MODULE 10: PHYSIOLOGIC HEALTH PROBS
Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce metabolic demand on the liver and increase its blood supply, but strict bed rest is unnecessary. The client should avoid taking medications, including acetaminophen (which is hepatotoxic), unless they are prescribed by the healthcare provider. The client must avoid all alcohol consumption. The client should consume small frequent meals that are low in fat and protein and high in carbohydrates to reduce the workload of the liver.
A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to: Maintain strict bed rest Limit the intake of alcohol Incorrect Take acetaminophen (Tylenol) for discomfort Eat small frequent meals that are low in fat and protein and high in carbohydrates Correct
An ECG taken in the presence of pain may reveal ischemic changes with ST-segment elevation or depression. Peaked T waves may indicate hyperkalemia. PVCs are caused by the firing of an irritable pacemaker in the ventricle. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block.
A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which of the following findings would the nurse expect to note in the event of an ischemic episode? Peaked T waves Incorrect ST-segment depression Correct Widened QRS complex An isolated premature ventricular contraction (PVC)
The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. Liquids are alternated with solids whenever possible to prevent food from being left in the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.
A client who is recovering from a brain attack (stroke) has residual dysphagia. Which of the following measures does the nurse plan to implement at mealtimes? Giving the client thin liquids Alternating liquids with solids Correct Giving foods that are primarily liquid Incorrect Placing food in the affected side of the client's mouth
Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting, twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a higher residual concentration gradient in the brain, caused by the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented with the use of shorter dialysis times or dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and tachycardia, and bradycardia and hypothermia are not associated with disequilibrium syndrome.
A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? Fever and tachycardia Headache and confusion Correct Bradycardia and hypothermia Irritability and generalized weakness
A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. Decreased pulse Decreased urine output Correct Increased blood pressure Incorrect Increased respiratory rate Correct Decreased respiratory depth Incorrect
Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The physician is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.
A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? Insert a Foley catheter in the client Prepare the client for insertion of a central IV line Administer the medication with the use of a macrodrip IV tubing set Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct
Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling.
A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? "I should put a steam vaporizer in her room." Correct "I'll take her out into the cool, humid night air." "I can open the freezer door and encourage her to breathe in the cool air." Incorrect "I can run the hot water in my bathroom and cuddle her in the steamy room."
When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression.
A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: 1 inch 1½ inches 2 inches Correct 4 inches
The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual's exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client's room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation.
A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? Visitors must be limited to one half-hour per day. Correct Visitors must remain at least 2 feet from the client. Incorrect A dosimeter badge must be placed on the client's bedside stand. The client may be maintained in a semiprivate room as long as the client uses a commode.
A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis (acid-fast bacillus), which is the organism responsible for the disease. The initial testing involves microscopic examination of stained sputum smears for acid-fast bacilli (a.k.a. the ABF test). In the tuberculin skin test, or Mantoux test, 0.1 mL of purified protein derivative (PPD) is injected intradermally on the dorsal surface of the forearm. The injection site is then assessed in 48 to 72 hours for the presence of an induration. In low-risk individuals (e.g., those who are not immunocompromised), an area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection indicates exposure to and infection with TB. Night sweats, a low-grade fever, cough, and mucopurulent sputum are clinical manifestations of TB but do not confirm the diagnosis.
A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? Night sweats and a low-grade fever Incorrect Positive result on an acid-fast bacillus smear Correct Cough and expectoration of mucopurulent sputum A Mantoux skin testing result that indicates 5 mm of redness
If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the physician is notified. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant.
A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately: Calls a code Holds the infant in an upright position Places the infant in the knee-chest position Correct Contacts the respiratory therapy department
When cord prolapse occurs, prompt action is taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Such positions include knee-chest, Trendelenburg, and the hips elevated on pillows with the client in a side-lying position. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it, because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by way of facemask is administered to the mother to increase fetal oxygenation. A tocolytic medication is administered to inhibit contractions on the order of the physician, and the client is quickly prepared for delivery, but these are not the actions that would be taken immediately.
A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately: Pushes the cord gently back into the vagina Prepares the client for cesarean delivery Places the client in the knee-chest position Correct Prepares to administer a tocolytic medication
The major neonatal complications of preexisting diabetes mellitus in the mother are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant, which is needed to keep the alveoli open after birth.
A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely? Hypercalcemia Hyperglycemia Incorrect Hypobilirubinemia Respiratory distress syndrome Correct
Clinical manifestations of iron-deficiency anemia vary with the degree of anemia but usually include extreme pallor with porcelainlike skin, tachycardia, lethargy, and irritability.
A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? Lethargy Correct Bradycardia Hyperactivity Reddened cheeks
Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles.
