Custom: RN Geriatric Practice 2019 A
A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight? Yogurt ?Milk ?Lettuce ?Honey
?Lettuce ?Lettuce is 95% water by weight.
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? "I am to take my blood sugar reading after meals." "Insulin allows me to eat ice cream at bedtime." "A weight reduction program will make me hypoglycemic." "I give the insulin injections in my abdominal area."
"I give the insulin injections in my abdominal area." The client should give insulin injections in one anatomic area for consistent day-to-day absorption. The abdomen is the area for fastest absorption.
A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood? Elevated blood urea nitrogen (BUN) Elevated HbA1c Decreased chloride Decreased bilirubin
Elevated blood urea nitrogen (BUN) As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.
A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? Pain Nausea Gag reflex Level of consciousness
Gag reflex The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.
A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching? "I will limit the use of emollient skin cream to once a week." "I will expect to have a mild, occasional fever." "I will avoid people who have just received an immunization." "I might experience harmless white patches in my mouth."
"I will avoid people who have just received an immunization." The client should avoid people who received a vaccination, especially a live vaccine, to prevent contracting the disease
A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? "Apply ice packs to your legs." "Use elastic stockings." "Remain on bed rest." "Place your legs in a dependent position while in bed."
"Use elastic stockings." Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.
A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? "You can expect fecal output within 24 hours." "You will need to increase your dietary intake of raw vegetables." "You can expect the stoma to be purplish in color for the first week." "You may experience a small amount of bleeding around the stoma."
"You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon.
A nurse is preparing to administer 0. 9% sodium chloride IV infusion 1-L bag at aterm-29 rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
200 mL1,000 mL = 1 hrX hr X hr = 5 hr Step 6: Round if necessary. Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 1,000 mL 0.9% sodium chloride IV to infuse 200 mL/hr, it makes sense to administer over 5 hr. The nurse should expect to set the IV pump to deliver 0.9% sodium chloride IV at 200 mL/hr over 5 hr.
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A reddened area over the sacrum Stiffness in the lower extremities Difficulty moving the upper extremities Difficulty hearing some types of sounds
A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.) Affects weight-bearing joints Crepitus can occur in affected joints Affects bilateral, symmetrical joints Causes joint stiffness Causes joint pain
Affects weight-bearing joints is correct. Stress from the use of weight bearing joints can result in joint degeneration and osteoarthritis. Crepitus can occur in affected joints is correct. Clients who have osteoarthritis can develop crepitus, or a grating sound, caused by friction in the joints. Affects bilateral, symmetrical joints is incorrect. Rheumatoid arthritis occurs in bilateral symmetrical joints. Causes joint stiffness is correct. Clients who have osteoarthritis have chronic joint stiffness. Causes joint pain is correct. Clients who have osteoarthritis have chronic joint pain.
A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? Place sandbags to maintain right plantar flexion. Position soft pillows against the bottom of the feet. Apply a protective boot to the right ankle. Splint the right lower extremity to maintain proper alignment.
Apply a protective boot to the right ankle. The nurse should apply padded splints or protective boots to the right ankle to keep the foot at a right angle to the leg to prevent footdrop.
A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? Apply downward pressure while the client shrugs his shoulders upward. Apply resistance while the client lifts his legs from the bed. Ask the client to grasp an object and form a fist. Apply resistance while the client flexes his arms.
Apply downward pressure while the client shrugs his shoulders upward. This assessment monitors the motor function of C4 to C5.
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? Give the ordered KCL as prescribed. Omit the KCL dose and document it was not given. Call the prescribing physician and inform her of the client's serum potassium level results. Call the lab to verify the client's results.
Call the prescribing physician and inform her of the client's serum potassium level results. As a potassium level of 5.2 mEq/L is above the expected reference range, the nurse should hold the medication and notify the provider of the client's serum potassium level.
How many calories are contained in a food item that has 15 g of carbohydrates, 4 g of protein, and 10 g of fat? calories
Carbohydrates contain 4 cal per g (15 x 4 = 60). Proteins contain 4 cal per g (4 x 4 = 16). Fats contain 9 cal per g (10 x 9 = 90). This adds up to a total of 166 cal.
