and involves the release of fluid, dead cells, and cellular products from the injured area. Cellular regeneration occurs during the last stage of the inflammatory process and does not cause redness or warmth.

Question 12

The nurse is caring for a client who has experienced a sports-related injury to the knee. During the morning assessment, which signs of inflammation should the nurse anticipate? Select all that apply.

Accepted Answer

A)Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.
B)Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.
C)Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.
D)Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.
E)Swelling, warmth, and pain are all signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.

Question 13

The nurse is providing instructions to a client who has been prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which information is highest priority for the nurse to explain to the client about this medication?

Accepted Answer

A)Nonsteroidal anti-inflammatory drugs (NSAIDs)are nephrotoxic; maintaining adequate hydration when taking these medications is important because it will help prevent kidney damage. Taking NSAIDs with food is recommended because doing so will decrease gastrointestinal (GI)irritation, but preventing kidney damage is more of a priority. Constipation is not an issue with NSAIDs.
B)Nonsteroidal anti-inflammatory drugs (NSAIDs)are nephrotoxic; maintaining adequate hydration when taking these medications is important because it will help prevent kidney damage. Taking NSAIDs with food is recommended because doing so will decrease gastrointestinal (GI)irritation, but preventing kidney damage is more of a priority. Constipation is not an issue with NSAIDs.
C)Nonsteroidal anti-inflammatory drugs (NSAIDs)are nephrotoxic; maintaining adequate hydration when taking these medications is important because it will help prevent kidney damage. Taking NSAIDs with food is recommended because doing so will decrease gastrointestinal (GI)irritation, but preventing kidney damage is more of a priority. Constipation is not an issue with NSAIDs.
D)Nonsteroidal anti-inflammatory drugs (NSAIDs)are nephrotoxic; maintaining adequate hydration when taking these medications is important because it will help prevent kidney damage. Taking NSAIDs with food is recommended because doing so will decrease gastrointestinal (GI)irritation, but preventing kidney damage is more of a priority. Constipation is not an issue with NSAIDs.

Question 14

The nurse is caring for a client in the emergency department who is suspected of having appendicitis. Based on this data, which orders should the nurse anticipate from the healthcare provider? Select all that apply.

Accepted Answer

A)Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated.
B)Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated.
C)Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated.
D)Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated.
E)Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated.

Question 15

The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory drugs (NSAIDs)for the treatment of their disease processes. Which of the following are the primary laboratory tests the nurse should assess prior to initiation of NSAID therapy? Select all that apply.

Accepted Answer

A)It is important to assess the client's creatinine clearance to determine kidney function prior to initiation of NSAID therapy. It is also important to assess the client's liver function tests and complete blood count (CBC)prior to beginning NSAID therapy. There is no need to assess the client's electrolytes or serum amylase, because neither of these levels are affected by NSAIDs.
B)It is important to assess the client's creatinine clearance to determine kidney function prior to initiation of NSAID therapy. It is also important to assess the client's liver function tests and complete blood count (CBC)prior to beginning NSAID therapy. There is no need to assess the client's electrolytes or serum amylase, because neither of these levels are affected by NSAIDs.
C)It is important to assess the client's creatinine clearance to determine kidney function prior to initiation of NSAID therapy. It is also important to assess the client's liver function tests and complete blood count (CBC)prior to beginning NSAID therapy. There is no need to assess the client's electrolytes or serum amylase, because neither of these levels are affected by NSAIDs.
D)It is important to assess the client's creatinine clearance to determine kidney function prior to initiation of NSAID therapy. It is also important to assess the client's liver function tests and complete blood count (CBC)prior to beginning NSAID therapy. There is no need to assess the client's electrolytes or serum amylase, because neither of these levels are affected by NSAIDs.
E)It is important to assess the client's creatinine clearance to determine kidney function prior to initiation of NSAID therapy. It is also important to assess the client's liver function tests and complete blood count (CBC)prior to beginning NSAID therapy. There is no need to assess the client's electrolytes or serum amylase, because neither of these levels are affected by NSAIDs.

Question 16

In the presence of inflammation, a client's erythrocyte sedimentation rate (ESR)

Accepted Answer

A)When an inflammatory process is active, the increased proportion of fibrinogen in a client's blood causes the red blood cells to stick to one another and settle faster. This, in turn, results in a higher ESR reading.
B)When an inflammatory process is active, the increased proportion of fibrinogen in a client's blood causes the red blood cells to stick to one another and settle faster. This, in turn, results in a higher ESR reading.
C)When an inflammatory process is active, the increased proportion of fibrinogen in a client's blood causes the red blood cells to stick to one another and settle faster. This, in turn, results in a higher ESR reading.
D)When an inflammatory process is active, the increased proportion of fibrinogen in a client's blood causes the red blood cells to stick to one another and settle faster. This, in turn, results in a higher ESR reading.

Question 17

The nurse is teaching the family of a school-age client diagnosed with inflammatory bowel disease regarding the administration of prednisone at home. At which time should the nurse instruct the parents to provide this medication to the client?

