halo-halo

A client is seen in the ambulatory care office for a routine examination. Which statement by the client should be most important for the nurse to follow up?

"I just lost a family member to gastrointestinal cancer."

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

"I need to avoid getting the cast wet."

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 pm."

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching?

"I will avoid driving at night because the vest limits the ability to turn the head."

The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching?

"I will not hear sounds clearly unless they are loud."

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply.

1.Femur 2.Skull 3.Tibia 6.Vertebrae

The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply.

2.Tetany 3.Diarrhea 4.Possible seizure activity 6.Positive Trousseau's sign

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should schedule the medication so that each dose is taken at which time?

30 minutes before meals

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36%

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

8 inches to the front and side of the client's toes

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse most question?

Acetaminophen

During admission data collection the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area?

Balance and coordination

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted?

Bowel movement every 5 days

A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerve (CN)?

CN VII

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the amount in use

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

Document the finding in the client's record.

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?

Doing active range of motion to finger joints

A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position?

Flat, turning from side to side as needed

The client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional data from the client to support this diagnosis?

History of alcohol use, smoking, and weight loss

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?

In semi-Fowler's position with the knee gatch slightly raised

The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which nursing intervention does the nurse document in the plan as a priority for this client?

Monitor urine output.

The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurological disorders

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?

Performing active range of motion (ROM) to the right ankle and knee

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The nurse has assisted the primary health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse should assist the client into which position?

Right side-lying with a small pillow or towel under the puncture site

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure?

Suctioning for longer than 30 seconds

The nurse is providing care for a client with a nasogastric tube. Which observation is most appropriate in determining that the tube is correctly placed?

The pH of the aspirate is 5.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

1.Pad the bed's side rails. 2.Place an airway at the bedside. 3.Place oxygen equipment at the bedside. 4.Place suction equipment at the bedside.

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce to the client? Select all that apply.

1.Provide meticulous and frequent oral hygiene. 2.Use additional lightweight blankets as needed. 4.Check blood serum vitamin B12 levels every 1 to 2 years.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet expecting which to be prescribed? Select all that apply.

1.Wound culture 2.Antibiotic therapy 4.Warm compresses

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

"I can't swallow very well today."

A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?

A temporary worsening of the condition

The nurse is assisting in caring for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?

Leakage of clear fluid from the nose

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours

The nurse is reinforcing instructions to a client taking divalproex sodium. The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test?

Liver function studies

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage?

36%

The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus?

Inability to pass flatus

The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?

Indicates that facial puffiness will be a permanent problem