Med surge Final

A nurse is working with a client diagnosed with SSD. What criteria would differentiate this diagnosis from illness anxiety disorder (IAD)?

The client diagnosed with SSD experiences physical symptoms in various body systems, and the client diagnosed with IAD does not.

An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression?

The client has a tense facial expression and body language.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon?

The client's intraarterial pressure may compromise the graft's viability.

A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient's health should the nurse focus most closely during the visit?

The patient's functional status

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention?

To assess for fine tremors

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.)

1. Sad mood on most days, 4. Sad mood for the past 3 years after spouse's death

A lethargic client is diagnosed with major depressive disorder. After taking antidepressant therapy for 6 weeks, the symptoms have not resolved. Which nutritional deficiency should a nurse identify as potentially contributing to the client's symptoms?

Iron deficiency

A nurse is planning a presentation about HIV for a church-based group. which of the following information about HIV transmission should the nurse include?

It is primarily transmitted through direct contact with infected body fluids

A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with inappropriate behavior. The nurse recognizes that this dissociation serves which function?

It serves to isolate painful events so that the primary self is protected.

A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?

Joint stiffness, especially in the morning

A nurse is caring for a client who is unconscious and has lost the corneal reflex. which of following actions should the nurse take?

Keep the room darkened

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?

Lactated ringers

A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what?

Laser treatment

A nurse is assessing the depth and extent of a client who has sever burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn?

Location of the burn

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave falls before the QRS complex.

A client inquires about the practice of therapeutic touch. Which nursing reply best explains the goal of this therapy?

"The goal is to re-pattern the body's energy field by the use of rhythmic hand motions."

A nurse is caring for a client who has hepatitis A. The client asks how he might have contracted the virus. Which of the following is a question the nurse should ask the client?

"Have you been to a third world country in the past?"

A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives?

"I don't have a green thumb. Any old fool can grow a rose."

At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phonea lawyer to file for a divorce. Unit rules state that no phone calls are permitted after10:00 p.m. Which nursing response is most appropriate?

"It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow."

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."

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

"Maintain stable blood glucose levels."

A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client?

"Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety."

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply?

"Weight gain is a common, but troubling, side effect."

An intraoperative nurse is applying interventions that will address surgical patients' risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

- Absence of reflexes - Diminished ability to communicate - Loss of pain sensation

How would a nurse differentiate a client diagnosed w/ panic disorder from a client diagnosed w/generalized anxiety disorder (GAD)?

- Depersonalization is commonly seen in panic disorder and absent in GAD - Depersonalization refers to being detached from oneself when experiencing extreme anxiety

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition?

- Severe dyspnea -Decreased level of consciousness -Headache -Hypotension

A nurse in an ER is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dl The nurse should anticipate which of the following prescriptions from the provider?

0.9% sodium chloride IV bolus

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

1. Being firm, consistent, and emphatic, while addressing specific client behaviors

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just do not feel good." What actions should the nurse take? Select all that apply.

1. Confirm the client's vital signs, and complete a quick assessment. 2. Inform the charge nurse of the change in condition, and initiate the hospital's 4. Stay with the client, and reassure the client. 5. Call the healthcare provider (HCP), and report the situation using SBAR format.

Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)

1. Maintain a calm demeanor. 2. Clearly delineate the consequences of the behavior. 4. Set limits on the behavior.

A nurse working the day shift on a cardiac unit receives the following shift report: At the conclusion of the report it is 0730. Put the clients in order from first to last in which the nurse should plan to assess them. All options must be used... 1. Admitted yesterday morning with hypokalemia Awaiting repeat electrolyte lab results drawn at 0600 2. Experiencing chest pain at 0630. Pain resolved after 2 sublingual nitro tablets 3. Scheduled for oral antihypertensive medication at 0900. Incontinent of urine during the night 4. Scheduled for coronary artery bypass surgery at 0800. The clients family is in the clients room

2,3,4,1

A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the listed client outcomes?Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night.

3, 1, 4, 2 ( Remain free from injury, maintains nutritional status, sleeps 6-8 hours a night, interacts appropriately with peers )

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?

A 74-year old with a low body mass index

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). What does the nurse expect to find?

A decrease in CD4 T cells

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? Select all that apply:

A. Administer Furosemide B. Implement a Low-sodium diet E. Measure the client's abdominal girth

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in ICP? (Select all that apply.)

A. Disorientation B. Pupillary changes D. Headache E. Slurred speech

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

A. Immunization B. Use of standard precautions

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include?

A. Oxygen B. Elevate side rails C. Provide suction at bedside

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply.

A. Tell me what happened B. What coping methods have you used, and did they work? C. Describe to me what your life was like before this happened.

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction?

A. Troponin I B. Troponin T C. CPK D. Myoglobin

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone odor to breath

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which item based on priority?

Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse implement?

Reduce stimuli

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20mL/hour for 2 hours. THe client received a single bolus of 500 mL if intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Acute kidney injury

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?

Acute respiratory failure

A nurse in the ER is caring fora client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first?

Administer IV fluids

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior?

Agitated and pacing. Exhibiting grandiosity. Mood labile.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which potentially fatal side effect will the nurse teach the client about?

