N3 Final Prep
Following a traumatic spinal cord severance, a client experiences severe leg spasms and asks the nurse what is causing them. How should the nurse respond?
"Spinal shock has subsided, and your reflexes are hyperactive."
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.
Rapid pulse Decreased urinary output
A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify? Select all that apply.
Anorexia Limb pain Splenomegaly
A client with multiple myeloma asks how the disease and therapy progresses. What would be appropriate to include in the client's teaching?
Frequent urinary tract infections may result.
Lithium carbonate, 600 mg by mouth three times a day, is prescribed for a client. The nurse concludes that the teaching about its side effects is understood when the client says that the primary healthcare provider will be notified immediately if what condition occurs?
Fine hand tremor or slurred speech
A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply.
Lethargy Thready, weak pulse Muscle weakness Cardiac dysrhythmias
A client with multiple myeloma who is receiving the alkylating agent melphalan returns to the oncology clinic for a follow-up visit. For which side effect should the nurse monitor the client?
Leukopenia
The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next?
Test the drainage from the client's ear with a glucose reagent strip
A school-aged child with newly diagnosed acute lymphocytic leukemia (ALL) is to undergo induction therapy with prednisone, vincristine, and asparaginase. After several days the child becomes constipated. What does the nurse suspect as the cause?
Vincristine, which decreases peristalsis
A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings?
Digoxin (Lanoxin)
The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately?
Immobilizing and stabilizing cervical spine
An adolescent client with antisocial personality disorder plans to live with the parents after discharge. The parents request advice on how to respond to their child's unruly behavior. What is the most therapeutic response by the nurse?
"Set clear limits, explain the consequences if your child disregards them, and firmly and consistently apply them."
A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition?
Hypothalamus The hypothalamus controls the body temperature.
A nurse is teaching the parents of a school-aged child with sickle cell anemia about ways to prevent sickling. What should the nurse explain as the primary cause of sickling?
Hypoxia
A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit?
Immobile posturing
A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply.
Impulsiveness Lability of mood Self-destructive behavior
What should a nurse include in the plan of care for a 9-year-old child with nephrotic syndrome?
Providing meticulous skin care
A 12-year-old boy with nephrotic syndrome is in remission for several months. One day the mother calls the clinic to report that for the past week her child's skin has a pale, muddy appearance; his appetite is poor; and he has been unusually tired after school. In light of the mother's description, what does the nurse suspect?
Impending renal failure
The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process?
Implementing the logrolling technique
A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?
Impulsive
A client has been prescribed lithium. What important nursing intervention must be implemented while this medication is being administered?
Regularly testing the level of the drug in the client's blood
Which drug most commonly causes extrapyramidal side effects (EPS)?
Haloperidol
A client with multiple myeloma is scheduled to have a chest x-ray and bone scan. What is the priority responsibility of the nursing and radiology staff?
Handle the client with supportive movements.
A 9-year-old child is admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. What does the nurse expect the admission urinalysis to reveal?
Hematuria
The nurse is caring for a client with autonomic dysreflexia. What should be the nurse's immediate action to manage the client's condition?
Placing the client in a sitting position
What should the plan of care include to minimize the potential for a sickling episode in a child with sickle cell anemia?
Promoting adequate oxygenation
A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so I can call you for a date?" What is the best response by the nurse?
"Our relationship is professional; therefore I will not see you socially."
A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction?
"Seek early treatment for respiratory infections."
A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention?
Checking the child's level of consciousness hourly
The parent of a child with hemophilia asks the nurse, "If my son hurts himself, is it all right if I give him two baby aspirins?" What is the best response by the nurse?
"Aspirin may cause more bleeding. Give him acetaminophen instead." same for ibuprofen give Tylenol instead
A 9-year-old child with a tentative diagnosis of leukemia will undergo bone marrow aspiration. What information will the nurse give the child before the procedure?
"You will be given medication to relax you before the test and you won't remember anything afterward." A sedative-hypnotic such as midazolam (Versed) or propofol (Diprivan) is used to produce conscious sedation. The child should feel relaxed and will not remember the procedure. The child can ambulate freely after the procedure
When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased?
48 hours postpartum
A practitioner prescribes routine checks of the client's lithium level to be performed. How many hours after the last dose of lithium should the nurse plan to obtain the blood specimen?
8 to 12
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply.
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply.
A nurse is assessing a school-aged child with a tentative diagnosis of nephrotic syndrome. What clinical finding supports this diagnosis versus a diagnosis of acute glomerulonephritis?
