Med surg final

the nurse is providing teaching to a client with a mild case of bunions. Which suggestion would be most important for the nurse to give this client?

Don proper footwear.

a client at a long term care facility informs the nurse that he is having cramping when trying to have a bowel movement and all that is coming out is liquid. when the nurse reviews the clients last bowel movement history, it is determined that the client has not had a bowel movement in 7 days. What does the nurse understand is most likely occurring with this client?

Encopresis

a client who comes to the clinic complaining of perineal pain, dysuria, and fever is diagnosed with prostatitis. the nurse understands that which of the following organisms would be the most likely cause?

Escherichia coli

The nurse is caring for a client who just returned from a trip requiring an airline flight. the client reported ear pain upon descent. the nurse is correct in stating which site as being the pressure equalizer in the ear?

Eustachian tube

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for?

Fasciotomy

the nurse is working at a public heath clinic. Which symptoms does thee nurse anticipate prior to assessing a client with secondary syphilis?

Fever, sore throat, lymph node enlargement

a client who is scheduled for an ileostomy surgery says to the nurse, "I'm afraid I won't be able to look at the stoma." Which response by the nurse would bee the most therapeutic?

I'll make sure there is a familiar nurse here with you the first time.

following ureterosurgerrey, for the removal of ureteral calculus, a stent is temporarily left in place. the client ask the purpose the stent provides which is the correct response from thee nurse?

Inflammation from the stone can block the flow of urine

the nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first?

Inspection

The nurse and the nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to do to avoid shearing when moving the client to a higher position in the chair?

Lift the client, do not slide them

a client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vitals signs. the nurse listens to the clients lungs after positioning. What finding related to the clients condition may thee nurse hear when listening to lung sounds?

Lung sounds maybe diminished in the apical area.

which of the following would indicate the need too increase fluids beyond what is recommended for fluid resuscitation?

Myoglobin in the urine

Client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class?

Raloxifene (Evista)

the nurse is caring for an 82- year-old client who needs bladder training. the nurse knows that bladder training is difficult for older adults with neurologic deficit because of what?

Relaxation of thee internal bladder sphincter.

The hemodialysis client is scheduled to receive weekly injections of epoetin. Which is the most important consideration to be taken by the nurse in the administration of this medication.

Schedule injection on non-dialysis.

The home health nurse is going to visit a client with a pressure ulcer who is being cared for by family members in the home. The nurse is going too change the dressing and observe the healing status. The wound is 6 x 7cm and 2 cm deep and exposes muscle. What does the nurse document this wound as?

Stage IV

While obtaining the history, the nurse learns the client's mother was treated with diethylstilbestrol (DES) during her pregnancy. The nurse determines that this client is at risk for which of thee following?

Vaginal cancer

the nurse is caring for client in the immediate postoperative phase after having a colostomy created. what type of appliance should the nurse use at this time?

a disposable or temporary appliance should be used

a client has a rash on the arm that has been treated with antibiotic without eradicating the rash. What type of examination using ultraviolet light can be used to determine if the rash is fungal rash?

a wood light examination

a client was playing softball and was hit in the right ankle by the bal, sustaining a contusion. what is the first action the nurse takes to help alleviate pain and swelling?

apply a cold pack to the ankle.

a client who will be having a portion of their colon removed and colostomy created informs thee nurse that he "will not be attractive any longer." The nurse determines the nursing diagnosis is Altered Body Image Perception related to the stoma and altered bowel elimination. What expected outcome related to this diagnosis will the client have?

client verbalizes what the changes will be and benefits to the future health.

there are several type of hearing loss. Which type of hearing loss benefits from the use of a hearing aid?

conductive

what intervention can the nurse encourage the client with diabetes insides to do in order to control thirst and compensate for urine loss?

consume adequate amounts of fluid.

th nurse is caring for a client prescribed oral griseofulvin for treatment of a fungal toenail infection. Which instruction by the nurse is essential in understanding the treatment plan?

continue medication regimen for several weeks

a client is to have a total colectomy and has been on prednisone 3 months for the treatment of Crohn disease. what medication does the nurse anticipate administering in the preoperative phase to prevent adrenal crisis?

intravenous hydrocortisone

a critical care nurse is documenting the assessment of a client. the client status is post resection of a brain tumor. the nurse document that the client is flaccid on the left this means the client:

is not responding to stimuli

A client asks the nurse what psoriasis is. What is the best answer?

it is characterized by patches of redness covered with silvery scales.

a client is admitted with weakness expressive aphasia and right hemianopia. the brain MRI reveals an infarct. the nurse understands these systems to be suggestive of which finding?

left-sided CVA

the client is having a total colectomy with an ileostomy created. what does the nurse explain to the client that the stool consistency will be?

liquid or mushy

the nurse is providing care to a client who has had surgery as treatment for breast cancer. the nurse would be alert for the development of which condition?

lymphedema

the client is admitted to the nursing unit for a biopsy of the urinary tract tissue. When planning nursing care for the period, which nursing intervention documents the prescribed activity level?

maintain the client on bedrest

a client is experiencing a GI bleeding from ruptured esophageal varices. What medication does the nurse prepare for Administration that mimics the actions of somatostatin that will reduce the GI bleeding?

octreotide

the nurse is assisting the physician in completing a cystoscopy. in which position would the nurse place the client when preparing for the procedure?

on the client's back with feet in the stirrups.

