EXIT K 5

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis?

Tensilon

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restore fluid volume

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?

Salicylate toxicity

Which action should the nurse implement when performing tracheal suctioning for a client with a tracheostomy?

Preoxygenate the client before suctioning.

Dexamethasone (Decadron) has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiological response?

Reduced cerebral edema

Diagnostic studies have been prescribed to assess a client's acid-base status. The nurse concludes that the laboratory value that indicates metabolic acidosis is:

Venous serum pH of 7.28

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. The Glasgow Coma Scale score that indicates the client is in a coma is a score of:

6

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, what does the nurse determine the client's score is?

7

A client has a leak of thoracic duct following a radical neck surgery. The nurse expects that the postoperative plan of care will include:

A chest tube, total parenteral nutrition (TPN), and bed rest

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is:

Addressing the pain

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, the nurse should:

Allow the client adequate time to speak

In the postanesthesia care unit after a below-the-knee amputation, a client begins crying after feeling for the affected lower leg. How should the nurse respond?

Allow the client to ventilate feelings of loss.

A client who had an above-the-knee amputation has an elastic bandage around the residual limb. The prescriptions include bathing the residual limb daily and rewrapping the elastic bandage as needed. What should the nurse do when wrapping the bandage on the client's residual limb?

Apply it smoothly without wrinkles or creases.

A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client?

Before the surgery

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate:

Corneal sensation

A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage?

Right side-lying

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?

Rises with inspiration and falls with expiration.

Which response should a nurse expect a client diagnosed with cerebellar dysfunction to exhibit?

Uncoordinated movements

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines. Record your answer using one decimal place. ___%

22.5

A common method for assessing the size of a burn wound is to use the Rule of Nines. Based on this method, estimate the extent of burns if the front chest, front abdomen, both sides of both upper extremities, and entire head were affected. Using the Rule of Nines, the estimate is: __% (Record your answer as a whole number)

45

A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the Rule of Nines to assess the percentage of total body surface area (TBSA) burned. What percentage should the nurse document in the client's hospital record?

9%

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

Aspiration

A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately?

Bleeding from the ears

A client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include:

Blurred vision along with episodes of vertigo

A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider?

Calcium supplements

A client, residing in an assisted living facility, is diagnosed with Parkinson disease and the health care provider prescribes selegiline (Eldepryl). What precaution should the nurse teach the client?

Change positions slowly.

After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should:

Check the system for air leaks-

A client with a history of pulmonary emboli is taking warfarin (Coumadin) daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client states:

Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting.

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply

Deep bone pain Depressed deep tendon reflexes

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion?

Difficulty breathing

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that a characteristic common to both crises is:

Difficulty breathing

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is:

Difficulty in expelling the air trapped in the alveoli

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply.

Double vision Scanning speech

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.

Dry cough Singed nasal hair Hoarse quality to the voice

A client returns from surgery after a total hip arthroplasty. A pillow to maintain abduction is in place. Under what conditions should the nurse remove this pillow?

During the client's bed bath.

A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the emergency department in crisis. To distinguish between myasthenic crisis and cholinergic crisis, the nurse expects the health care provider to prescribe:

Edrophonium chloride (Tensilon).

After sustaining a head trauma, a client reports hearing ringing noises. The nurse considers that an injury to what part of the body is likely to cause this clinical indicator?

Eighth cranial nerve (vestibulocochlear)

After a long leg cast is removed, the nurse should instruct the client to:

Elevate the leg when sitting

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for:

Elevated hemoglobin

A client had spinal anesthesia for surgery. On the second day after surgery the client complains of a headache. How should the nurse respond?

Encourage the client to drink 3 L of fluids in 24 hours

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?

Encourage the client to rest for short periods

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. The nurse instructs them to:

Encourage the client to speak while being patient with each attempt

A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period?

Encouraging coughing and deep breathing

A client has a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness in the postanesthesia care unit?

Encouraging deep breathing

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, the most important nursing intervention is to:

Ensure nothing by mouth (NPO) until the gag reflex returns

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly?

Evenly darkened skin of the residual limb

A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take?

Explain this is expected.

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intracranial pressure? Select all that apply.

Fever Stupor

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply.

Follow the same bedtime ritual each night Perform deep-breathing exercises

The nurse is caring for a client who is wearing a prosthesis after a single-leg amputation. Which crutch gait should the nurse teach the client to use?