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? Dietary iron restrictions Intestinal malabsorption syndrome Chronic blood loss Intestinal parasites
Chronic blood loss A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occurs over time, although the colitis may result in erosion of the intestine and hemorrhage. These clients often report bloody stools and are therefore at increased risk for developing anemia.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? Daily weight Sodium level Tissue turgor Intake and output
Daily weight Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? Explain to the client what is about to happen. Make sure the room temperature is cool. Provide music as an environmental distraction. Inform the client that the provider will examine sensitive areas first.
Explain to the client what is about to happen. Explaining assessment techniques can decrease stress and anxiety. It also increases trust and promotes a therapeutic nurse-client relationship.
A nurse is developing an education program for a community group about dietary intake of vitamins and minerals in the diet. The nurse should include which of the following foods as sources of vitamin C? (Select all that apply.) Green pepper Orange Cabbage Strawberries Milk
Green pepper is a correct response. Green peppers are a source of vitamin C and should be included as a source of vitamin C.Orange is a correct response. Oranges are a good source of vitamin C and should be included as a source of vitamin C.Cabbage is a correct response. Cabbage should be included as a source of vitamin C.Strawberries is a correct response. Strawberries should be included as a source of vitamin C.
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? Immunoglobulin G (IgG) Immunoglobulin A (IgA) Immunoglobulin E (IgE Immunoglobulin M (IgM)
Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? Facial flushing Increasing dyspnea Decreasing respiratory rate Friction rub
Increasing dyspnea The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain.
A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan? Take the client's rectal temperature each day. Increase raw produce in the client's diet. Limit visitors to healthy adults. Instruct the client to floss his teeth daily.
Limit visitors to healthy adults. The expected reference range of absolute neutrophil count is 2500 to 8000/mm3. This client has a reduced absolute neutrophil count (neutropenia) and is immunosuppressed. A client who has neutropenia is at an increased risk for infection. The nurse should restrict visitors for a client who has neutropenia to healthy adults to reduce the risk for infection.
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? "It is caused by the lack of production of insulin by the pancreas.." "It is caused by the lack of production of aldosterone by the adrenal gland." "It is caused by the overproduction of growth hormone by the pituitary gland." "It is caused by the overproduction of parathormone by the parathyroid gland."
It is caused by the lack of production of aldosterone by the adrenal gland." Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland.
A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome? History of asthma Large waist size Hypotension Hypoglycemia
Large waist size Central obesity due to excessive abdominal fat is a risk factor for metabolic syndrome. Metabolic syndrome increases the risk for the development of diabetes and coronary artery disease.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? Suggest that the client use a salt substitute. Obtain a 12-lead ECG. Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level.
Obtain a 12-lead ECG. This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes.
A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased? WBC RBC Granulocytes Platelets
Platelets The nurse should recognize that ITP results from the destruction of platelets by antibodies; therefore, the nurse should expect a platelet level below the expected reference range.
FLAG A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication? Sleepy, but arousing when her name is called Respiratory rate 8/min Pain level of 6 on a scale from 0 to 10 SaO2 94%
Respiratory rate 8/minA respiratory rate of 8/min represents an adverse effect of the morphine and the nurse should notify the provider. Expected respiratory rate is 12/min or greater.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness
Restlessness 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 in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect? Report of recent exposure to poison ivy Scaling and redness between the client's toes Circular, erythematous patches on the scalp Report of a recent prescription for an antiseizure medication
Scaling and redness between the client's toes Scaling and redness between the toes are expected findings of tinea pedis, which is commonly referred to as athlete's foot.
A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor? The nurse wears an N95 respirator mask. The nurse admits another client who has shingles to the client's double room. The nurse wears gloves when providing direct care to the client. The nurse wears a gown when bathing the client.
The nurse admits another client who has shingles to the client's double room. When a private room is not available, clients who are infected with the same organism may be placed together in a double room. However, cohorting is reserved for clients who both require droplet precautions. This client should be in a private room.
A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order of performance. Use all the steps.)