A client is informed of having a benign bone tumor but this type of tumor that may become malignant. the nurse know that this is characteristic of which type of tumor?

osteoclastoma

the nurse is demonstrating how to perform ROM exercises for a patient with tendinitis of the wrist. What intervention can the nurse encourage the client to use in order to decrease discomfort when performing the exercise?

perform the exercises with the hand and wrist under warm water.

During the physical examination of a client the nurse months for signs that may indicate a urinary tract disorder. which of the following would suggest that the client may have a urinary tract disorder?

periorbital edema

the nurse is teaching a family member how to instill ear drops to the client to remove impacted cerumen. What is important to teach this family member?

place the container in warm water before instillation

the nurse is caring for a client with hypoparathyroidism. When the nurse taps the clients facial nerve, the clients mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?

positive chvostek sign

a nurse is reading an article that describes thee function of the neurohypophysis. the nurse identifies this structure as part of which of the following?

posterior pituitary

the nurse is preparing a client for surgery and observes on the operative permit that the client will behaving a double-barrel colostomy. the nurses explains to the clients spouse that this is performed on what portion of the large intestine?

transverse

the nurse is caring for a client who is describing urinary symptoms of needing too go to the bathroom with little notice. When the nurse is documenting these symptoms, which medical term will the nurse document?

urinary urgency

a client has a fractured jaw sustained in an automobile accident and has had the fracture surgically reduced and immobilized with a wire loop. What should the nurse ensure is present at the clients bedside in case of vomiting?

wire cutters

a client is scheduled for a joint replacement surgery. Which action would be most important for the nurse to take?

withhold administration of aspirin before the surgery.

a client in skeletal traction has a nursing diagnosis of altered tissue integrity risk: related to puncture wound; pins. what expected outcome would be appropriate for this client?

wounds heal without infection.

Which oof the following nursing instructions is most important for the nurse to emphasize to the client with a new HSV-2 diagnosis?

you must inform all sexual partners.

when assessing a client with chronic glomerulonephritis, the nurse notes that the client has generalized deem. How does the nurse document this?

anasarca

the nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. what type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?

anticoagulation therapy

an emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

a client is having cryosurgery too remove a growth on the leg. How long will. the client be informed that healing will take?

4 to 6 weeks

a client with diabetes comes too the clinic for a follow-up visit. the nurse reviews the client's glycosylated hemoglobin test results. which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5%

A client with severe hypoparathyroidism is experiencing tetary. What medication prescribed by the physician for emergency use, will the nurse administer to correct the deficit?

Calcium gluconate

which zone consists of the area where the injury is most severe and deepest?

Coagulation

the nurse is caring for a client about to have the first stage of an ileoanal anastomosis. What should the nurse inform the client they will experience?

Continuous discharge of mucus from the anus.

A client asks the nurse why a creatinine clearance test is an accurate indicator of kidney function. The nurse is most correct to reply which of the following?

Creatinine is broken down at a constant rate and the total amount is excreted by the kidney.

a nurse is caring for a client who has exhibited repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client?

Dabbing the eyes multiple times with a washcloth.

a client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead the nurse to suspect that the client is experiencing rejection?

Tenderness over transplant site.

The emergency department nurse is reporting the location of a fracture to the clients primary care physician. When stating the location of the fracture on thee long shaft of the femur. The nurse would be thee mist correct to state which terminology locating the fractured site?

The fracture is on the diaphysis

a older adult client slipped on an area rug at home and fractured the left hip. the client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain

administer prescribed analgesic around the clock.

the nurse is caring for a client with increased fluid accumulation in the ye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?

canal of schlemm

the physician 's office nurse is caring for a client who has a history oof a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status oof the aneurysm?

cerebral angiography

the nurse is caring for a client who was involved in an automobile accident and sustained multiple traumas. Thee client has a Volkmann contracture to the right hand, what objective data does the nurse document related to this finding?

claylike deformity of the right hand without ability too extend fingers.

The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working?

intraocular pressure 15 mmHg

the nurse is caring for a client receiving insulin isophane suspension (NPH) at breakfast. what is an important dietary consideration for the nurse to keep in mind?

encourage midday snack.

which recommendation would a nurse advocate during infancy and childhood to help reduce potential adults complications such as orchitis?

ensure immunization against infectious diseases such as mumps.

the nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this Agee group?

enuresis

a client is being seen in the clinic to receive he results of the lab work to determine thyroid levels. he nurse observes the clients eyes appear to be bulging and there is swelling around the eyes. what does the nurse know to be correct documentation of this finding?

exophthalmos

a 68-yeear-old female client who had a blow the knee amputation is to be discharged because her healing is almost complete. which of the following would be most important for the nurse to discuss with this client?

exploring factors related to the client's home environment.

