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The nurse is teaching a client about starting glatiramer acetate. Which statement by the client indicates a need for further teaching?
"I need to take this drug before breakfast at least once a week while I have weakness."
The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data?
"I usually drink two vodkas to help me get to sleep each night."
For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.)
* Cyanosis of oral mucous membrane *Tracheal deviation *Sensation of air hunger
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply.
*.A hyperinflated chest noted on the chest x-ray *.Decreased oxygen saturation with mild exercise
for which signs and symptoms will the nurse assess in a client who has acute respitory acidosis with a paco2 of 88 mmHg? SATA
*Acute confusion *Hypotension *Lethargy
The nurse cares for a client with traumatic brain injury. The nurse notes the client's intracranial pressure (ICP) is elevating. Which actions does the nurse perform to decrease the ICP? Select all that apply
*Administer mannitol as prescribed. *Position the head in a midline, neutral position *Maintain normal temperature and blood pressure ranges according to client baseline.
Which is a common cause of acute respiratory acidosis? (Select all that apply.
*Anxiety *Pneumonia *Opiate overdose *Pulmonary edema *. Foreign body aspiration
Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (SATA)
*Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. *Children are naturally active, energetic & spontaneous.
Which factors or conditions will the nurse identify as increasing the risks for clients to develop aspiration pneumonia SATA
*Decreased level of consciousness *Continuous Ng tube suctioning *Bronchoscopy procedure *Stroke
Which is a sign of major depressive disorder? SATA
*Feeling irritable *Significant weight change or change in appetite *Depressed mood or loss of pleasure in activities for at least 2 weeks
The nurse is caring for a client admitted with acute exacerbation of COPD. During assessment the nurse finds the client is experiencing dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood?
*Hypercapnia from retained PaCo2 *Poor gas exchanged from decreased alveolar surface area *Increased AP CHEST diameter from the air trapping. *Respiratory acidosis with a low PH
What symptom would a nurse expect to see in a client experiencing dyspnea? SAT
*Nasal flaring *Respiratory grunting *Diaphoresis
The nurse cares for a client who has been prescribed quetiapine last year for bipolar disorder. for which adverse drug effect will the nurse observe? SATA
*Parkinsonism *Urinary retention *Restlessness
Which patient has the greatest risk for aspiration pneumonia? SATA
*Patient with seizure *patient with head injury *patient receiving NG tube feeding
What is codependence in the context of substance abuse disorder?
*Paying addict bills *Bailing addict out of jail *Helping call in sick to work for addict
A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse." I am such a burden to my family. These statements support which nursing diagnoses? (SATA
*Powerlessness *Chronic low self-esteem
A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family?
*Provide structure *Limit credit card access *Monitor the patients sleep patterns
The nurse working in a community outreach program for foster children plans care knowing which health conditions are common in this population? Select all that apply.
*Sleep problems *. Bipolar disorder *Aggressive behavior *Aggressive behavior
. A client has received atropine sulfate preoperatively. The nurse monitors the client for which effect of the medication in the immediate postoperative period?
*Urinary retention *Dry mouth
An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:
*delirium
The client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many packyears? Fill in the blank and record your an
7.5__ pack-years
A 4-year old child needing to use a metered-dose inhaler to treat asthma cannot coordinate her breathing to use it effectively. The appropriate intervention by a nurse is to use which piece of respiratory equipment?
: Spacer-The medication in a metered- dose inhaler is sprayed into the SPACER. The child can then inhale the medication without having to coordinate the spraying and breathing
The nurse has just received reports for a group of clients. Which client is the nurse first prioty?
A 30-year-old with acute asthma with O2 sat of 89
The nurse is caring for a school-aged child with Duchenne muscular dystrophy in the elementary school. Which of the following would be an appropriate nursing diagnosis?
Activity intolerance
A 6-year-old child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. What sign or symptom does the child have that indicates a revision is necessary?
Alteration in level of consciousness
The nurse administered a prescribed dose of natalizumab for a client who is diagnosed with multiple sclerosis. For what adverse drug event will the nurse assess as the priority for this client within the first hour after administration?
Anaphylactic or allergic reaction
A client returns to the neurosurgical floor after undergoing a traditional anterior cervical discectomy and fusion, what is the nurse first action?
Assess airway and breathing
The client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has rightsided weakness. What does the nurse do first?
Assesses airway, breathing, and circulation
PEFR (peak expiratory flow rate).
Asthma establishes a baseline, to assess the severity of asthma
The nurse is caring for a client with respiratory acidosis with a nursing diagnosis of Injury, Risk for. What factor increases the client's risk for injury?
Blurred vision
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?
Check for an air leak, because the bubbling should be intermittent.
The RN has received report about all of these clients. Which client needs the most immediate assessment?
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
For which client does the nurse remain alert for the possibility of respiratory acidosis?
Client with multiple rib fractures
The nurse cares for a client with obsessive compulsive disorder. Which statement can be applied to this mental health disorder?