The nurse should first perform hand hygiene before assisting with the procedure as part of medical asepsis to reduce the growth and transmission of infectious agents. The nurse should then remove the bottle cap carefully to avoid touching inside the cap and the bottle, because these areas are sterile. After removing the cap, the nurse should place it with the inside of the cap face-up on a clean surface, because it is sterile on the inside. The nurse should pick up with the label against the palm of the hand This prevents the solution from running down the side of the bottle, which may damage the label. The nurse should then pour 1 to 2 mL of solution into a receptacle to be discarded. This cleans the inside lip of the bottle. The final step is to pour the solution onto the sterile gauze. The nurse should not hold the bottle over the sterile field. Make sure the lip of the bottle does not come into contact with the sterile gauze. Hold the bottle high enough to avoid splashing of the solution.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Anticoagulants NSAIDs Cardiac glycosides Thyroid hormones
Thyroid hormones Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss.
A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.) Tingling in the arms Low back pain Shoulder pain Hip pain Stiff neck
Tingling in the arms is correct. Numbness and tingling in the upper extremities are common manifestations of a herniated cervical intervertebral disc.Low back pain is incorrect. Low back pain with muscle spasms is a common manifestation of a herniated lumbar intervertebral disc.Shoulder pain is correct. Shoulder pain, particularly on the top of the shoulders, is a common manifestation of a herniated cervical intervertebral disc.Hip pain is incorrect. Hip pain is a common manifestation of a herniated lumbar intervertebral disc.Stiff neck is correct. Pain and stiffness in the neck are common manifestations of a herniated cervical intervertebral disc.
FLAG A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain? Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club Has ankle pain after running a 16 km (10 mile) race Twisted his foot while running bases during a baseball game Was hit by another soccer player on the field
Twisted his foot while running bases during a baseball game A sprain is a stretching injury to ligaments around a joint. Wrenching or twisting motions cause this type of injury.
A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize that which of the following medications is incompatible with warfarin? Furosemide Alprazolam Vitamin K Vitamin A
Vitamin K These two medications are not compatible. Vitamin K antagonizes the action of warfarin and is the antidote for warfarin toxicity.
A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron? Fiber Vitamin A Vitamin C Oxalates
Vitamin. C
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? "Incorporate nonverbal cues in the conversation." "Ask multiple choice questions as part of the conversation." "Use a higher-pitched tone of voice when speaking." "Use simple, child-like statements when speaking."
"Incorporate nonverbal cues in the conversation." Nonverbal cues enhance the client's ability to comprehend and use language.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? "Large incisions will be made in the eschar to improve circulation." "This procedure involves placing the client into a shower and removing the dead tissue." "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." "Dead tissue will be non-surgically removed."
"Large incisions will be made in the eschar to improve circulation." An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
A nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include? "Use a rectal suppository if constipated." "Swish with a commercial mouthwash after brushing the teeth." "Notify the dentist of your condition prior to invasive procedures." "Take aspirin for headaches."
"Notify the dentist of your condition prior to invasive procedures." The client is at high risk for bleeding; therefore, the client should avoid dental work if possible, especially tooth extractions. If the client must have dental work, the dentist should be aware to decrease the risk of bleeding and to hold pressure for longer time frames if bleeding occurs.
A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? Request a prescription for a medication to ease the client's anxiety. Irrigate the NG tube with 100 mL of sterile water. Check to see if the suction equipment is working. Remove and reinsert the NG tube.
Check to see if the suction equipment is working. The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.
A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include? History of smoking Obesity History of hypertension Genetics
Genetics Genetics is a nonmodifiable risk factor, which the client is unable to control.
A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? Hypernatremia Hyperuricemia Hypercalcemia Hyperchloremia
Hyperuricemia The nurse should monitor the client who is receiving IV furosemide for hyperuricemia. The nurse should instruct the client to notify the provider for any tenderness or swelling of the joints.
