Adult Health exam 3
Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder? a. "Have you experienced any blurring or double vision?" b. "Do you have to get up at night to empty your bladder?" c. "Have you had a recent unplanned weight gain or loss?" d. "What methods do you use to help cope with stress?"
The correct answer is: "Have you had a recent unplanned weight gain or loss?" Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.
The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response? a. "Do you crave sugary drinks?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Are you anorexic?"
The correct answer is: "Have you lost weight lately?" Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Begin thyroid hormone replacement. b. Plan for emergency tracheostomy. c. Administer IV calcium gluconate. d. Prepare for endotracheal intubation.
The correct answer is: Administer IV calcium gluconate. The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Thyroid hormone replacement may be needed eventually but will not improve the symptoms of hypocalcemia.
Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures? a. Monitor level of consciousness (LOC). b. Obtain computed tomography (CT) scan. c. Administer lorazepam (Ativan) 4 mg IV. d. Give phenytoin (Dilantin) 100 mg IV.
The correct answer is: Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis? a. Grip strength b. Respiratory effort c. Level of consciousness d. Pupil size
The correct answer is: Respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient's bilirubin level decreases. b. The patient denies nausea or anorexia. c. The patient has at least one stool daily. d. The patient is alert and oriented.
The correct answer is: The patient is alert and oriented. The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Acetaminophen (Tylenol) 650 mg rectally. b. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. c. Start norepinephrine to keep blood pressure above 90 mm Hg. d. Administer normal saline IV at 500 mL/hr.
The correct answer is: Administer normal saline IV at 500 mL/hr. Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.
Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Antithyroid medications may take several months for full effect. c. Restriction of iodine intake is needed to reduce thyroid activity. d. Surgery will eventually be required to remove the thyroid gland.
The correct answer is: Antithyroid medications may take several months for full effect. Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.
A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. Have the patient practice her facial and tongue exercises with a mirror. b. Ask questions that the patient can answer with "yes" or "no." c. Develop a list of words that the patient can read and practice reciting. d. Prevent embarrassing the patient by answering for her if she does not respond.
The correct answer is: Ask questions that the patient can answer with "yes" or "no." Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Assess the patient's respiratory effort. b. Check the blood pressure and pulse. c. Support the patient's head with pillows. d. Observe the dressing for bleeding.
The correct answer is: Assess the patient's respiratory effort. Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.
To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? a. Support selection of a high-protein diet. b. Assist to plan a prescribed bowel program. c. Discuss options for sexuality and fertility. d. Use quad coughing to strengthen cough efforts.
The correct answer is: Assist to plan a prescribed bowel program. Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.
A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Liver 3 cm below costal margin b. Elevated total bilirubin level c. Jaundiced sclera and skin d. Asterixis and lethargy
The correct answer is: Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.
Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula? a. Irrigate the fistula site with saline every 8 to 12 hours. b. Auscultate for a bruit at the fistula site. c. Compare blood pressures in the left and right arms. d. Assess the quality of the left radial pulse.
The correct answer is: Auscultate for a bruit at the fistula site. The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.
Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital? a. Providing perineal hygiene to patients daily and as needed b. Encouraging adequate oral fluid and nutritional intake c. Testing urine with a dipstick daily for nitrites d. Avoiding unnecessary urinary catheterization
The correct answer is: Avoiding unnecessary urinary catheterization Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful but are not as useful as decreasing urinary catheter use.
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min b. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min d. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
The correct answer is: Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
Which finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Cloudy and foul-smelling urine b. Blood pressure 90/48 mm Hg c. Temperature 100.1° F (57.8° C) d. Flank tenderness to palpation
The correct answer is: Blood pressure 90/48 mm Hg The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.
A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan to teach the patient? a. Including whole grains in the diet to prevent constipation b. Bisphosphonates to reduce bone demineralization c. Increasing fluid intake to decrease risk for nephrolithiasis d. Calcium supplements to normalize serum calcium levels
The correct answer is: Calcium supplements to normalize serum calcium levels Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.
During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first? a. Check the blood pressure (BP). b. Give prescribed PRN antiemetic drugs. c. Slow down the rate of dialysis. d. Review the hematocrit (Hct) level.
The correct answer is: Check the blood pressure (BP). The patient's reports of nausea and dizziness suggest hypotension, so the first action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response? a. Decorticate posturing b. Decerebrate posturing c. Localization of pain d. Flexion withdrawal
The correct answer is: Decorticate posturing Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect? a. Low urine specific gravity b. Increased serum chloride c. Elevated hematocrit d. Decreased serum sodium
The correct answer is: Decreased serum sodium When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Right-sided neglect b. Hyperactive left-sided tendon reflexes c. Difficulty comprehending instructions d. Impulsive behavior
The correct answer is: Difficulty comprehending instructions Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones? a. Using a filter to strain all urine b. Avoiding dietary sources of calcium c. Choosing diuretic fluids such as coffee d. Drinking 3000 mL of fluid each day
The correct answer is: Drinking 3000 mL of fluid each day A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with kidney stones. Coffee tends to increase stone recurrence. Straining all urine routinely after a stone has passed will not prevent stones.
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Insertion of a mini-tracheostomy with frequent suctioning b. Administration of 100% O2 by non-rebreather mask c. Endotracheal intubation and positive pressure ventilation d. Initiation of continuous positive pressure ventilation (CPAP)
The correct answer is: Endotracheal intubation and positive pressure ventilation The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will promote removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Lipase c. Bilirubin d. Potassium
The correct answer is: Lipase Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Tell the patient that the aspirin is used to prevent a fever. b. Explain that the aspirin is ordered to decrease stroke risk. c. Document that the patient refused the aspirin. d. Call the health care provider to clarify the medication order.