Anasarca -observable edema throughout the body
A nurse discusses the implications of diet and fluid intake with a client who is receiving lithium therapy. What will the nurse teach the client and family about nutrition?
A regular diet should be maintained.
Which adverse effect could occur in clients treated with MAOIs for depression?
A serious increase in blood pressure
Extrapyramidal side effects (EPS)?
Acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.
A client has been taking the prescribed dose of clozapine. The nurse will assess the client for which life-threatening side effect of this drug?
Agranulocytosis
Akathisia
Akathisia, an extrapyramidal side effect of typical antipsychotics, is motor restlessness. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet
A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client?
Ambivalence
A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects which diagnostic finding specific for multiple myeloma?
Bence Jones protein in the urine
What is the most definitive test to confirm a diagnosis of multiple myeloma?
Bone marrow biopsy
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
Bradycardia Hypotension Bladder dysfunction
A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?
Checking that a bag-valve mask is available during the transfer
A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located?
Cerebellum
The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear?
Crackles
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion?
Deep respirations and fruity odor to the breath
Which teratogenic effect is seen due to lithium?
Ebstein anomaly (cardiac defects)
The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care?
Exhibits lack of empathy for others
A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation?
Express anger or frustration
A client with the diagnosis of paranoid schizophrenia refuses to eat at mealtime. What nursing action is most beneficial?
Giving the client food in unopened packages Clients with paranoia often have delusions that the food is poisoned
A nurse is caring for a school-aged child with acute lymphoid leukemia. While examining the child's laboratory results, the nurse notes that the child is neutropenic. What does the nurse recognize as the cause of the neutropenia?
Increased immature cell growth
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. Which complication does the nurse suspect?
Intracranial hemorrhage
Which drugs may cause an increase in the serum clozapine level? Select all that apply.
Ketoconazole Erythromycin
The nurse assesses a 5-year-old child after a shunt procedure is performed to correct increased intracranial pressure. Which finding is of most concern?
Marked irritability
A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?
Metabolic acidosis
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect?
Metabolic acidosis
A child with acute lymphoid leukemia is started on a chemotherapy protocol that includes prednisone. What side effect of this medication does the nurse anticipate?
Mood changes
A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone. Which outcomes indicate that the medication has minimized these symptoms? Select all that apply.
More interest is shown in unit activities. The client performs activities of daily living independently.
A nurse recalls that the blockage of dopamine by antipsychotic drugs can cause extrapyramidal side effects such as akathisia. Which client behaviors reflect the presence of akathisia?
Motor restlessness, foot tapping, and pacing
A 9-year-old child with leukemia is to be discharged home on a protocol that includes several antineoplastic medications. What should the nurse plan to teach the parents?
Notify the practitioner if the child has a temperature of 100° F (37.8° C) to obtain an antibiotic prescription.
A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply.
Seizures Vomiting Decreased respiratory rate A 2-year-old child's fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. The inflammatory process of meningitis causes an increase in temperature.
While a nurse is assisting with morning care for a client with the diagnosis of schizophrenia, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior?
Somatic delusion A somatic delusion is a false feeling about the physical self that is caused by a loss of reality testing.
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply.
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. VomitingIrritability Decreased level of consciousness
A nurse is caring for a toddler with the diagnosis of nephrotic syndrome. What is the best indicator of kidney function in this toddler?
Urine output
A 4-year-old child is being treated for nephrotic syndrome. What assessment finding indicates that the child's condition is improving?
Urine specific gravity decreases.
The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply.
Vomiting Headache Irritability
The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L (2.3 mmol/L). What does the nurse expect when assessing this client?
Vomiting, diarrhea, and decreased coordination
A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply.
Breathing Heart rate
What nursing care to prevent a crisis is the same for school-aged children with sickle cell anemia and celiac disease?
Protecting the child from infection
Which nursing intervention is most important for a client who has the diagnosis of antisocial personality disorder?
Providing clear boundaries and consequences
An 8-year-old child is admitted to the pediatric unit with nephrotic syndrome. What measures should the nurse expect to include in the plan of care for this child? Select all that apply.
Providing symptomatic care Eliminating high-sodium foods Monitoring response to steroids
After taking a typical antipsychotic medication for 1 month, a client reports, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude that the client has developed?
Pseudoparkinsonism
Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiologic response?
Reduced cerebral edema
A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use?
Regression Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety.
A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health?
