Physiological Adaptation

During dinner a client suddenly begins to cough heavily, have deep inspirations, and grasp the throat. What is the nurse's immediate action?

Ask the client if they can speak.

A nurse checks the fundus of a postpartum client and notes that the fundus is situated in the client's left abdomen. What is the priority action by the nurse?

Ask the client to empty her bladder.

A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan?

Place the baby in an upright position when giving a bottle.

A nurse reinforces education for a pregnant woman who is scheduled for a cesarean birth regarding prevention of complications that can develop after the birth. Which statement by the client indicates a need for further education?

"At least one complication I don't have to worry about is blood clots."

After the nurse has discussed the causes of diabetes insipidus with the parents of a neonate, which statement made by a parent indicates the need for further education?

"Drinking alcohol during my pregnancy caused this condition."

A nurse is caring for a 3-year-old child diagnosed with viral meningitis. Which signs and symptoms does the nurse anticipate finding when gathering data? Select all that apply.

-fever -nuchal rigidity -irritability -photophobia

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur?

1 week to 1 year, peaking at 2 to 4 months

Which client statement given when obtaining data is consistent with the diagnosis of varicose veins?

"My legs feel tired and have a dull ache, especially when I walk or stand for long periods."

Preoperatively, the health care practitioner orders antiembolism stockings for a client scheduled for open heart surgery. The client asks the nurse what is the purpose of antiembolism stockings. How does the nurse appropriately responds?

"The stockings will reduce or prevent edema in your legs and feet."

A client who is 9 days postpartum and breastfeeding her baby reports pain, redness, swelling of her left breast and is diagnosed with mastitis. The nurse is reviewing information with the client about how to care for her infected breast. Which information should the nurse most likely reinforce?

"Use a warm, moist compress over the painful area."

The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to observe in this child? Select all that apply:

-bulging fontanels -high-pitched cry -Irritability

A client with tachycardia is admitted to the telemetry unit for monitoring. Which factors might the nurse expect to see when reviewing this client's chart? Select all that apply.

-fear or pain -caffeine or nicotine use

The nurse is obtaining vital signs for several clients. Which client's vital signs would be the priority to report to the health care provider?

postoperative client with a pulse of 110 beats/minute on awakening in the morning

A female client who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of the client's hyperglycemia?

Acromegaly

The nurse is caring for a client who has been diagnosed with delirium. Which of the following is characteristic of delirium?

Acute onset and lasts hours to a number of days

A client arrives in the emergency department with hives and redness after a bee sting stating, "I can't breathe! I am going to die." What action is anticipated by the nurse?

Administer an injection of epinephrine stat.

A 6-year-old child has been hospitalized with rheumatic fever for 4 weeks. Symptoms have gradually subsided, and the child is ready for discharge. The nurse is reinforcing education with the parents. What is a priority nursing action for the child's future well-being?

Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.

When preparing to feed an infant with pyloric stenosis, which intervention should the nurse give highest priority?

Burp the infant frequently.

A client presents with diaphoresis, palpitations, jitters, and tachycardia approximately 4 hours after taking the prescribed usual morning insulin. What is the nurse's priority action?

Check blood glucose level, and administer carbohydrates.

A client had a transurethral prostatectomy for benign prostatic hyperplasia (BPH). He is currently being treated with continuous bladder irrigation and is reporting an increase in severity of bladder spasms. What should the nurse do first for this client?

Check for the presence of clots, and make sure the catheter is draining properly.

The telemetry monitor technician notifies the nurse that a client has sinus bradycardia with a heart rate of 42 beats/minute. What should the nurse do first?

Check the client's level of consciousness, obtain vital signs, and assess the client for symptoms.

The NICU nurse is caring for an infant with heart failure. Which nursing intervention is most appropriate?

Cluster nursing activities.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin

A client who's 2 months pregnant reports urinary frequency and says she gets up several times at night to go to the bathroom. She does not have other urinary symptoms. What is the best nursing intervention?

Explain that urinary frequency is expected during the first trimester.

A client has been diagnosed with a tic disorder. Which information can the nurse provide to help the client reduce the frequency of the tics?

Get plenty of rest and reduce stress.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

The nurse cares for a client with a spinal cord injury who exhibits anxiety, flushing of the face, shoulders, and neck with profuse diaphoresis. Which intervention should the nurse perform first?

Inspect the urinary catheter for obstructions.

A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?

Intercostal retractions

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

Ketones in urine

The nurse is caring for a preschool aged child who has been prescribed a preoperative intramuscular (IM) injection at 07:00. To elicit the child's cooperation in administering this medication, the nurse should use which approach?

Let the preschooler choose which leg to use for the injection.

The nurse is assisting with the care of a neonate born to a mother with type 1 diabetes. When gathering data on the neonate, the nurse would suspect that the neonate is experiencing hypoglycemia based on which finding?

Lethargy

A 10-month-old child is found choking and soon becomes unconscious. Which intervention should the nurse attempt first after opening the airway?

Look inside the infant's mouth for a foreign object.

A client who is 34 weeks' pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client is not in labor. Which intervention would be most appropriate at this time?

Monitor the amount of vaginal blood loss.

A nurse is monitoring a client who has just returned from a cardiac catheterization. Which is an appropriate nursing intervention?

Palpate the peripheral pulses.

