Physiological Adaptation - ML4

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breast-feed her neonate?

Discourage breast-feeding because HIV can be transmitted through breast milk.

The nurse is caring for a client diagnosed with Parkinson's disease. The nurse is most correct to correlate the client's uncontrolled tremors as a physical characteristic of a lack of which neurotransmitter?

Dopamine

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery.

The nurse assesses the postpartum client and notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What is the nurse's priority intervention?

Massage the fundus.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

Nuchal rigidity

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

Which electrolyte is a major cation in body fluid?

Potassium

The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take?

Report the finding to the healthcare provider.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis

A client with a brain tumor is undergoing radiation and chemotherapy for treatment of cancer. The client has recently reported swelling in the gums, tongue, and lips. Which is the most likely cause of these symptoms?

Stomatitis

A client underwent a transurethral resection of the prostate gland 24 hours ago and is prescribed continuous bladder irrigation. What nursing intervention is appropriate?

Use sterile technique if manual irrigation of the catheter is required.

Nursing assessment findings reveal a temperature of 39.5 C (103.2°F), tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:

Wound infection

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a urine output consistently above 40 ml/hour (40 mL/hour)

Which substance reduces the transmission of pain?

endorphins

A client has been diagnosed with osteoporosis after a bone density test and is asking what has caused it. Discussion of risk factors would include:

heavy smoking, sedentary lifestyle, and high intake of carbonated drinks

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

hypertonic

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

lateral recumbent, with chin resting on flexed knees

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

pericardial tamponade

Cullen's sign

superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

sweating, tremors, and tachycardia

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again."

The nurse is providing teaching to the mother of a newborn with early jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the mother makes which response?

"Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects."

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis."

Trousseau's sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

Broca's sign

Broca's (expressive) aphasia is a type of non-fluent aphasia in which an individual's speech is halting and effortful. Misarticulations or distortions of consonants and vowels, namely phonetic dissolution, are common.

A physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by

Checking and taping all connections.

Chvostek's sign

Clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen's sign

A client is brought to the emergency department after injuring their right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?

One side of the bone is broken and the other side is bent.

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client was hit in the right temporal lobe. What abnormalities would the nurse expect the client to demonstrate? Select all that apply.

1. difficulty comprehending language 2. decreased hearing 3. amnesia for recent events

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen toxicity

Which condition poses the greatest risk to a 32-year-old client who is 15 weeks pregnant and has a history of hypertension?

abruptio placentae

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

trigeminal neuralgia