EAQ for Exam 1

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan

- Chemotherapy - blood transfusion - radiation therapy

A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings?

- Lethargy - thready, weak pulse - muscle weakness

A nurse is teaching a 12-year-old child about a bone marrow aspiration. What should be included?

- My hip will be sore after the procedure - You'll put a tight bandage on me where the needle goes in - The doctor is going to stick a needle into the middle of one of my hip bones

A student nurse is describing palliative care to a client's family.

- Palliative care focuses on the care of the client. - Palliative care includes symptoms management in the client - Palliative care is an interprofessional approach to the delivery of care

A nurse is assessing a client for dehydration. The client has had diarrhea and vomiting fro 48 hours. Which assessment findings alert the nurse that the client is dehydrated?

- Postural hypotension - The skin on the client's forehead remains tented after being pinched

The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia.

- The client would show signs of twitching - the client would show signs of muscle cramping - the client would show signs of skeletal muscle weakness

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit?

- Vomiting - Muscle weakness - Irregular heart rate

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?

- epistaxis - hematuria - hemarthrosis - easy bruising - dark-colored tarry stools

A client who was admitted with diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia

- headache - hematuria - Ecchymosis

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit?

- oliguria - hypotension - tenting tissue turgor

The nurse is caring for a client with chronic pain who is an opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which condition of the client should the nurse consider as highest priority?

- sedation - respiratory rate

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significat?

- seizures - confusion

The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive type of care?

-When the expected death of the client is within 6 months - When the client seeks no aggressive disease management - When the client has been issued a "do not resuscitate" order.

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress?

Assisting the client in developing new coping mechanisms

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?

Respirations

A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1 year-old daughter with sickle cell anemia. SHe asked the nurse, "will this baby also have sickle cell anemia?" How should the nurse respond?

The chance that another child will have sickle cell anemia is 25%

How should a nurse expect a client's anxiety to be manifested physiologically?

Increased blood glucose level

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement?

Red blood cells appear normal in size and color; however, there is a decreased amount produced.

A client has a platelet count of 49,000/mL (40 x 10 9/L). The nurse should instruct the client to avoid which activity?

Blowing the nose

What is the most definitive test to confirm a diagnosis of multiple myeloma?

Bone marrow biopsy

A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as a primary benefit with this type of therapy?

Client is able to self-administer pain-relieving drugs as necessary

What is true about cortisol

Cortisol stimulates gluconeogenesis

A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?

Naloxone administration

After a surgical thyroidectomy a client exhibits carpopedial spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations?

Calcium gluconate

A client develops iorn-deficieny anemia. Which lab result would be decreased?

Ferritin level

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

Hemolytic

A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective?

I have to be careful about which over-the-counter cold preparations I take when I have a cold.

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 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 nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

alcohol