A nurse is caring for a client who has a tracheostomy. Day 1, 1530: Client appears restless. SaO2 92% on 40% humidified oxygen via tracheostomy collar. Lung fields with scattered rhonchi throughout. Tracheostomy suctioned for thin clear secretions. Day 1, 1545: Client appears less anxious. SaO2 98% on 40% humidified oxygen via tracheostomy collar. Breath sounds clear throughout. Day 3, 1530: Client appears restless. Buccal mucosa dusky. SaO2 88% on 40% humidified oxygen via tracheostomy collar. Lung fields with coarse crackles, diminished at right lower lobe. Tracheostomy suctioned for thick yellow secretions. Day 3, 1545: Client continues to appear restless. SaO2 94% on 40% humidified oxygen via tracheostomy collar. Breath sounds with intermittent crackles, diminished at right lower lobe. Day 1, 1530: Temperature 36.9° C (98.5° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 124/74 mm Hg SaO2 92 % on 40% humidified oxygen Day 3, 1530: Temperature 39.4° C (103° F) Heart rate 106/min Respiratory rate 24/min Blood pressure 128/76 mm Hg SaO2 88% on 40% humidified oxygenay 1, 1530: Temperature 36.9° C (98.5° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 124/74 mm Hg SaO2 92 % on 40% humidified oxygen Day 3, 1530: Temperature 39.4° C (103° F) Heart rate 106/min Respiratory rate 24/min Blood pressure 128/76 mm Hg SaO2 88% on 40% humidified oxygen Day 3: Drag words from the choices below to fill in each blank in the following sentence.
Hypoxia and pneumonia are correct. Manifestations of hypoxia include decreased oxygen saturation, cyanosis, restlessness, anxiety, tachycardia, and increased respiratory rate. Manifestations of pneumonia include elevated temperature, purulent pulmonary secretions, adventitious breath sounds, and areas of lung inflammation on a chest x-ray.
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? Sputum culture for acid-fast bacillus (AFB) Nucleic acid amplification test (NAAT) CT scan Chest x-ray
Nucleic acid amplification test (NAAT) The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum.
A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take? Position the client's legs in an adducted position. Offer to administer analgesia. Tell the client to bend forward at the waist when getting out of bed. Bathe and dress the client.
Offer to administer analgesia. The nurse should offer to premedicate the client prior to painful procedures, such as physical therapy, to help keep pain under control.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Severe headache Bradycardia Blurred vision Oriented to person, place, and year
Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.
A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? Shake the container vigorously. Be sure the child has not eaten within the hour. Perform mouth care. Check the child's blood pressure.
Shake the container 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.
A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client? Soy milk Cheddar cheese Low-fat yogurt Cottage cheese
Soy milk Soy milk is the best choice for this client because soy milk is lactose-free
A nurse is teaching a client who is to start taking warfarin about herbal supplements. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin? Valerian Black cohosh Echinacea St. John's wort
St. John's wort The nurse should instruct the client that St. John's wort can decrease anticoagulation when taking warfarin.
A nurse is caring for a client who has cancer and is undergoing chemotherapy. Physical Examination January: Weight 70.5 kg (155 lb)BMI 24 February: Weight 69 kg (152 lb)BMI 23 Diagnostic Results January: Complete Blood Count:WBC count 5,500/mm³ (5,000 to 10,000/mm³)RBC count 4.2 (4.2 to 5.4)Hgb 12 g/dL (12 g/dL to 16 g/dL)Hct 37% (37% to 47%)Platelet count: 150,000/mm³ (150,000 to 400,000/mm³) February: Complete Blood Count:WBC count: 4,500/mm³ (5,000 to 10,000/mm³)RBC count 4 (4.2 to 5.4)Hgb: 14 g/dL (15 g/dL to 16 g/dL)Hct: 36% (37% to 47%)Platelet count: 140,000/mm³ (150,000 to 400,000/mm³) Nurses' Notes January: Client reports fatigue and nausea following chemotherapy treatments. States, "It just makes me not want to eat. When I do eat, the food taste funny." Client teaching: Instructed client to attempt to eat small meals several times daily, to eat food cold or at room temperature, to avoid fried foods. Encourage client to rest before eating meals. Oral mucosa is inflamed. Client teaching: Instructed