The correct answer is: Explain that the aspirin is ordered to decrease stroke risk. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level
The correct answer is: Glomerular filtration rate (GFR) GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Oral glucose tolerance test b. Fasting blood glucose c. Urine dipstick for glucose and ketones d. Glycosylated hemoglobin (A1C)
The correct answer is: Glycosylated hemoglobin (A1C) The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not used for monitoring glucose control after diabetes has been diagnosed.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy extremities b. Inspiratory crackles c. Temperature 101.2° F (38.4° C) d. Heart rate 45 beats/min
The correct answer is: Heart rate 45 beats/min Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? a. Help the patient to a lateral position. b. Transfer the patient to radiology. c. Enforce NPO status for 4 hours. d. Administer a sedative medication.
The correct answer is: Help the patient to a lateral position. For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect? a. Increased urinary cortisol b. Elevated serum aldosterone c. Low urinary catecholamines d. Decreased serum thyroxine
The correct answer is: Increased urinary cortisol Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. The anterior pituitary does not control aldosterone and catecholamine levels.
What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? a. Inquire about urinary tract problems. b. Ask the patient about any increase in libido. c. Inspect the skin for rashes or discoloration. d. Assess for the presence of chest pain.
The correct answer is: Inquire about urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Insert nasogastric tube to low suction. b. Turn patient side to side every 2 hours. c. Apply cold packs intermittently to face. d. Keep the head of bed elevated.
The correct answer is: Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Hemoglobin and hematocrit b. Intracranial pressure c. Oxygen saturation d. Blood pressure
The correct answer is: Intracranial pressure Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Cluster nursing interventions to provide rest periods. c. Position the patient with knees and hips flexed. d. Keep the head of the bed elevated to 30 degrees.
The correct answer is: Keep the head of the bed elevated to 30 degrees. The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
A 26-yr-old female who has type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and reports a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. What should the nurse advise the patient to do? a. Decrease carbohydrates until glycosylated hemoglobin is less than 7%. b. Limit intake of calories until the glucose is less than 120 mg/dL. c. Use only the lispro insulin until the symptoms are resolved. d. Monitor blood glucose every 4 hours and contact the clinic if it rises.
The correct answer is: Monitor blood glucose every 4 hours and contact the clinic if it rises. Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Deflate the gastric balloon if the patient reports nausea. c. Monitor the patient for shortness of breath. d. Verify the position of the balloon every 4 hours.
The correct answer is: Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.
A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Prepare the patient for craniotomy. b. Type and crossmatch for blood transfusion. c. Administer IV furosemide (Lasix). d. Initiate high-dose barbiturate therapy.
The correct answer is: Prepare the patient for craniotomy. The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? a. Ensure privacy for teaching by asking the family to leave. b. Delay teaching until closer to discharge date. c. Offer multiple options for management of therapies. d. Provide written reminders of information taught.
The correct answer is: Provide written reminders of information taught. Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is complex, teaching should be started well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.
A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? a. Purplish streaks on the abdomen b. Decreased axillary and pubic hair c. Bronzed appearance of the skin d. Chronically low blood pressure
The correct answer is: Purplish streaks on the abdomen Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.
Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Bounding peripheral pulses b. Hot, flushed face and neck c. Persistent skin tenting d. Rapid, deep respirations
The correct answer is: Rapid, deep respirations Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.
Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? a. Level of consciousness b. Respiratory rate c. Pupil reaction d. Reflex reaction time
The correct answer is: Respiratory rate Vital centers that control respiration are located in the medulla and part of the brainstem. They require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent.
A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority? a. Risk for electrolyte imbalance b. Disturbed body image c. Impaired nutritional status d. Difficulty coping
The correct answer is: Risk for electrolyte imbalance The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.
After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care? a. Support the surgical incision during patient coughing and turning in bed. b. Remind the patient that PCA use may slow the return of bowel function. c. Offer sips of fruit juices at frequent intervals. d. Irrigate the nasogastric (NG) tube frequently.
The correct answer is: Support the surgical incision during patient coughing and turning in bed. Protecting the incision from strain decreases the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure (BP) is 144/90 mm Hg. b. The patient's speech is difficult to understand. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
The correct answer is: The patient has atrial fibrillation and takes warfarin (Coumadin). The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? a. The patient is confused and lethargic. b. The patient's urine specific gravity is 1.003. c. The patient reports a recent head injury. d. The patient has a urine output of 400 mL/hr.
The correct answer is: The patient is confused and lethargic. The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.
Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient is continuously drooling saliva. b. The patient's sacral area skin is reddened. c. The patient's blood pressure (BP) is 150/82 mm Hg. d. The patient reports severe pain in the feet.
The correct answer is: The patient is continuously drooling saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.
The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient is more difficult to arouse. c. The blood pressure increases to 140/62 mm Hg. d. The patient reports a headache.
The correct answer is: The patient is more difficult to arouse. The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Transluminal angioplasty b. Surgical endarterectomy c. Intravenous heparin drip administration d. Tissue plasminogen activator (tPa) infusion
The correct answer is: Tissue plasminogen activator (tPa) infusion The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Urine output 65 mL over the past hour. b. Hemoglobin is within normal limits. c. Mean arterial pressure (MAP) is 72 mm Hg. d. There are no signs of hemorrhage.
The correct answer is: Urine output 65 mL over the past hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.
A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highestpriority on assisting the patient to: a. ambulate the evening of the operative day. b. turn, cough, and deep breathe every 2 hours. c. choose preferred low-fat foods from the menu. d. perform leg exercises hourly while awake.
The correct answer is: turn, cough, and deep breathe every 2 hours. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.