When checking a client's incision one day after surgery, the nurse expects to see which finding as a sign of a local inflammatory response?

Redness and warmth

During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?

Relieves swelling by reducing blood flow to the injury site

A client who had a stroke is admitted to the hospital. Four hours later, a nurse obtains these vital signs: blood pressure, 170/80 mm Hg; apical pulse, 58 beats/minute with a regular rhythm; respiratory rate, 14 breaths/minute; axillary temperature, 101° F (38.3° C). Which initial nursing action is most appropriate?

Report the vital signs to the registered nurse (RN).

Lochia normally progresses in which of the following patterns?

Rubra, serosa, alba

On a visit to the family physician, a client reports painful swelling on the lateral side of the great toe, at the metatarsophalangeal joint. After determining that the swelling is a bunion, the physician injects an intra-articular corticosteroid. The client asks the nurse what causes bunions. Which answer is correct?

Some bunions are congenital; others are caused by wearing shoes that are too short or narrow.

A client has flushed skin, bulging eyes, and perspiration, and states he or she has been "irritable" and having palpitations. Which interpretation of these findings might the nurse suspect?

hyperthyroidism

A nursing student is reviewing the respiratory system for an upcoming examination. Which term will the student review that describes the amount of air inspired and expired with each breath?

Tidal volume

For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?

Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.

The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?

activity of the brain

A client has been admitted after reporting acute abdominal pain in the mid-epigastric region, back tenderness, nausea, and vomiting. The nurse recognizes these findings to be associated with which condition?

acute pancreatitis

Which intervention would a nurse expect to use to prevent venous stasis after skeletal traction application?

antiembolism stockings or an intermittent compression device

Which condition most commonly results in coronary artery disease (CAD)?

atherosclerosis

A client who is minimally responsive requires suctioning to clear airway secretions. Which assessment finding would indicate suctioning has been effective?

clear breath sounds bilaterally

The client is being evaluated for hypothyroidism. The nurse should stay alert for:

decreased body temperature and cold intolerance.

A child in skeletal traction for a fracture of the right femur reports new and constant left calf pain. Also, the nurse notes that the child's left calf is 1 inch larger than the right and that he has nonpitting edema below the left knee. The nurse knows these signs are most consistent with which condition?

deep vein thrombosis (DVT)

A 10-year-old child has been experiencing insatiable thirst and urinating excessively and the serum glucose is normal. Which condition is the child most likely experiencing?

diabetes insipidus

A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first?

dyspnea

A nurse is caring for a 10-year-old child with rheumatic fever. When obtaining the child's health history from the parent, the nurse should ask if the child recently had which illness?

strep throat

A client is diagnosed with a long bone fracture. What potential complication related to this form of fracture should the nurse carefully monitor?

fat emboli

The red blood cell (RBC) production in a client with chronic renal failure (CRF) has decreased. The nurse should monitor this client for:

fatigue and weakness.

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?

fetal heart rate of 80 beats/minute

A client sustained a femur fracture while skiing. After the client undergoes surgery to stabilize the fracture, what does the nurse determine will assist with healing of this fracture?

formation of new bone tissue

A health care provider tells a client to return 1 week after treatment to have a repeat culture done to verify the cure. This order would be appropriate for a woman with which condition?

gonorrhea

A neonate develops significant respiratory distress about 14 hours after birth. After reviewing the neonate's medical record, the nurse finds that the neonate's mother experienced prolonged rupture of membranes. Based on the nurse's knowledge of this condition, the nurse suspects that which organism most likely contributed to this problem?

group B beta-hemolytic streptococci

The parents of a child with attention deficit hyperactivity disorder (ADHD) say they are concerned because the child is losing weight. Which suggestion can the nurse give to the parents regarding the weight loss?

have high-calorie finger foods available for the child to eat

A client with hyperparathyroidism develops renal calculi. The nurse should expect to see which electrolyte levels?

increased calcium levels

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which term best identifies the discharge?

lochia rubra

An anxious client is brought to the walk in clinic with difficulty breathing following a bee sting. Which of the following is the nurse's priority action?

monitor the client's airway

In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?

nonreactive pupils

The nurse is caring for a client who underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?

on the unaffected side

A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis?

pruritic papules, pustules, and linear burrows of the finger and toe webs

A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about:

recent streptococcal infection.

A client comes to the emergency department with status asthmaticus. Based on the documentation note shown, the nurse suspects that the client has what abnormality?

respiratory alkalosis

The nurse is monitoring a client with a symptom of increased intracranial pressure (ICP) after head trauma. What observation does the nurse recognize as an early sign?

restlessness and confusion

A client arrives in the local clinic and reports a chronic cough and fatigue. The client admits to smoking two packs of cigarettes daily for 10 years and also informs the nurse of a 9 kg weight loss over the last 2 months. Which test, required for a definitive diagnosis of cancer, does the nurse prepare the client for?

surgical biopsy

A 1-year-old child is brought to the emergency department with a mild respiratory infection and a temperature of 101.3° F (38.5° C). Otitis media is diagnosed. Which sign would the nurse also expect to find?

tugging on the ears

The nurse is collecting data on a 6-year old child. The child reports dysuria and urgency. The parent reports that the child has recently had some enuresis. The nurse recognizes these as signs and symptoms of which condition?

urinary tract infection