exam 2 lecture
Make arrangements to transfer the child to the hospital.
A 2-year-old child is brought to the urgent care center for treatment of burns on both hands. The parent reports that the child pulled the coffee pot over and the hot liquid splashed on to the child's hands. The nurse examines the child and notes that the backs of the hands are reddened with a well-defined line of demarcation at the wrists. Several medium to large blisters are also present. What initial action should the nurse take?
3 years
A 25-year-old client asks the nurse how often he should have a testicular examination. After instructing the client about the American Cancer Society's guidelines, the nurse determines that the client has understood the instructions when he says he should have a testicular examination every
0.818mg
A 6-year-old child weighing 60 pounds has been prescribed Lanoxin 30 mcg/kg PO daily. How many mg will the child be given?
Battle sign
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:
Degenerative joint disease
A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?
nausea and vomiting
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
Western blot test for confirmation of diagnosis.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
28-year-old salesperson who alternates between overactivity and periods of depression
A group of clients are being screened to see which clients would be the best candidate for a psychotherapeutic drug trial for the treatment of bipolar disorder. Which client would be best suited for this trial?
"Client is reporting abdominal pain is rated at 8/10."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?
colchicine
A nurse is caring for a client with a warm and painful toe from gout. What medication will the nurse administer?
increased risk of hyperkalemia.
A physician has prescribed triamterene to a client with renal disease. The client informs the nurse that they are taking potassium supplements to address some heart problems. The nurse would be alert for which of the following?
"Evidence shows that talking about suicide with clients doesn't cause suicide attempts."
A psychiatric nurse's colleague has expressed a reluctance to assess a client's risk for suicide, stating, "The last thing I want to do is to plant the thought in the client's head and bring on a suicide attempt." What is the nurse's best response?
absence seizure
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
101.60 cm (40 in)
A waist circumference greater than which value indicates excess abdominal fat in men?
"We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive." "This system fits nicely into how we work."
An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.
Performance
An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?
assess and massage the fundus.
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
usability
Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?
Yes, fever and rash may follow 14 asymptomatic days.
The clinic nurse is triaging a client who had visited a smallpox affected community 14 days ago. The client has developed a fever but no rash. Should the nurse consider the client at risk for smallpox?
"This hospital is concerned about keeping our clients' records private, so we take special precautions to prevent unauthorized access."
The nurse is admitting a 75-year-old client who is accompanied by a spouse. The spouse wants to know where the information being obtained is going to be kept, and the nurse describes the system of electronic health records. The spouse states, "I sure am not comfortable with that. It is too easy for someone to break into computer records these days." What is the nurse's best response?
Remove all dangerous items from the client's room.
The nurse is caring for a client with major depressive disorder who has been admitted to a psychiatric-mental health facility. After assessing the client, the nurse has developed a nursing diagnosis of "risk for violence toward others related to agitation and low tolerance level." Which would be an appropriate intervention for this client?
after completion of administration of each drug
The nurse is caring for a client with pneumonia who requires administration of medications. When does the nurse document administration in the medication administration record (MAR)?
The skin is ashen gray and dull.
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?
Prolonged use of corticosteroids
The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?
Halos and glare
The nurse should monitor for which manifestation in a client who has undergone LASIK?
Ewing sarcoma
The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of:
Parents ultimately are the decision makers regarding medical treatment for their children younger than the age of 18.
The pediatric nurse knows that the children being treated are considered minors. Which statement accurately describes the regulations related to consent for medical treatment?
see-saw respirations
When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding?
HIV-1 is more prevalent than HIV-2 subtypes
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?
Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore."
Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse?
A 79-year-old client with an indwelling catheter
Which client is likely at the greatest risk of developing a urinary tract infection?
excessive thirst
Which is a clinical manifestation of diabetes insipidus?
weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm
Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?
Older adult female client admitted with an indwelling Foley catheter that has been in place for 1 month
Which of the following clients is at greatest risk for developing a urinary tract infection (UTI)?
Holism
Which of the following is a theory and philosophy that focuses on connections and interactions between parts of the whole?
Acetylcholine
Which of the following neurotransmitters are deficient in myasthenia gravis?
utilizing a reporting form and allowing time for any questions
Which strategy would provide the most effective form of change of shift report?
Position the client in upright position, and correct the initiating stimulus.
Which treatment should take place immediately in a client experiencing autonomic dysreflexia?
The one who inhaled the toxin
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first?