Skin grafts are necessary for what type of burn?

full-thickness

a client is suspected of having acromegaly. what definitive diagnostic testing is the most reliable method of continuing acromegaly?

glucose tolerance test in combination with a GH measurement.

the nurse is reporting on the results of client blood work to the the oncoming nurse. Upon reviewing the data, the nurse notes that the client has an elevated uric acid level. Which inflammatory process would the nurse screen for on shift rounds?

gout

the nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence but how do I help my loved one to move past that? the nurse is most helpful to say which of the following?

grief is a normal process. Leet's discuss offering support throughout the process.

which of the following precautions would b most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor?

handle body fluids carefully

A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client?

identify and avoid factors that precipitate or intensify an attack.

the nurse is coming for a client diagnosed with bladder cancer and requiring a cystectomy. the nurse overhears the physician instructing the client on the presence of a stoma with temporary pouch. in gathering information for the client, which urinary diversion would the nurse select?

illeal conduit

the nurse is performing a weber test on a client. During this test where should the nurse place the tuning fork?

in the midline of the clients skull or in the center of the forehead.

the nurse us caring for a client with an inoperable brain tumor. what is a major threat to this client?

increased cranial pressure

the nurse is caring for a client with a new tattoo. Which nursing diagnosis is of the highest priority?

infection risk

a client comes to the walk-in clinic reporting feeling a "bug in my ear." What action should be taken when there is an insect in the ear?

instillation of mineral oil

the nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which characteristic would the nurse inform the group is associated with type 2 diabetes?

insulin resistance or insufficient insulin production

the nurse is assessing a client for fecal impaction and when inserting a lubricated, gloved finger the stool feels like small rocks. What does the nurse document this finding as?

scybala

the nurse is caring for a client who has had a fracture reduction using a cast. What would be most important for the nurse to assess?

sensation and mobility status

the client with diabetes asks the nurse why shoes and socks are removed at each office visit. the nurse gives which assessment finding as the explanation for the inspection of feet?

sensory neuropathy.

a nurse is working in an outpatient studies unit administering neurological test. the client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

shampoo

a client with rheumatoid arthritis has infiltration of the lacrimal and salivary glans with lymphocytes as a result of the disease. what does the nurse understand that this clinical manifestation is?

sicca syndrome

a client comes to the emergency department and it is found that the client's radial head is partially dislocate. what is this partially dislocated radial head documented as?

subluxation

an instructor is teaching a group of students about the incidence of sexually transmitted infections (STIs) and those that must be reported by law. The instructor determines that the students have understood the information when they stat that which STI must be reported?

syphilis

a client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. the nurse is talking with the client and hears an audible click when the client is moving the jaw. what does the nurse suspect may b happening?

temporomandibular disorder

Following a colposcopy, the confirmation of in situ carcinoma of the cervix has been determined. Which comment by the client indicates an appropriate understanding of the diagnosis?

the cancer has not spread.

the nurse assists the health care provider in completing a lumbar puncture. Which should the nurse note as a concern?

the cerebrospinal fluid is cloudy in nature.

the nurse is caring for a client who is following a treatment to decrease urinary tract infections. what indicates the need to change the treatment plan?

the client exhibits continued symptoms.

the nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

the client has cerebral spinal fluid leaking from the ear

a nurse is assessing a client for a fracture to the body orbit. What would the nurse document if the assessment for fracture was positive?

the client has diplopia.

a client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. how would the nurse differentiate thee first-deegree strain from other strains and sprains?

the client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices.

a client realizes that regular user of laxatives has led to bowel pattern improvement. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

the client's natural bowel function may become sluggish.

A client states having difficulty noting details soon faces or television. Which of the following structures of the eye allows for detailed vision?

the macula lutea

the nurse is assessing a client who is hospitalized for dehydration from persistent vomiting. How would the nurse assess that the clients skin turgor is related to the state of dehydration?

the nurse grasp the skin over the sternum between the thumb and forefinger with slow recoil observed.

the nurse is teaching a parent how to instill drops in a 12-year-old child's eyes. Which action would the nurse instruct the parent to perform first?

tilt the head slightly backward

a client complains of having tender and painful breast tissue. the nurse would need to gather additional information about which oof the following?

timing of symptoms in relation to the menstrual cycle.

the nurse has assessed a clients superficial fungal infection that begin in the skin between the toes and has spread to thee soles of the feet. How would the nurse document this finding?

tinea pedis

The nurse is caring for a client who will be moving artificial implants for breast reconstruction. The client is arriving at the physicians office for which procedure to be completed before the surgery can be done?

tissue expansion