Four-point

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

Give prescribed drugs to promote bronchiolar dilation.

A health care provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning?

Gurgling sounds with each breath

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:

Having the client breathe into a paper bag,

A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. The nurse recognizes that, postoperatively, the position that is most appropriate for this client is:

Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment

A hospice client who has severe pain asks for another dose of oxycodone (OxyContin). The nurse's primary consideration when responding to the client's request is to:

Help reduce the client's pain immediately

When assessing a client, the nurse identifies that the client has weakness of some of the muscles of the body. What should the nurse document in the medical record when describing weakness in the area indicated in the shaded portion of the illustration?

Hemiparesis

The client with emphysema complains of increased shortness of breath and becomes anxious. The health care provider prescribes oxygen at 1 L/minute via nasal cannula. The nurse understands that this prescription is appropriate because:

High concentrations of oxygen eliminate the respiratory drive.

What is the most effective way for the nurse to loosen respiratory secretions for a client with an endotracheal tube?

Humidify the prescribed oxygen.

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints?

In the morning on awakening

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals is to:

Increase chewing strength

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?

Increased restlessness

Which nursing action is important when suctioning the secretions of a client with a tracheostomy?

Initiate suction as the catheter is being withdrawn

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?

Instruct the client to splint the wound with a pillow when coughing

A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client's affected extremity?

Internal rotation with extension of the knee and hip

A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide (Mestinon), and long-term steroid therapy has been initiated. It is especially important for the nurse to ensure that the client:

Is monitored for an exacerbation of symptoms,

A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. The statement by the nurse that best describes the procedure is:

It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it."

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. The type of respirations that the nurse expects the client to exhibit is:

Kussmaul's breathing

In which position should the nurse initially place a client who has experienced a cerebrovascular accident (also known as a "brain attack")?

Lateral

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy

A client who has been taking spironolactone (Aldactone) is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply.

Lethargy Thready, weak pulse Muscle weakness

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply.

Numbness Prolonged capillary refill

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?

Palpate around the tube insertion sites for crepitus.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

Paroxysmal hypertension and bradycardia

Bed rest is prescribed after a client's cerebrovascular accident (also known as "brain attack") results in hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack?

Passive range-of-motion exercises

A client who has experienced a fracture of the femur is experiencing respiratory difficulties, and the nurse suspects a pulmonary embolus. Which of these assessment findings is specific to a fat embolism?

Petechiae

A client sustains a fracture of the head of the femur and the nurse is concerned about the client experiencing a fat embolus. The nurse should assess the client for which clinical indicator common to a fat pulmonary embolus?

Petechial hemorrhages on the chest

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus?

Pinpoint red spots on the chest

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?

Place client in a high-Fowler position

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

Prevent pressure ulcers

A client with a pneumothorax has a chest tube inserted and attached to a closed-chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" The nurse explains that the water:

Prevents reflux of air back into the chest

The nurse is providing care to a client with acute arthritis who is on bed rest. The client reports bilateral painful and swollen knee and wrist joints. What position will help prevent flexion deformities during the acute phase of this client's care?

Prone

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?

Push-ups to strengthen arm muscles

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed.

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question?

Reduce inflammation

Acetylsalicylic acid (aspirin) is prescribed for a client with rheumatoid arthritis. The nurse understands that the major rationale for this treatment is:

Reduction of joint inflammation

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction?

Relieve muscle spasm and pain

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?

Remove the air that is present in the intrapleural space

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy?

Reposition the client by log rolling.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60. These blood gases require nursing attention because they indicate:

Respiratory acidosis

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. What frequent assessment does the nurse determine is most important for a client with this syndrome?

Respiratory exchange

Which clinical indicators does the nurse expect a client with Parkinson disease to exhibit? Select all that apply.

Resting tremors Flattened affect Slow voluntary movements

A client returns from a radial neck resection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority and requires immediate nursing intervention?

Restlessness and dyspnea

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Restlessness...

Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly?

Rises in the tube of the water seal chamber during inspiration.

The nurse is caring for a client with Parkinson disease. Which of the following is a priority nursing concern?

Risk for injury

The nurse provides self-care instructions to a client who is receiving external radiation therapy for metastasis to the bone. Which intended activity identified by the client demonstrates a need for further teaching?