Compulsive behaviors neutralize obsessive thoughts
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status?
Decreased fluid intake
A patient admitted to an alcoholism rehabilitation program tells the nurse,"I'm actually just a social drinker.I usually have a drink at lunch,two in the afternoon,wine with dinner,and a few drinks during the evening." The patient is using which defense mechanism?
Denial
The nurse is caring for an older adult client who has been under the care of a psychiatrist for 10 years. What is the most commonly occurring mental health disorder in the older adult population?
Depression
The nurse is teaching family members of a child newly diagnosed with muscular dystrophy about early signs. The nurse knows that teaching was successful when a parent states that which of the following signs may indicate the condition early?
Difficulty climbing stairs.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
Diminished breath sounds
. A client with severe muscle spasticity has been prescribed Tizanidine ( Zanaflex, Sidalud) the nurse instructs the client about which severe adverse effect of the medication?
Drowsiness
The nurse cares for clients in the psychiatric unit. The nurse is MOST concerned if a client receiving phenelzine sulfate eats which menu item?
Grilled cheddar cheese on wheat bread
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
How to draw up and administer injections of the medication
Which statement made by a client prescribed a reliever drug inhaler for asthma indicates to the nurse correct understanding of the therapy?
I will keep this inhaler with me all times
The emergency department nurse is caring for an adult client who is a victim of family violence which Priority instruction should be included in the discharge instructions?
Information regarding leaving the violent situation
The emergency department nurse is caring for an adult client who is a victim of family violence which Priority instruction should be included in the discharge instructions?
Information regarding leaving the violent situation, information regarding shelters
What is a crisis state?
Internal, everyone's definition of a crisis is different.
The patient with Parkinson disease is being discharged home with his wife. To promote compliance to the management plan, which discharge action is most effective?
Involving the patient and his wife in developing a plan of care
Which clinical finding is associated with duchenne muscular dystrophy?
Loss of independent ambulation by 9 to 12 years of age
. The client is admitted with a cerebrovascular incident. Which tool does the nurse use to facilitate a focused neurologic assessment of the client?
National Institutes of Health Stroke Scale (NIHSS
A client with the diagnosis of pneumonia experiences dyspnea when engaging in activities. Which action should the nurse implement to help address client safety
Observe vital signs and oxygen saturation periodically during activity.
Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia?
Overproduction of hydrogen ions
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk?
Place patients with altered consciousness in side-lying positions.
The nurse assessing a child with initial symptoms of tetanus, which assessment finding indicates a severe or progressive involvement of the injection?
Progressive stiffness of neck and jaw
A client is experiencing Mania. Which nursing intervention is appropriate for this mood disorder?
Provide for frequent rest periods
A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?
Rationalization
Which action is most important for the nurse to take when a client with chronic obstructive pulmonary disease who is taking a cholinergic antagonist now reports nausea, blurred vision, headache, and inability to sleep
Reporting the symptoms to the primary health care provider immediately
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the highpressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?
Right pneumothorax
A graduate nurse worked at a hospital for several months resigned and then took a position at another hospital. In the new position, the nurse often volunteers to pass meds, after med errors, investigation reveals the nurse using patient narcotics. What early indication of the nurse' drug use was evident?
Seeking to be assigned as a medication nurse
A patient admitted for a heroin overdose received naloxone (Narcan). The patient's breathing pattern improved. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct
Symptoms of opiate withdrawal are present
The nurse cares for a client following traumatic brain injury. The client's Glasgow Coma Scale score is 11. Which signs and symptoms does the nurse report immediately to the HCP
The client responds to pain only, has incomprehensible speech, and withdraws only to pain.
Which consideration would be important in planning nursing care for an infant following surgical insertion of a ventriculoperitoneal shunt?
The infant is placed in a flat, supine position immediately after surgery
The mother of a child with Duchenne muscular dystrophy asks the nurse who in the family should have genetic screening. Who should the nurse say must be tested? Select all that apply.
The mother and father.
You are caring for a 3-year-old who has returned to the pediatric intensive care unit (PICU) after insertion of a ventriculoperitoneal (VP) shunt to correct hydrocephalus. Which assessment finding is most important to communicate to the surgeon?
The right pupil is 1 mm larger than the left pupil.
An infant with a congenital heart defect is receiving palivizumab (Synagis). What is the purpose of this medication?
This should prevent respiratory syncytial virus (RSV) infection.
What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza?
Wearing a disposable particulate mask N95 respirator with face shield or goggles.
The nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. Which clinical finding warrants immediate intervention?
abdominal distension
The nurse would expect an older adult to have higher blood alcohol levels because older adults have:
decreased liver metabolism and kidney functioning.
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should
monitor intracranial pressure (ICP)
A 4-year-old girl is brought to the emergency room. She has a "froglike" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should:
notify the physician immediately and be prepared to assist with a tracheostomy or intubation.
The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of:
pneumothorax.
A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates:
soothing inflamed mucous membrane.
