Adult Med Surg EAQ
On reviewing the x-ray report of a client with rheumatoid arthritis, the nurse learns that three small joints are involved. According to the diagnostic criteria for rheumatoid arthritis, which score will the nurse assign the client for joint involvement?
2
A client with cholelithiasis has a laser laparoscopic cholecystectomy. What is most appropriate for the nurse to do postoperatively?
Ambulate the client when the client is alert and oriented
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged?
Anterior cerebral
A client is placed into a whirlpool tub for range-of-motion exercises. The nurse should explain that rehabilitating exercises carried out underwater make use of what property of the water?
Buoyant force Rehabilitating exercises carried out underwater minimize strain on the body. The buoyant force of the water enables the limbs to move more easily.
A nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching by the nurse is effective? .
Jelly sandwich Lean roast beef Scrambled eggs
As part of the teaching plan for a client with scleroderma, the nurse addresses the need for special skin care. Which instructions will the nurse provide to the client?
Keep the hands warm. Raynaud phenomenon is a component of scleroderma.
Which visual system assessment technique provides a magnified view of the retina and optic nerve head?
Ophthalmoscopy
A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing?
Right ventricular failure
A nurse is caring for a client with chronic occlusive arterial disease. Which precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?
Trauma from mechanical, chemical, or thermal sources
A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity, 1.015; urine output, 50 mL/hr; hematocrit, 42 (0.42 volume fraction); albumin, 3.6 g/dL (36 g/L); and pulmonary arterial wedge pressure, 10 mm Hg. Which conclusion will the nurse draw based upon the laboratory results?
Fluid therapy is successful. All the values provided are within expected limits for an adult, indicating successful fluid therapy. Urine output is greater than 30 ml/hr. The albumin is in the expected range for an adult. There is no evidence of kidney failure; all the values provided are within expected limits for an adult. The hematocrit is within the expected limits for an adult; with hemoconcentration the hematocrit is elevated.
The nurse assesses for which major complication in a client who has had a gastroscopy?
Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis.
Which part of the brain contains the client's "central switchboard" of the central nervous system?
Diencephalon The thalamus is considered to be the major relay station or "central switchboard" for the central nervous system (CNS). The thalamus, along with the hypothalamus and epithalamus, are located in the diencephalon of the brain.
The registered nurse (RN) is teaching an older adult with a hearing problem due to cerumen impaction. Which instructions should the nurse share with the client?
Encourage the client to wash the external ears daily using a soapy, wet washcloth over the index finger. Make certain that the irrigating fluid is about 98.6° F (37° C) to reduce the chance for stimulating the vestibular sense.