week 9 part 2

Which client will the nurse be assessing in relation to problems with thermoregulation? 45-year-old client with a T8 fracture secondary to a diving accident. 22-year-old client with damage to the cerebellum secondary to a motorcycle accident. 68-year-old client with end-stage neurosyphilis. 66-year-old client with damage to the hypothalamus secondary to a cerebral vascular accident.

66-year-old client with damage to the hypothalamus secondary to a cerebral vascular accident.

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Septicemia Disseminated intravascular coagulation (DIC) Stevens-Johnson syndrome from the administration of antibiotics

Disseminated intravascular coagulation (DIC)

A nurse is caring for a client receiving heparin therapy. Five days after the start of therapy the nurse notices a sudden decrease in the platelet count. Which complication of heparin therapy can cause platelets to decrease? Heparin-induced thrombocytopenia Thrombotic microangiopathies Disseminated intravascular coagulation Anaphylaxis

Heparin-induced thrombocytopenia

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? Thrombin time, calcium levels, and potassium levels Platelet count, prothrombin time, and partial thromboplastin time Platelet count, blood glucose levels, and white blood cell (WBC) count Fibrinogen level, WBC, and platelet count

Platelet count, prothrombin time, and partial thromboplastin time

Atrial fibrillation is common in patients with atrial septal defects (ASDs) and further increases the risk of which of the following? Splenomegaly Stroke Heart failure Cardiomegaly

Stroke

To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant therapy, what should the nurse do? Use the radial artery to obtain blood gas samples. Encourage physical activity. Maintain arterial pressure for 10 seconds. Administer IM injections.

Use the radial artery to obtain blood gas samples.

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? a client 4 days postoperative after mitral valve replacement a client with hypertrophic cardiomyopathy a client with a history of repaired ventricular septal defect a client 1 day post coronary stent placement

a client 4 days postoperative after mitral valve replacement

Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? edema hemorrhagic skin rash cyanosis dyspnea on exertion

hemorrhagic skin rash

A family member expresses that a client who is aphasic after a cerebral vascular accident (CVA) has not been incontinent at home and questions why a urinary catheter has been inserted without consent. The nurse would recognize this treatment best aligns with which standard of care? inability to obtain consent for treatment because the client was aphasic treatment for the patient's benefit treatment without consent of the patient, which is an invasion of rights treatment that does not need special consent

treatment that does not need special consent

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? "DIC is a complication of an autoimmune disease that attacks the body's own cells." "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." "DIC is caused when hemolytic processes destroy erythrocytes." "DIC occurs when the immune system attacks platelets and causes massive bleeding."

"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. Carotid endarterectomy Balloon angioplasty of the carotid artery followed by stent placement Percutaneous transluminal coronary artery angioplasty Administration of tissue plasminogen activator Removal of the carotid artery

Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident? Occupational therapist Speech pathologist/therapist Physical therapist Physician assistant

Speech pathologist/therapist

When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which technique? ultra-high-frequency sound waves cutdown procedure to place a catheter general anesthesia catheter placed in the right femoral vein

catheter placed in the right femoral vein

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: preserving full range of motion in all affected joints. providing emotional support to the client and family. planning for the client's rehabilitation and discharge. maintaining the client's fluid, electrolyte, and acid-base balance.

maintaining the client's fluid, electrolyte, and acid-base balance.

When assessing a neonate who was born at 30 weeks gestation, a nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects tetralogy of Fallot. atrial septal defect. patent ductus arteriosus. ventricular septal defect.

patent ductus arteriosus.