By blocking access to dopamine receptors at the postsynaptic receptor site
A toddler is scheduled to receive methotrexate for treatment of leukemia. The mother asks the nurse whether the child should be started on vitamin supplements because the child seems so weak. How will the nurse respond?
"Supplements that contain folic acid interfere with the effectiveness of chemotherapy." Vitamins are contraindicated because methotrexate is a folic acid antagonist
What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position?
1 to 2 hours
A client is diagnosed with multiple myeloma. What does the nurse expect the plan of care to include?
Chemotherapy employing a combination of drugs
The registered nurse is teaching a nursing student regarding education a client who is on treatment with monoamine oxidase inhibitors (MAOIs). Which statement made by the nursing student indicates further teaching?
"I should encourage the client to take food high in tyramine." Because of the potential for a dangerous hypertensive crisisvoid foods high in tyramine should be avoided when taking MAOIs (Bologna, Cheese and processed meats contain tyramine)
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?
"I'll start to have symptoms when I drink less fluid."
A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse share in the client's preoperative teaching plan? Select all that apply.
"The kidney may not function immediately." "Precautions are needed to prevent infection." "A urinary catheter will be present postoperatively."
An adolescent with acute lymphocytic leukemia (ALL) completes parenteral chemotherapy, and the healthcare provider prescribes mercaptopurine. The nurse teaches the adolescent about this medication. What statement indicates that the adolescent has understood the information?
"This will help prevent a relapse."
An older client develops hypokalemia, and an intravenous infusion containing 40 mEq of potassium is instituted. The client tells the nurse that the IV stings a little. What is the nurse's best reply?
"You are receiving a large dose of potassium, and unfortunately it often causes a stinging sensation."
A 30-year-old who began lithium carbonate therapy 3 weeks ago is having blood drawn for a lithium drug level. Which range will the nurse recognize as therapeutic?
0.4 to 1.3 mEq/L (0.4 to 1.3 mmol/L) Lithium levels of 0.4 to 1.3 mEq/L (0.4 to 1.3 mmol/L) are therapeutic and effective in treating symptoms of mania. A level below 0.3 mEq/L (0.3 mmol/L) is too low to be therapeutic. At levels above 1.5 mEq/L (1.5 mmol/L), early signs of toxicity may occur; at levels of 2.0 mEq/L (2.0 mmol/L) and higher, severe lithium toxicity may occur, constituting a life-threatening emergency.
The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition?
3 mEq/L (3 mmol/L) serum lithium levels
A healthcare provider prescribes clozapine to a client with schizophrenia. Which parameters should be assessed before initiating the drug? Select all that apply.
Body mass index White blood cell count Absolute neutrophil count
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.
Irritability High-pitched cry Ineffective feeding behavior
A nurse is assessing the status of a school-aged child with leukemia who is receiving vincristine. What laboratory test result alerts the nurse that fluid intake should be increased?
Blood uric acid level of 7.5 mg/dL The normal blood uric acid level for children ranges from 2.5 to 5.5 mg/dL. An increase in the uric acid level caused by the destruction of cells
A child in sickle cell crisis is admitted to the pediatric unit. Which actions will the nurse take? Select all that apply.
Administer hydroxyurea Apply oxygen via nasal cannula Offer age-appropriate activities Administer intravenous (IV) hydration
A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. What will the nurse do first?
Administer the platelets rapidly through the intravenous (IV) line Platelets are fragile and should be administered as quickly as possible, within 1 hour, or as fast as the child can tolerate the infusion.
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case?
Administer the prescribed antipyretic and notify the primary health care provider.
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period?
Administering prescribed analgesics
A nurse is assessing a 10-year-old child admitted to the pediatric unit with acute poststreptococcal glomerulonephritis (APSGN). What specific signs and symptoms does the nurse expect? Select all that apply.
Anorexia Periorbital edema Increased creatinine level
During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition?
Blowing the nose and sneezing
A nurse is caring for a child with a tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). What test does the nurse expect to be used to confirm the diagnosis?
Antistreptolysin O titer
A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply.
Apathy Flatness
A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect?
Aphasia Aphasia of the receptive type is a condition in which the client cannot understand written or verbal speech
The survivors of an explosion develop heat stroke. Which intervention should be performed by the nurse on the disaster management team?
Apply ice packs on the client's scalp.
A 4-year-old child is admitted to the pediatric neurologic service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply.
Assessing the seizure Turning the child on the side Pulling the padded side rails up
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do?
