N-clex prep

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see?

A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS) results. If the severity of alkalosis increases, convulsions and coma may occur.

young child who arrived from the emergency department after treatment for acetaminophen overdose

Acetaminophen overdose is harmful to the liver. Thyroid function is not affected by acetaminophen. A urine medication screen and kidney function tests may be evaluated; however, these laboratory values are not the priority concern.

Post op care for mastoidectomy?

After mastoidectomy, the nurse should assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should monitor for signs of pain, dizziness, or nausea. The client should be instructed to lie on the unaffected side to prevent disruption of the surgical site. The head of the bed should be elevated at least 30 degrees. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document

Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care?

Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims' is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client?

Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate.

The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time?

Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the residual limb is placed flat on the bed to reduce hip contracture. Edema is also controlled by residual limb wrapping techniques.

Which information provided by the nurse accurately describes electroconvulsive therapy?

Electroconvulsive therapy (ECT) as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition

The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home?

Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement?

In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations. Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency?

Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies.

The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply.

Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm)

A client has been hospitalized for removal of a cervical radiation implant used to treat cancer. The implant is removed, and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instruction?

Some foul-smelling vaginal discharge is expected and is not a sign of an infection in this client. As well, this type of discharge will occur for some time after removal of a cervical radiation implant.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn?

The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?

The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%.

The nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further teaching about the diuretic phase of acute kidney injury

The diuretic phase of acute kidney injury is characterized by an increase in urine output of more than 1000 mL in a 24-hour period. This increase in urine output indicates the return of some renal function; however, blood urea nitrogen and creatinine levels continue to rise during the first few days of diuresis. The diuretic phase develops about 14 days after the initial insult and lasts about 10 days.