Clinical Decision PREPU
The most common cause of cholinergic crisis includes which of the following?
Overmedication
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
respiratory alkalosis.
A patient who is scheduled for a gynecologic examination and Pap smear informs the nurse that she just began her menstrual cycle. What is the best response by the nurse?
"We will reschedule your examination when you have finished menstruating."
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
A client reports to the nurse that over the past few months the elderly mother has become increasingly angry, responds inappropriately to conversations, and does not respond to calls if her back is turned away. What is the nurse's best response?
Ask if the mother could come in for a hearing evaluation.
The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?
B12
A client with calculi in the gallbladder is said to have
Cholelithiasis
Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What willl the nurse suspect?
Compartment syndrome.
The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?
Coolness and mottling of a newly constructed breast site
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?
Decreased level of erythropoietin
Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function?
Decreased or absent deep tendon reflexes
The nurse obtains a client's oral temperature reading of 36.8°C. How should the nurse proceed?
Document the client's temperature result as obtained.
A nursing instructor is discussing the causes of the increasing number of people with chronic conditions. Which of the following would the nurse correctly identify as a cause?
Early detection and treatment of diseases
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?
Edema of the upper airway
After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?
Hyperactive bowel sounds
A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply.
Hypothermia Hypotension Hypoventilation
A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?
Labetalol
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is
Motor vehicle crashes
Which of the following would a nurse least likely assess in a client experiencing anxiety?
Positive self-talk
Parents request that a test be done to determine if the fetus has Down syndrome. What type of test does the nurse anticipate the physician will order?
Prenatal screening
A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
Pseudomembranous colitis
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?
The woman may be experiencing an exacerbation of right-sided HF.
The nurse evaluates teaching as effective when a female client states that she will
Use sunscreen when outdoors.
The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as
coma
Which phase of the Trajectory Model does the nurse recognize is present when the patient is in remission, after an exacerbation of illness?
comeback
When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
every 15 min
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease; caused by food or environmental
What does decreased pulse pressure reflect?
reduced stroke volume
When the client tells the nurse that his vision is 20/200 and then asks what that means, the nurse informs the client that a person with 20/200 vision
sees an object from 20 feet away that a person with normal vision sees from 200 feet away.
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
urge; Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an overdistended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?
Amniocentesis
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication prescription for breakthrough pain.
A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect?
Avascular necrosis
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?
Avoid fibrous foods, lactose, fat, and caffeine.
Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply.
Encourage the client to keep a list of medications and review it frequently for updates. Use easy-to-open lids. Provide a written medication schedule.
Genetics-related health care is basic to the holistic practice of nursing. What should nursing practice in genetics include?
gathering relevant family and medical history information
The nurse is caring for a client who reports orange urine. The nurse suspects which factor as the cause of the urine discoloration?
phenazopyridine hydrochloride; Orange to amber-colored urine is caused by concentrated urine due to dehydration, fever, bile, excess bilirubin or carotene, and the medications phenazopyridium hydrochloride and nitrofurantoin. Infection would cause yellow to milky white urine. Phenytoin would cause the urine to become pink to red. Metronidazole would cause the urine to become brown to black.
A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in:
serum glucose level.
A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?
Urinary calculi
Which of the following would be inconsistent with a normal grief reaction?
elation
A waist circumference greater than which value indicates excess abdominal fat in men?
101.60 cm (40 in)
The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn for pain. The client rates the pain as a 7 on the numeric scale of 0/10. The nurse should administer how many oxycodone/acetaminophen?
2; The nurse should administer 1 tablets for pain less than 5 on a numeric scale of 0/10, and administer 2 tablets for pain greater than 5 on a numeric scale of 0/10.
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?
Altered patterns frequently affect the heart's ability to pump blood effectively.
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention?
Request an order from the physician for IV rehydration therapy.
A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.)
A pulsatile abdominal mass Low back pain Lower abdominal pain
A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?
Decreases in the physiologic function of major organs
During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care?
Delay the client's treatment for a few hours if other clients need immediate care
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide?
Elevate the head of the bed.
After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next?
Notify the healthcare provider.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?
Radiates from the back to the front
A client comes to the clinic with concerns about her pregnancy. She is in her first trimester and is now experiencing moderate abdominal pain on the right side. What would be the nurse's first action?
Recommend an abdominal ultrasound to the doctor since this may be ectopic pregnancy.
The nurse is assessing a patient for psoriatic lesions after treatment with a nonsteroidal cream. What type of lesion does the nurse know is characteristic of psoriasis?
Red, raised patch covered with silver scales
A client complains to the nurse about having difficulty seeing to read, but reports no difficulty with driving. What test would the nurse prepare for the physician to administer to this client?
Rosenbaum; Having difficulty reading but not driving indicates a problem with near vision. A Jaeger chart or Rosenbaum Pocket Vision Screener evaluates near vision. These charts contain words, numbers, and letters in various print sizes. The examiner instructs the client to cover one eye and then hold the chart approximately 14 inches away and read the smallest print that he or she can see comfortably. The size of the print the client reads indicates the quality of his or her near vision. A Snellen chart evaluates visual acuity, the ability to see far images clearly. An Ishihara test evaluates color vision. Jobst is not a vision test.
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
Stop the procedure, monitor heart rate and blood pressure.
A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply.
Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. Report the behaviors to the unit manager for further investigation.
A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take?
Talk with the client's family about the client's right to decide for themself.
A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?
neurogenic shock; Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
stage II pressure ulcer; A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.
The general adaptation syndrome (GAS) is a nonspecific physiologic response to a stressor. Which stage is not a part of the process?
stress awareness stage; The general adaptation syndrome can cycle many times through the alarm and resistance stages before reaching the exhaustion stage. The process occurs through the neuroendocrine and autonomic nervous systems.
A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs?
using a systematic method to plan and implement care to reach desired outcomes
A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?
"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
Moisten sterile gauze with normal saline and place on the protruding organ.; A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?
Peritonitis
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in?
Priority 1; Triage category "Immediate" is priority 1 (red) and includes injuries that are life threatening but survivable with minimal intervention, such as sucking chest wound, airway obstruction secondary to mechanical cause, and shock.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