client to avoid mouthwashes that contain alcohol, to increase water intake to 2 or more liters daily, and to avoid hot foods. Reviewed laboratory findings and stressed the need to protect self from illness due to immunosuppression. Client teaching: Instructed client to not eat raw or undercooked meat, to drink only pasteurized milk, and to boil water before drinking it; take temperature daily and report fever, avoid crowds, wash hands frequently with antimicrobial soap. Reviewed laboratory findings and stressed need for bleeding precautions. Client states, "I've had bleeding from these ulcers in my mouth." Client teaching: Use an electric razor, take a stool softener if constipation occurs, avoid coarse-textured foods. February: Client has experienced weight loss of 1.5 kg (3 lb), has experienced decrease in hct and hgb, WBC, and platelet count. Client reports still not able to consume much food; has increased intake of water. Oral mucosa with less inflammation. Client reports no bleeding episodes. Which of the following assessments indicates an improvement in the client's condition?Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.) WBC count Oral health Bleeding episodes Platelet count Weight change
WBC count is incorrect. The client's WBC count has decreased over the month. Therefore, it is not an improvement in the client's condition. A decreased WBC count places the client at increased risk of infection. Oral health is correct. The nurse's assessment and the client's report of increase in water intake indicate an improvement in the client's condition. Platelet count is incorrect. The client's platelet count has decreased over the month. Therefore, is not an improvement in their condition. A decreased platelet count places the client at an increased risk of bleeding. Weight change is incorrect. The client's weight has decreased. Therefore, it is not an improvement in their condition. Bleeding episodes is correct. Despite a decreasing platelet count, the client reports no further bleeding episodes. Therefore, this indicates an improvement in the client's condition.
Nurses' Notes Client admitted to medical-surgical floor from the emergency department (ED). Client has a history of HIV, first diagnosed 15 years ago, that has recently progressed to AIDS. Client presents with headache, diarrhea, night sweats, and weight loss for approximately 1 week. Vital Signs Day 1: Temperature: 37.3° C (99.1° F)Heart rate: 98/minRespiratory rate: 16/minBP: 104/74 mm HgOxygen saturation: 96% on room air Day 2:Temperature 38.4 C (101.1 F)Heart rate 100/minRespiratory rate 18/minBP 98/54 mm HgOxygen saturation 95% on room air Diagnostic Results Day 1: WBC count 3,500/mm3 (5,000 - 10,000 mm3)Hemoglobin 16 g/dL (12 to 18 g/dL)Hematocrit 48% (37% to 52%)Potassium 3.7 mEq/L (3.5 to 5 mEq/L)Sodium 141 mEq/L (136 to 145 mEq/L)CD4 t-cell count 200 mm3 (800 to 1,000 mm3) Day 2: WBC count 3,100/mm3 (5,000 to 10,000 mm3)Hemoglobin 17 g/dL (12 to 18 g/dL)Hematocrit 51% (37% to 52%)Potassium 3.9 mEq/L (3.5 to 5 mEq/L)Sodium 140 mEq/L (136 to 145 mEq/L)CD4-T-cell count 198 mm3 (800 to 1000 mm3) Drag 1 condition and 1 client finding to fill in each blank in the following sentence
ox 1 Infection is correct. When using the urgent vs non-urgent approach to client care, the nurse should determine that the client is at greatest risk for infection. This client has a CD4-T-cell count of 198 - 200 mm3, indicating that the client has decreased immune function. Impaired gas exchange, hypokalemia, cardiac dysrhythmias, and pneumocystis pneumonia are incorrect. While the client is at risk for all of these complications, the client does not currently show manifestations of any of them; therefore, there is another higher risk for the client. Box 2 CD4-T-cell count is correct. This client has a CD4-T-cell count of 198 - 200 mm3, indicating that the client's has decreased immune function. This decrease in the function of the client's immune system places the client at greatest risk for opportunistic infections. Oxygen saturation, diarrhea, potassium level, and respiratory findings are incorrect. The client's oxygen saturation and potassium levels are both within the expected reference range and do not place the client at risk for developing any of the possible complications identified. The client does have diarrhea, which places the client at risk for developing hypokalemia; therefore, there is a higher risk for the client.