A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. Slow pulse Decreased urine output Skeletal muscle weakness Correct Hyperactive bowel sounds Correct Hyperactive deep tendon reflexes Incorrect
If unexpected extubation occurs, the nurse must first assess the client for airway patency and spontaneous breathing. The nurse remains with the client, calls for assistance, and prepares for reintubation. The rapid response team is called when there is a change in the client's status in a hospital area outside the ICU. The nurse would not administer an antianxiety medication, because this could affect the client's breathing. The nurse would not restrain the client, because restraints could increase the client's anxiety.
A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then: Prepares for reintubation Correct Restrains the client's wrists Calls the rapid response team (RRT) Incorrect Administers an antianxiety medication to the client
To prevent graft occlusion, the nurse limits elevation of the head of the bed to 45 degrees. The nurse does assess the client for signs of graft occlusion, but assessment will not prevent occlusion. The signs of graft occlusion include changes in peripheral pulses, cool-to-cold extremities distal to the graft, white or blue extremities or flanks, severe pain, and abdominal distention. Bowel sounds and urine output are also assessed, but these parameters are unrelated to graft occlusion.
A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? Monitoring urine output Monitoring bowel sounds Checking pedal pulses distal to the graft site Incorrect Limiting elevation of the head of the bed to 45 degrees Correct
Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion.
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply. Hypotension Abdominal distention Correct Trousseau sign Correct Skeletal muscle weakness Incorrect Decreased deep tendon reflexes Incorrect
Kawasaki disease is an acute systemic vasculitis that primarily affects the cardiovascular system. The subacute phase is characterized by continued irritability, anorexia, desquamation of the fingers and toes, arthritis and arthralgia, and cardiovascular manifestations, including CHF. Nursing care is focused on observation of the child for signs of CHF. The nurse is alert for an increased respiratory rate, increased heart rate, dyspnea, congestion and crackles, and abdominal distention. Bleeding, a high fever, and failure to thrive are not directly associated with this disorder. In the subacute phase, the fever subsides. Symptom: strawberry colored tongue.
A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for: Bleeding A high fever Incorrect Failure to thrive Signs of congestive heart failure (CHF) Correct
Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. An increased BUN level indicates kidney damage, a result of the preeclampsia.
A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition? Trace protein in the urine Correct Blood urea nitrogen (BUN) of 40 mg/dL Incorrect Blood pressure 148/94 mm Hg Complaint of headache
Graves disease is characterized by a hypermetabolic state, and the client benefits most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high in protein. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment.
A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which of the following interventions does the nurse include in the plan? Placing extra blankets on the client Keeping the room warm Providing a high-calorie, high-protein diet Correct Encouraging frequent ambulation and activities Incorrect
Some hematuria is normal for several days after transurethral resection of the prostate. If bright-red bleeding occurs, the physician needs to be notified, particularly if the client exhibits a change in vital signs. These findings are a potential sign of excessive blood loss and the need for emergency surgical intervention. Continuing to monitor the client delays necessary interventions. The nurse would not increase the rate of flow of an IV without a physician's order. Placing pressure on the bladder to aid expulsion of any additional clots is an inappropriate and unsafe action that could worsen the bleeding.
A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? Contacting the physician Correct Continuing to monitor the client Increasing the flow rate of the intravenous (IV) solution Placing pressure on the bladder to aid expulsion of any additional clots Incorrect
Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.
A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which of the following assessment findings indicates to the nurse that the client may be experiencing hypotonic contractions? Fetal hypoxia Incorrect Discomfort with each contraction Increased frequency and longer duration of contractions Contractions that can be indented easily with fingertip pressure at their peak Correct
Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia.
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. Paresthesias Muscle weakness Correct Increased urine output Correct Chvostek sign Hyperactive deep tendon reflexes
Rationale: In the child with intussusception, bloody mucus stools, commonly described as "currant jelly" stools, and diarrhea may occur. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees to the chest. This pain progresses to a more severe constant pain. Vomiting may be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are not manifestations of this disorder.
A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which of the following occurrences does the nurse expect the mother to report? Scleral jaundice Projectile vomiting Hard, pale stools Bloody mucus stools and diarrhea Correct
If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which causes the infant to make a high-pitched cry or induces changes in level of consciousness, such as lethargy. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urine output is not expected. The anterior fontanel normally bulges when the infant cries.
A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include? Call the physician if the infant is lethargic. Correct Expect increased urine output with the shunt. Call the physician if the anterior fontanel bulges when the infant cries. Incorrect Position the infant on the side of the shunt for sleep.
Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.