Accepted Answer

A)Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce this irritation. It should not be given on an empty stomach.
B)Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce this irritation. It should not be given on an empty stomach.
C)Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce this irritation. It should not be given on an empty stomach.
D)Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce this irritation. It should not be given on an empty stomach.

Question 18

A nurse is providing instruction to the parents of a pediatric client who is experiencing inflammation due to respiratory infection. Which of the following points would be most appropriate for the nurse to include as part of this teaching?

Accepted Answer

A)As compared to adults, children have a larger tongue relative to the oral cavity, decreased airway muscle tone, a shorter epiglottis, a more anteriorly positioned larynx, a shorter and narrower trachea, and prominent adenoid and lymphoid tissue. These factors increase a child's risk of airway obstruction, especially when the child is supine and/or the neck is hyperflexed. Hence, these positions should be avoided. Also because of children's small size, absolute volumes of fluid loss represent a larger proportion of total body fluid. For this reason, adequate fluid intake is especially important for pediatric clients with inflammation. Finally, whereas adults typically respond to dehydration and hypovolemia with a compensatory increase in heart rate, tachycardia is frequently a late symptom of hypovolemia in children.
B)As compared to adults, children have a larger tongue relative to the oral cavity, decreased airway muscle tone, a shorter epiglottis, a more anteriorly positioned larynx, a shorter and narrower trachea, and prominent adenoid and lymphoid tissue. These factors increase a child's risk of airway obstruction, especially when the child is supine and/or the neck is hyperflexed. Hence, these positions should be avoided. Also because of children's small size, absolute volumes of fluid loss represent a larger proportion of total body fluid. For this reason, adequate fluid intake is especially important for pediatric clients with inflammation. Finally, whereas adults typically respond to dehydration and hypovolemia with a compensatory increase in heart rate, tachycardia is frequently a late symptom of hypovolemia in children.
C)As compared to adults, children have a larger tongue relative to the oral cavity, decreased airway muscle tone, a shorter epiglottis, a more anteriorly positioned larynx, a shorter and narrower trachea, and prominent adenoid and lymphoid tissue. These factors increase a child's risk of airway obstruction, especially when the child is supine and/or the neck is hyperflexed. Hence, these positions should be avoided. Also because of children's small size, absolute volumes of fluid loss represent a larger proportion of total body fluid. For this reason, adequate fluid intake is especially important for pediatric clients with inflammation. Finally, whereas adults typically respond to dehydration and hypovolemia with a compensatory increase in heart rate, tachycardia is frequently a late symptom of hypovolemia in children.
D)As compared to adults, children have a larger tongue relative to the oral cavity, decreased airway muscle tone, a shorter epiglottis, a more anteriorly positioned larynx, a shorter and narrower trachea, and prominent adenoid and lymphoid tissue. These factors increase a child's risk of airway obstruction, especially when the child is supine and/or the neck is hyperflexed. Hence, these positions should be avoided. Also because of children's small size, absolute volumes of fluid loss represent a larger proportion of total body fluid. For this reason, adequate fluid intake is especially important for pediatric clients with inflammation. Finally, whereas adults typically respond to dehydration and hypovolemia with a compensatory increase in heart rate, tachycardia is frequently a late symptom of hypovolemia in children.

Question 19

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply.

Accepted Answer

A)Systemic manifestations of infection include elevated or abnormally low temperature, tachycardia, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment all indicate a local reaction.
B)Systemic manifestations of infection include elevated or abnormally low temperature, tachycardia, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment all indicate a local reaction.
C)Systemic manifestations of infection include elevated or abnormally low temperature, tachycardia, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment all indicate a local reaction.
D)Systemic manifestations of infection include elevated or abnormally low temperature, tachycardia, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment all indicate a local reaction.
E)Systemic manifestations of infection include elevated or abnormally low temperature, tachycardia, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment all indicate a local reaction.

Question 20

The nurse is caring for a client who has extensive deep tissue damage. The nurse notes that the client is also vegan. Which dietary information should the nurse teach this client to enhance the healing process?

Accepted Answer

A)Carbohydrates are important to meet the energy demands of healing, and protein is needed for cell growth. This client needs to be taught to eat proteins that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-complex vitamins.
B)Carbohydrates are important to meet the energy demands of healing, and protein is needed for cell growth. This client needs to be taught to eat proteins that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-complex vitamins.
C)Carbohydrates are important to meet the energy demands of healing, and protein is needed for cell growth. This client needs to be taught to eat proteins that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-complex vitamins.
D)Carbohydrates are important to meet the energy demands of healing, and protein is needed for cell growth. This client needs to be taught to eat proteins that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-complex vitamins.

Quiz 10: Inflammation

The nurse instructs an older adult client with arthritis on the side effects of nonsteroidal anti-inflammatory drug (NSAID) therapy. Which client statement would indicate that this teaching has been effective?