Assume a standing position for voiding.
A 6-year-old child undergoes supratentorial craniotomy for evacuation of a subdural hematoma. In what position should the nurse place the child during the first 24 hours after surgery?
At a 45-degree angle
The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor?
Atherosclerotic plaques within arteries
The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition?
Bending over at the waist
A client is admitted to the emergency department with a head injury. A computed tomography (CT) scan shows a subdural hematoma. How should the nurse interpret this finding of a subdural hematoma?
Blood between the dura mater and the arachnoid layer
A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe?
Blood replacement
A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. What injury does the nurse conclude that drainage from the ear and nose indicates?
Basilar fracture A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear
A nurse is caring for a client with the diagnosis of schizophrenia. During assessment the nurse identifies both positive (type I) and negative (type II) signs and symptoms. Which clinical findings should the nurse document as positive? Select all that apply.
Disorganized thoughts Auditory hallucinations
Severe hypertension develops in a child with acute glomerulonephritis. What medication does the nurse anticipate that the healthcare provider will prescribe?
Captopril or Furosemide
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
Check for a pulse
A 10-year-old child who has sustained a head injury is brought to the emergency department by his parents, and a diagnosis of a mild concussion is made. What instructions should the nurse include at the time of discharge?
Check for changes in responsiveness every 2 hours for 2 days.
A child with leukemia is to continue taking prednisone (Meticorten) at home. The nurse discovers that the child's sibling is home from school with chickenpox. What is the nurse's priority concern?
Chickenpox can be fatal to individuals with leukemia.
An adolescent is admitted with an acute hemophilia episode. For what are rest, ice, compression, and elevation most helpful?
Controlling bleeding and retaining joint function
The laboratory results of a client with a pulmonary hemorrhage and glomerulonephritis reveal the presence of IgG antibodies. Which type of hypersensitivity reaction should a nurse suspect?
Cytotoxic reaction A client with a pulmonary hemorrhage and glomerulonephritis with deposits of IgG antibodies in the lungs and kidneys may have Goodpasture's syndrome.
A 4-year-old child with nephrotic syndrome is admitted to the pediatric unit. What clinical finding does the nurse expect when assessing this child?
Dark, frothy urine
A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for?
Decrease in the level of consciousness
A client has end-stage kidney disease and is receiving hemodialysis. During dialysis the client reports nausea and a headache and appears confused. Operating on prescribed protocols, which action will the nurse take?
Decrease the rate of exchange.
When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.
Diarrhea Seizures
A client who is taking clozapine calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What will the nurse instruct the client to do?
Discontinue the medication and, if the primary healthcare provider is unavailable today, go to the emergency department for evaluation.
Which clinical findings indicate to the nurse that a 6-year-old child has nephrotic syndrome (NS) rather than acute glomerulonephritis (AGN)? Select all that apply.
Generalized edema Massive proteinuria Unchanged blood pressure
A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list? Select all that apply.
Epistaxis Hematuria Hemarthrosis Easy bruising Dark-colored tarry stools
A nurse is assessing a child with leukemia who is undergoing chemotherapy. Which side effect does the nurse anticipate?
Epistaxis Nosebleeds (epistaxis) are expected in a child with leukemia who is undergoing chemotherapy because the bone marrow is depressed
A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional assessment should be made during every visit? Select all that apply.
Evidence of urinary tract infection Presence of hyperemesis gravidarum
A nurse is performing an assessment on a fifth-grader who has been admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify?
Fatigue and ecchymotic areas
Which of the following clinical findings should the nurse expect to find during the assessment of a child with acute glomerulonephritis (AGN)? Select all that apply.
Flank pain Periorbital edema
A client receiving hemodialysis has an external shunt for circulatory access. With which life-threatening complication associated with external cannulas should the nurse be most concerned?
Hemorrhage
A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for which complication?
Hepatitis B
A nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. What does the nurse expect analysis of the child's urine to reveal?
High protein level
A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis (painful episode). What are the priority nursing concerns? Select all that apply.
Hydration Pain management Oxygen supplementation
A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. When assessing the client, what does the nurse expect to observe?
Hyperextension of both the upper and lower extremities
The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?
Hypertension and bradycardia
A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?
Hypertensive crisis
A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis?
Increased protein level
The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?
Increased restlessness
A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate?
Increased white blood cell (WBC) count
A client's serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.
Irregular heart rate Muscular weakness Decreased bowel sounds Flattened/low P waves
A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply.
