EAQ Nursing Process - Data Collection

After a thoracentesis is performed for pleural effusion, a client returns to the health care provider's office for a follow-up visit. Which client statement leads the nurse to suspect a recurrence of the pleural effusion?

"I get a sharp pain when I take a deep breath."

The good boy-nice girl orientation stage corresponds to which thought from an adolescent?

"I should complete my homework on time so that the teacher will reward me."

A client at 28 weeks' gestation who has gained 13 lb (5.9 kg) tells the nurse in the prenatal clinic that she is glad that she has not gained as much weight as her sister did during her pregnancy. How should the nurse respond?

"Tell me what you've been eating lately."

Which of the following signs and symptoms are likely to be found in an adult experiencing sexual abuse? Select all that apply.

*Anorexia *Flat affect *Panic attacks

What are the considerations for bariatric surgery in an adolescent? Select all that apply.

*Attainment of physical maturity *Failed attempt at weight loss for at least 6 months *Ability to give informed consent to surgical treatment

The nurse suspects serotonin syndrome in a client prescribed second-generation antidepressants for depression. Which assessment findings observed by the nurse would be beneficial in diagnosing the severity of the syndrome? Select all that apply.

*Hyperthermia *Rhabdomyolysis

When reviewing the results of a toddler's complete blood count, a nurse concludes on the basis of decreased hemoglobin and hematocrit levels that the child has iron-deficiency anemia. Which other laboratory findings are indicative of iron-deficiency anemia? Select all that apply.

*Microcytic red blood cells *Slightly reduced reticulocyte count

The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority? Select all that apply.

*Stroke *Active hemorrhage *Respiratory distress

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is what?

36

Which stage is observed in a 2-year-old child according to Freud's theory?

Anal

Which nurse has the following authorizations: change plans whenever necessary; function as part of the interprofessional team by communicating, planning, and implementing care directly to the client; and assess the cohort risks?

Clinical nurse leader (CNL)

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?

Decreased sounds

An older client reports fatigue, restlessness, insomnia, slowed speech, and anxiety lasting longer than two weeks. Which disease does the nurse suspect?

Depression

A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for AIDS?

Enzyme-linked immunosorbent assay (ELISA)

Which hormone levels do not need to be monitored during the administration of menotropins for infertility?

Gonadotropin-releasing hormone

A client is admitted to the hospital with a diagnosis of peptic ulcer. The nurse should assess the client for which complication commonly associated with the diagnosis?

Hemorrhage

A client who wishes to postpone having children until she and her husband are financially sound tells the nurse she has been taking oral contraceptive pills for several years. What finding indicates a potential risk in regard to continued use of birth control pills?

Increased blood pressure

Which client is at increased risk for postpartum hemorrhage?

One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

Blood studies are being performed on a client with the potential diagnosis of hyperparathyroidism. What serum blood level should the nurse expect to be decreased when reviewing this client's hematological studies?

Phosphorus

A client tells the nurse during the admission history that an oral hypoglycemic agent is taken daily. For which condition does the nurse conclude that an oral hypoglycemic agent may be prescribed by the health care provider?

Reduced insulin production

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client?

Serum potassium of 7.2 mEq/L (7.2 mmol/L)

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I can't take this a minute longer." What does this behavior indicate to the nurse caring for her?

She is entering the transition phase of labor.

For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected?

Unresponsiveness to the environment

A nurse is caring for a client who had a pneumonectomy. What is the priority nursing assessment?

Ventilatory exchange

Which drug will most likely cause the client's eyelids to itch and eyes to burn as side effects?

Vidarabine