medi surg W2

A nurse is caring for a client who is scheduled to have a MRI scan. The client asks the nurse what to expect during the procedure. Which statements should the nurse make?

"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.

A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine, the nurse should explain to the client that the medication is for which of the following indications? (all that apply)

1.Controlling emesis is correct. Hydroxyzine is an effective antiemetic that may be used to control nausea and vomiting in preoperative and postoperative clients. 2.Diminishing anxiety is correct. Hydroxyzine is an effective antianxiety agent that may be used to diminish anxiety in surgical clients, as well as in clients who have moderate anxiety. 3.Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine potentiates the actions of narcotic pain medications; therefore, narcotic requirements may be significantly reduced. 4.Drying secretions is correct. Hydroxyzine, an antihistamine, commonly causes drying of the oral mucous membranes.

A nurse is admitting a client who is in the mani phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the clients?

A private room in a quiet location on the unit. A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.

A nurse is instructing the caregiver of a toddler who has bacterial conjuctivitis and a new prescription for an ophthalmic oinment. Which instruction should the nurse provide?

Apply the ointment in a thin line into the conjunctival sac. The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication comes in contact with the surfaces of the eye when the child blinks. If applied to the globe of the eye, most of the medication will end up in the child's lashes when the child closes her eye.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of actions should the nurse take to assess cranial nerve IIII?

Checking the pupillary response to light Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of nursing responses should the nurse make?

Encourage the client to write down questions to ask the provider. The nurse does not know the answers to the client's questions, so helping the client to prepare questions for the provider addresses the client's needs.

A nurse at a rehabilitation center is planning care for a client who has a left hemispheric CVA 3 wks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of manifestations should the nurse tell the family to expect?

Forgetulness gradually progressing to disorientation Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of statements by the client's parent is the nurse's priority?

He has so many new bruises on his body. When using the urgent vs non-urgent approach to client care, the nurse determines that the priority concern is frequent bruising because this is a manifestation of carbamazepine toxicity. Carbamazepine toxicity can cause bone marrow depression, including leukopenia, anemia, and thrombocytopenia. The parent should monitor the client for bruising, bleeding, and sore throat and have periodic blood work drawn to monitor for myelosuppression.

A nurse is caring for a client who frequently attempts to remove his IV cathter. A family member requests that the nurse apply restraints. Which responses should the nurse make?

I will cover the catheter so he can not see it. Using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of actions should the nurse take?

Place the client on his side. The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of actions is the nurse's priority?

Position the child side-lying. This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of actions should the nurse include in the plan of care?

Provide a consistent daily routine. A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which responses should the nurse make?

The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss. The main side effects are mild disorientation and confusion immediately after the treatment, a slight headache, and short-term memory problems.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of actions should the nurse take first?

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

Visual acuity A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of statements by the client indicates a need for further teaching?

I'll be glad when I can stop taking this medication. Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). Which of statements indicates an understanding of the teaching?

My memory loss will last several minutes after treatment. During the recovery phase, the nurse should orient the client frequently due to confusion and short-term memory loss that tend to follow ECT. During this time, the nurse should continue to monitor the client's vital signs, mental status, and memory. The client and client's family should understand short-term memory loss, confusion, and disorientation can occur immediately following the procedure and can persist for a few weeks.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identfy as an indication of ICP?

Restless ; Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the response should the nurse make?

The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible. The client is seeking information. This open-ended therapeutic response gives the client the information that the client needs to cope, reassures the client of the nurse's presence, and encourages further communication.

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for tx of PNA. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which actions should the nurse take?

Assisting the client to the correct room protects both clients. It helps reorient the client who is unable to find her own room, and it protects the other client from an invasion of her personal space.

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (all that apply)

Grooming ; Long term memory ; Affect. Grooming is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Long-term memory is included in an MSE which consists of appearance, behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Support systems are not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Affect is included in an MSE which consists of appearance, behavior, speech, and mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. The presence of pain is not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.

A nurse in ED is monitoring a client who has a cervial spinal cord injury from a fall. The nurse should monitor the client for which of complications? (select all that apply.)

Hypotension ; Absence of bowel sounds ; Weakened gag reflex. Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord.Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles.Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input.Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus.Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of statements by the cleint indicates a correct understanding of hospice care?

I should expect the hospice team to help me my dypnea Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.