Irritability Bradycardia
A nurse is caring for a client with the diagnosis of schizophrenia who is started on fluphenazine decanoate. What is the primary advantage of this medication?
It has a long-lasting effect.
The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?
Kussmaul respirations
Schizophrenia is associated with negative symptoms. In the assessment of a client with schizophrenia, which symptoms are classified as negative symptoms? Select all that apply.
Lack of energy Poor grooming
A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? Select all that apply.
Left leg Left arm Left side of face
A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder?
Loose association These ideas are not well connected and there is no clear train of thought.
A nurse obtains a health history from the parents of a toddler who is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). What problems does the nurse expect the parents to report? Select all that apply.
Loss of appetite Paleness of the skin Purplish spots on the skin
Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement?
Lowering of the T wave
A 6-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. What should the plan of care include during the acute phase?
Promoting frequent position changes
Which clinical finding would the nurse associate with hypokalemia?
Muscle weakness
A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply.
Nausea and vomiting Increased weight Decreased serum sodium Decreased level of consciousness
A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report?
Needing to use three pillows at night to sleep
A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client?
Neuroleptic malignant syndrome
A nurse is caring for a 7-year-old child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma. The healthcare provider prescribes intravenous mannitol. The nurse monitors the child's intracranial pressure and urine output because mannitol belongs to which classification of diuretics?
Osmotic
A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply.
Pale skin Eating less food Purplish spots on the skin
The caretaker of a client who sustained a head injury reports to the nurse that the client always says that food tastes unappealingly bland even though the food is good. Which area of the brain may the nurse suspect to be affected in the client?
Parietal lobe Any injury to the parietal lobe causes absence of taste perception
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Placing the child in the side-lying position
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?
Plasma proteins moving out of the intravascular compartment
While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for the client?
Preparing for endotracheal intubation and mechanical ventilation
A client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention?
Presenting a united, consistent staff approach
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure?
Projectile vomiting
A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. How does folic acid help this client?
Promotes production of hemoglobin
An adolescent with leukemia is to be sent home on a protocol that includes several antineoplastic agents. Before discharge, what medication instructions should the nurse give the parents?
Schedule laboratory blood tests to evaluate response to the medication.
A child with meningitis suddenly assumes an opisthotonic position. In what position should the nurse position the child?
Side-lying
A client is receiving imatinib for chronic myelogenous leukemia (CML). The nurse should assess for which complication of this protein-tyrosine kinase inhibitor? Select all that apply.
Signs of infection Bleeding tendencies Imatinib affects the bone marrow, causing neutropenia;
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?
Somatic delusion A somatic delusion is a fixed false belief about one's body
The nurse is caring for a client with a head injury. The Glasgow Coma Scale score of the client is 9. Which nursing intervention should be performed in the client immediately?
Stabilize cervical spine.
An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected?
Stating wishes verbally
A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited?
Stroking the outer sole of the foot from the heel to the little toe
A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs?
Suctioning the oropharynx routinely Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure.
A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?
Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.
A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?
Teaching the client to use head movements to scan the left field of vision
A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment?
Tender mass in the left upper abdomen The spleen is located high in the abdomen on the left side and usually is not palpable unless it is enlarged
A nurse in the pediatric clinic is assessing an infant who had a revision of a ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial pressure has increased?
Tension of the anterior fontanel
A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy?
The MMR vaccine contains attenuated live virus and should not be administered to a child undergoing chemotherapy
A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care?
The body initially attempts to compensate by maintaining peripheral vasoconstriction.
A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?
Thirst, cool skin, and orthostatic hypotension
A client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, which intervention should the nurse perform?
Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures.
The laboratory report of a client undergoing long-term treatment with lithium carbonate indicates a level of 1.5 mEq/L (1.5 mmol/L). What will the nurse do?
Watch for signs of lithium toxicity.
A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?
Weighing the child at the same time each day
A 3-year-old child with nephrotic syndrome has been receiving prednisone for 1 week. The nurse reviews the child's progress record and determines that the medication has been effective. What information supports this conclusion? Select all that apply.
Weight loss Decreased lethargy Increased urine output
Pseudoparkinsonism
has characteristics similar to those of Parkinson disease (e.g., shuffling gait, tremors, rigidity, bradykinesia).
Tardive dyskinesia
is facial, ocular, oral/buccal, lingual/masticatory, and systemic movements.
Dystonia
is muscle spasms of the face, tongue, head, neck, jaw, or back, usually resulting in exaggerated posturing.