Rub on talcum powder after washing the area with water.

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer?

Sacrum

A debilitated older client with glaucoma who places great value on independence is being prepared for discharge from the hospital. To promote independence, the nurse should encourage the client to:

Self-administer the eye medications using appropriate technique

A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort?

Semi-Fowler

A client who had the left hand amputated after a traumatic injury is being fitted for a permanent prosthesis. What should the nurse teach the client about the most important factor for successful adaptation to the permanent prosthesis?

Shrinkage of the residual limb must be completed

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client?

Significance of a safe environment

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? Select all that apply.

Skin color Movement of the hand Sensations in the extremity

A client is diagnosed as having expressive aphasia. What type of impairment does the nurse expect the client to exhibit?

Speaking or writing

To make a definitive client diagnosis of tuberculosis, the nurse expects what diagnostic test to be prescribed?

Sputum tested for acid fast bacilli

A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of:

Steroids

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, the nurse should:

Suction as needed

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?

Suction as needed,

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?

Suction the client's oropharynx.

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves by testing the client's ability to:

Swallow

Which function must be addressed in the plan of care when a client has dysphagia?

Swallowing

Following an injury to the spinal cord, a client experiences severe headache, paroxysmal hypertension, diaphoresis, nausea, and bradycardia that characterize episodes of autonomic hyperreflexia (autonomic dysreflexia). The nurse recognizes that the episodes occur if the spinal injury is at or above a specific level of the spinal cord. Using the illustration, fill in the specific level of the spinal cord in the blank.

T6

A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in the affected extremity

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. How will the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in the affected extremity.

The nurse considers that a 70-year-old female can best limit further progression of osteoporosis by:

Taking supplemental calcium and vitamin D

The nurse is caring for a client who is suspected of having a brain tumor who is scheduled for a computed tomography (CT) scan. The nurse expects that the pre-procedure plan of care will include:

Telling the client about what to expect during the examination

A nursing assistant assigned to provide hygiene to a client who has a history of transient ischemic attacks (TIAs) asks the nurse what a TIA is. What explanation should the nurse provide?

Temporary episodes of neurologic dysfunction.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond?

That must have really shocked you. Tell me what the health care provider told you about it.

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response?

The disorder is considered one of hypersensitivity and the exact cause is unknown.

What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord?

Tracheostomy set and oxygen

A client with a cerebrovascular accident (also known as a "brain attack") is comatose on admission. Which clinical indicator is the nurse most likely to identify?

Urinary incontinence

A client with osteoarthritis who had a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position?

Use pillows to keep the client's legs abducted.

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care?

Venous thromboembolism prevention (VTE)

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take?

Wear a particulate respirator when caring for the client.

The nurse is preparing to initiate intravenous antibiotic therapy on a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intravenous antibiotics, which task should the nurse ensure has been completed?

Wound culture

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

Check the tube to ensure that it is not kinked.

The nurse is preparing to insert an intravenous (IV) catheter in a client who is being admitted for uncontrolled diabetes. Upon assessment of the client's forearm for a potential insertion site, the nurse notes that the client has an excessive amount of hair. What should the nurse plan to do in order to properly prepare the site for insertion?

Clip the hair.

A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia? Select all that apply.

Confusion Muscle weakness

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine (Mestinon) is prescribed. When teaching the client about this medication, the nurse explains that the desired effect is to increase:

Contraction of skeletal muscles

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for:

Control of pain

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to:

Control the intraocular pressure.

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Controlling intraocular pressure

The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include:

Coughing and deep breathing every hour

The chemotherapy protocol prescribed for a client with tuberculosis includes vitamin B6 and isoniazid (INH). The nurse determines that vitamin B6 is used to:

Counteract the peripheral neuritis that isoniazid may cause

A client is admitted to the intensive care unit with pulmonary edema. What clinical finding does the nurse expect when performing the admission assessment?

Crackles at bases of the lungs

Thick mucous gland secretions, elevated sweat electrolytes, meconium illeus, and difficulty maintaining and gaining weight are associated with this autosomal recessive disorder:

Cystic fibrosis

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure—

What should the nurse assess for in the immediate postoperative period after a client has brain surgery?

Decreased level of consciousness,

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?

Decreased sounds

A health care provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply

Double vision Difficulty swallowing saliva Drooping of the upper eye lids

A health care provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.