A nurse is completing a client's history and physical examination. Which of information should the nurse consider subjective data?

Nausea. Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

A nurse on a LT care unit is creating a plan of care for a client who has Alzheimer's diease. Which of following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time. The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vincinity The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?

Providing for adequate hydration and rest. Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a sofe diet. The client is not eacting well and tells the nurse that hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

Because of your surgery, you have an altered ability to smell and taste. Clients who have lost their larynx commonly complain of poor ability to smell and taste. This is because they now breathe through the tracheal stoma, rather than the mouth and nose, which bypasses the location of the olfactory and gustatory nerve cells.

A nurse in LT care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take.

In the event of a fire, it is helpful to recall the mnemonic RACE to prioritize the actions to take: R - Rescue and remove the clients, A - Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The nurse's priority action is to remove the clients from the room. The nurse should then sound the fire alarm and close the door to confine the fire. Finally and if possible, the nurse should extinguish the fire.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of actions is most likely to facilitate resolution of the headache?

Increase fluid intake. The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of findings indicates the client is exhibiting manifestations of prolonged grieving?

Leaves the child's room exactily as it was before the loss. Grieving becomes dysfunctional when the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. An example of dysfunctional grieving is making the loved one's room a shrine for more than a year.

a nurse is caring for a client who has a bacterial infection and is receiving gentamicin. Which of the following actions should the nurse take to minimize the risk of an adverse effect of the medication?

Monitor the serum medication level: A disadvantage of gentamicin, an aminoglycoside, is the association with nephrotoxicity and ototoxicity, both of which are a result of elevated trough levels. Monitoring the serum medication levels is an important action to minimize the risk of an adverse effect of gentamicin.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of ethical principles should the nurse use to support the decision not to administer the medication?

Nonmaleficence. Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. which of nursing actions is appropriate?

Offer to make arrangements for the Sacrament of the Sick Practicing Roman Catholics often wish to receive the Sacrament of the Sick from a priest during times of illness or when death is approaching.

A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client?

On the unoperated side. The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site.

A nurse is admitting a client who has acute pancreatitis. Which provider's prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV boulus twice daily. The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-3 vertebrea. When planning care, the nurse should anticipate which of the following types of disability?

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

Refusing to look at the dressing or surgical incision. Clients who refuse to look at the surgical incision or surgical dressing are having difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client is not yet ready to acknowledge the results of the surgery.

A nurse suspects that a client admitted for treatment of bacterial menigitis is expericing incrased ICP. Which of the following assessment findings by the nurse supports this suspension?

Restlessness Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, " I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing what crisis?

Situational. diagnosis of HIV is a situational crisis which is one that is unexpected but is part of regular life such as a serious illness or financial loss.

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the does of morphine this week to obtain pain relief. Which of scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medication. The nurse should document that the client has developed a tolerance to the medication. Morphine is a narcotic analgesic used for the treatment of severe pain. Tolerance is an adverse effect of narcotic analgesics in which a larger dose is needed to produce the same response.

The nurse is making a home visit with a client diagnosed with Alzheimer's disease and the client's partner. which of observations indicated to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 LB in the past 2 months. A large weight loss by the caregiver is an indication of caregiver role strain.

A nurse is caring for a client who has chemotherapy-indueced peripheral neuropathy. The nurse should expect the client to report having which of symptoms?

Tingling feeling in the extremities Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.

A nurse is caring for a client who has expressive aphasia following a CVA. Which of parameters should the nurse use first in order to assess the client's pain level?

a self- report pain rating scale. Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client's self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

A nurse is caring for a lcient who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

inability to recognize his family members. The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse in ED is caring for a client who has a compression fx of a spinal vertebra. During transport to the facility, the client was medicated with IV morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fx. Staff members have been unable to reach the client's family. Which of actions should the nurse anticipate teh neurosurgeon taking?

invoking implied consent. The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the client's best interest. The neurosurgeon should document the specifics of the situation in the client's medical record.

A nurse accidently administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. the client could rightfully sue the nurse for which of the following.

malpractice Malpractice MY ANSWER The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of actions should the nurse take before administering each dose?

shake the contiainer vigorously. A suspension form of medication refers to one in which the particles of medication are mixed with, but not dissolved in, a fluid. It is important for the nurse to shake the container that contains the suspension because the child can be under-medicated if the medication is not evenly distributed.