A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which of the following findings would the nurse expect to note? Hypertension Correct Low serum potassium Increased creatinine level Cloudy yellow urine
Insulin should never be independently stopped or decreased, and the client is instructed to take prescribed insulin even if he or she is vomiting or unable to eat. Acute illness may cause a counterregulatory hormone response, resulting in hyperglycemia. During times of illness, the client should monitor the blood glucose level and notify the physician if it exceeds 250 mg/dL. Adequate fluids and carbohydrates are essential during illness. The client should eat 10 to 15 g of carbohydrate every 1 to 2 hours and drink a small quantity of fluid every 15 to 30 minutes to help prevent dehydration and ketoacidosis. The client should notify the physician of a fever over 100° F.
A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to: Refrain from eating or drinking during periods of vomiting Take the prescribed insulin dose even if he is unable to eat Correct Contact the physician if a fever over 102° F occurs Contact the physician when the premeal blood glucose value is greater than 350 mg/dL Incorrect
A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia.
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding? 3.1 mEq/L Correct 4.2 mEq/L 4.5 mEq/L 5.4 mEq/L Incorrec
Limiting sodium and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client's room should be darkened to reduce the acute symptoms of vertigo. The client should limit head movement to prevent worsening of the symptoms of vertigo.
A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to: Limit sodium in the diet Correct Increase fluid intake to at least 3000 mL/day Lie down when vertigo occurs and keep a light on in the room Move the head from the right to the left when vertigo occurs to determine the extent of its effects
Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states: "It's important for me to drink a lot of fluids." "A fad diet or starvation diet can cause an acute attack." "I don't need medication unless I'm having a severe attack." Correct "Physical and emotional stress can cause an attack." Incorrect
Positions that will help the client with COPD breathe more freely include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, sitting up in a chair, and standing and leaning against the wall. These positions allow for the greatest expansion of the lungs and respiratory cage in all directions. Lying on the side is not effective.
A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? "I should sit up in my recliner." "I should lie on my right side in bed." Correct "I should sit on the side of my bed and lean on the overbed table." "I should stand with my back and hips against the wall and my shoulders bent slightly forward."
In an infant or child, the rate of chest compressions is at least 100/min.
A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? 15 Incorrect 30 50 100 Correct
Because the client is experiencing respiratory distress, the client should be manually ventilated with the use of a resuscitation bag until the problem can be determined. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Such alarms must be activated and functional at all times. The low exhaled volume alarm sounds when there is a disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff. A code is called when the client requires resuscitation. An anesthesiologist may be needed to insert an endotracheal tube or to assist with a code. Accumulation of secretions in the respiratory system and the need for suctioning would trigger the high-pressure alarm.
A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first: Call a code Suction the client Incorrect Call the anesthesiologist Manually ventilate the client, using a resuscitation bag Correct
Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety.
A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. Bradypnea Severe chest pain Correct Absence of fetal heart tones Correct Increased blood pressure Incorrect Increased frequency of uterine contractions Incorrect
Rationale: Chest pain that is unrelieved by rest and three doses of nitroglycerin taken 5 minutes apart may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client's wife to call an ambulance to transport her husband. The client's wife must not drive the client, because the client should not exert energy and place an increased workload on the heart and the client's wife would not be able to provide care if an emergency arose during transport to the hospital. Telling the wife that she will have to discuss the situation with the physician, who will call her as soon as he gets to his office, delays necessary interventions. Having her husband rest delays necessary interventions; also, the usual procedure is to have the client take three nitroglycerin tablets before seeking medical attention.
The wife of a client with angina pectoris calls the physician's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client's wife to: Take her husband to the emergency department (ED) immediately Incorrect Have her husband rest and, if no relief is obtained, call back Discuss the situation with the physician, who will call her as soon as he gets into the office Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED Correct
Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The physician is notified, and then the nurse documents the occurrence and the actions taken.
A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately: Documents the event Notifies the healthcare provider Checks the client's bladder for distention Correct Checks to see whether the client has a prescription for an antihypertensive
Signs of left-sided heart failure result from decreased cardiac output and increased pulmonary venous congestion, and the nurse would note signs related to the respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation of the lungs. Right-sided heart failure is associated with increased systemic venous pressure and congestion, and the nurse would note signs such as neck vein distention, dependent edema, abdominal distention, and weight gain.
The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. Dyspnea Correct Dependent edema Incorrect Neck vein distention Incorrect Abdominal distention Crackles on auscultation of the lungs Correct
Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the physician. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction.
Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? Assessing the pin sites at least every 8 hours Incorrect Removing the traction weights to provide skin care Applying lanolin to the skin of the right leg once per shift Checking the skin integrity of the right leg at least every 8 hours Correct