Double vision Difficulty swallowing saliva Drooping of the upper eye lids

A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe:

Hyperextension of both the upper and lower extremities

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube?

Hyperoxygenate with 100% oxygen before and after suctioning.

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

Hypothalamus

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?

Increased restlessness,,

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply.

Increased weight Decreased serum sodium Decreased level of consciousness

What are expected changes that the nurse might identify when assessing the skin of an older adult? Select all that apply.

Increased wrinkles Hyperpigmented patches

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological responses to this disease?

Levodopa (l-Dopa)

The nurse is providing care during the immediate postoperative period for a client that had a radical neck dissection. The best method to assess for stridor is:

Listen with a stethoscope over the trachea

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply.

Liver Shellfish

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report?

Loss of central vision

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report:

Loss of peripheral vision

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?

Maintain an open airway.

A nurse is caring for a client who is admitted to the hospital with a severe head injury. What does the nurse identify is the priority nursing care for this client?

Maintaining respiratory exchange and ventilation.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify:

Altered mental status

A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do?

Assess the client's pain before increasing the dose of morphine.

A health care provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eye drops to the client. Which ophthalmic solution is contraindicated for this client?

Atropine

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride (Tensilon) test. To treat a common complication associated with the test, the nurse should have what drug available?

Atropine (Atro-Pen)

When caring for a person with myasthenia gravis, a nurse considers the differences between myasthenic and cholinergic crises. The nurse concludes that:

Atropine is used to treat cholinergic crisis.

The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate breath sounds.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate the lungs.

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?

Avoid bending from the waist

The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply

Avoid bending from the waist. Do not blow your nose.

The nurse provides discharge instructions to a client who had a rhinoplasty. The client will have packing in place for several days after discharge from the hospital. The instructions should include:

Avoid items that may trigger sneezing

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?

Avoid leaning forward.

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3 mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these findings indicate:

Azotemia

A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a:

Basilar fracture

A client with Parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic the client complains of some numbness in the left hand. What is the nurse's priority intervention?

Make arrangements immediately for further medical evaluation by the client's primary health care provider

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, what response does the nurse expect?

Metabolic acidosis

A client with major burns of the head and chest is admitted to the burn unit. Twenty-four hours after the burn, the client is complaining of severe thirst. The average urinary output is 60 mL/hr for the last 10 hours. No bowel sounds are heard. The nurse's best action is to:

Moisten the lips with wet gauze

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result?

Molecular diffusion

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis?

Monitoring respiratory status.

Which medication should the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema?

Morphine

During rounds, a nurse observes a client who is experiencing a tonic-clonic seizure. Which actions by the nurse are correct? Select all that apply.

Move obstacles away from the client Turn the client to the side.

A client that 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.

What clinical indicators should the nurse expect when interviewing and assessing a client with Ménière's disease? Select all that apply.

Nausea Dizziness Jerky lateral eye movements.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

Obese client with leg trauma

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all that apply.

Monitor the seizure activity. Turn the client on the left side.

An older female client is seen in the health care provider office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch since the last visit one year ago. The nurse knows that what is the most likely reason for this finding?

Older adults may have osteoporosis-related height changes

The nurse is caring for a client who had surgery for a total hip replacement. Which client position should be avoided?

Orthopneic

A nurse administers carbidopa-levodopa (Sinemet) to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to produce?

Replacement of a neurotransmitter in the brain

A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?

Yellow sclera

A client complains of left-sided chest pain after the client finished playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify:

Absence of breath sounds on auscultation

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?

Absence of breath sounds over the affected area

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally, the nurse should discuss the concerns with:

Adult Protective Services

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to:

Advance the cane and the affected extremity simultaneously

A nurse is caring for a client who had an above-the-knee amputation. In what position should the nurse encourage the client to keep the hip to promote early and efficient ambulation?

Functional alignment

A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort?

Semi-Fowler position

While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in what position?

Side-lying

The health care provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client complains of itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?

Stop the transfusion immediately.

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, a nurse identifies tachycardia, tachypnea, and dyspnea. What term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client? Listen to the audio

Stridor

A client is at risk for increased intracranial pressure (ICP). Which of the following assessment findings reflects an increase in ICP?

Unequal pupil size

The nurse is caring for a client that has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. Select all that apply.

Unilateral chest pain Sudden onset of shortness of breath