Agranulocytosis

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Airway patency

A nurse in an emergency department is preparing to care for a client who is brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care?

Airway protection

The nurse would evaluate that defibrillation of a client was most successful if which observation was made?

Arousable, sinus rhythm, BP 116/72 mm Hg

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the EKG?

Atrial fibrillation

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking a dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.)

B. Saw palmetto C. Glucosamine D. Gingko biloba

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician?

Blood pressure of 180/100 mm Hg

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

C. Nausea D. Tachycardia E. Diaphoresis

A nurse understands that when a practitioner corrects subluxation by manipulating the vertebrae of the spinal column the practitioner is employing which therapy?

Chiropractic therapy

A client has returned from the cardiac catheterization lab after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?

Client has become more somnolent

A client with a migraine headache says, "My nurse practitioner told me that acupuncture may enhance the effect of the medications and physical therapy prescribed." What type of therapy is the nurse practitioner recommending?

Complementary therapy

A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following?

Confirm return of gag reflex

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Confusion

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Constant bubbling in the suction-control chamber

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

D. Place a pillow under the client's head E. Loosen restrictive clothing

The nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Decrease in systolic pressure by more than 10 mmHg during inspiration

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder?

Delusions of reference

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem?

Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Edematous bruises on forehead

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern?

Electrolyte imbalance

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. which of the following interventions should the nurse take?

Elevate the head of the bed 30 degrees.

Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (Canada: 25 mmol/L). What nursing action should be taken?

Encourage the client to take deep, cleansing breaths

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse included in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?

Erythema

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of a hemorrhagic stroke

A nurse is reviewing progress notes on a newly admitted client. One progress note reveals that the client purposefully inserted a contaminated catheter into urethra, leading to a urinary tract infection. The nurse recognizes this behavior as characteristic of which mental disorder?

Factitious disorder

A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?

Fatigue Related to Pain

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Flail chest

A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the patient should be informed that this procedure will involve the removal of which ofthe following? Select all that apply:

Gallbladder, Part of the stomach, duodenum, part of the bile duct (A,B,C,D)

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool?

Glasgow coma scale

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's physiological need?

Have the client breathe into a paper bag.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

Looking at a slightly bleeding paper cut, the client screams, "Somebody help mequick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic ofwhich personality disorder?

Histrionic personality disorder

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was?

Hoarseness

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Hyperkalemia

A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize?

Impaired Skin Integrity

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alteration in function should the nurse expect?

Inability to recognize his family members

A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following?

Increased uric acid levels

1. A nurse is caring for a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Increasing dyspnea

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

Ineffective airway clearance related to airway alterations

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?

Intravenous infusion of normal saline

What should the nurse expect when assessing a client with pleural effusion?

Reduced or absent breath sounds at the base of the lungs

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate?

Metabolic alkalosis

A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following?

Methotrexate (Rheumatrex)

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Movement of the ET tube into the right main bronchus

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?

Note escalating behaviors and intervene immediately.

A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasound

The PACU nurse is caring for a male patient who had a hernia repair. The patient's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

Pain, hypoxia, or bladder distention

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Paraplegia

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Place a pillow under the clients head

A nurse is caring for a client who has quadriplegia from a SCI and reports having severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in high-fowler's position

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Placing the client on one-to-one observation while monitoring suicidal ideations.

A client was recently admitted to the inpatient unit after a suicide attempt and is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse teaches the client about serotonin syndrome. Which of the following is a symptom of serotonin syndrome?

Priapism

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing?

Psychiatric emergency crisis

The nurse is reviewing the chart information for a patient with increased ascites. The data include the following: temperature of 98.9F, heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first:

Raise the head of the bed

A nurse is preparing to administer an osmotic diuretic iv to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Regular (Humulin R)

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values: pH. 7.22, PaCO2 68, Bicarb 26.

Respiratory acidosis

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

Rest frequently throughout the day

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

Restlessness and muscle rigidity

A highly emotional client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a séance." Which personality disorder should a nurse associate with this behavior?

Schizotypal personality disorder

A nurse is assessing a client who has a concussion from a sports injury. which of the following manifestations should the nurse expect?

Sensitivity to light

The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?

Shortness of breath

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and ABGs

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?

Stridor

A nurse is caring for a client who is unconscious client following cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

Symptoms indicate lithium carbonate toxicity.

The nurse is discussing treatment options with a client who has arachnophobia. Which commonly used behavioral therapies for phobias should the nurse explain to the client? SATA

Systematic desensitization Imploding (flooding)

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)?

Teaching participants to limit their sun exposure

A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered "prn for EPS." When will the nurse plan to give this medication?

When the client exhibits tremors and a shuffling gait

A nurse is caring for a client admitted to a mental health facility who asks, "can i refuse the scheduled electroconvulsive therapy? which of the following should be the nurse's response

You have the right to refuse even though the consent has been signed

A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response?

Your husband needs to deal with the consequences of his drinking.

A nurse is performing triage for a group of clients following a mass casualty incident. which of the following clients would the nurse plan to care for first?

a client experiencing a tension pneumothorax

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

abnormally prominent U wave

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

increased respiratory rate of 18 to 44/min