Final Exam H&I II

Which condition would the nurse suspect in an emergency department client with c8 tetraplegia, blood pressure 80/40mm Hg, pulse of 48 beats per minute, and respiratory rate of 18 breaths per minute?

neurogenic shock

A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time?

parenterally replace the clients fluids and electrolytes

The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohns disease. Which finding is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?

Involvement starting distally with rectal bleeding that spreads continuously up the colon

Which medication is prescribed to improve the physical manifestations of parkinson disease?

carbidopa-levodopa

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours?

to prevent development of pressure injuries

Which adverse effect will the nurse instruct the client to anticipate when prescribed albuterol to relieve severe asthma?

tremors palpitations

Which recommendation is essential for the nurse to include when providing counseling to a client with systemic lupus erythematosus?

wear a large-brimmed hat take your temperature daily balance periods of rest and activity

Which complication would the nurse be concerned about if there is removal of the parathyroid glands during a thyroidectomy?

tetany

Which clincal finding would the nurse observe in a client diagnosed with bipolar disorder, manic episode?

Grandiosity talkativeness distractibility

Which clinical manifestation would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal cord at c7-c8?

flaccid paralysis lack of reflexes below the injury

Which medication would be administered to a client who reports sweating, tachycardia, and tremors with a laboratory report that reveals serum cortisol less than normal and a blood glucose level of 60?

glucagon

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia?

having suction available during meals

Which action would the nurse take in caring for a client after surgical placement of an external fixator on the clients leg?

perform a neurovascular assessment of the lower extremities

Which nursing action would be a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia?

place in a sitting position

Which clinical manifestation exhibited by a client taking levothyroxine for hypothyroidism for 3 months would cause a nurse to suspect that a decrease in dosage is needed?

tremors heat intolerance

Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma?

use of peak flow meter

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?

Oxygen saturation 89%

The nurse is providing immediate postoperative care for a client who had a thyroidectomy. The nurse would monitor a client for which clinical manifestation?

Signs of respiratory obstruction

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg, PaCO2 55 mm Hg, and HCO3 23 mEq/L. How would the nurse interpret these findings?

Uncompensated respiratory acidosis

A client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force?

Use lift sheets to pull up, transfer, and position the client

Which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture?

Venous thromboembolism prevention

Which assessment findings would indicate a possible asthma exacerbation?

Wheezing tachycardia

Which manifestation may indicate that the client with type 1 diabetes has insulin-induced hypoglycemia?

excessive hunger weakness diaphoresis

Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons?

stage IV

Which nursing intervention would be contraindicated for a client who has a fracture and has compartment syndrome?

applying cold compress elevating the extremity above heart level

Which signs and symptoms would the nurse find in a client who is in the depressive phase of bipolar I disorder?

apathy loss of appetite sleep disturbance

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?

Diminished breath sounds on auscultation

Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32 PCO2 53 mm Hg, and HCO3 25 mEq/L. Which action would the nurse take?

Encourage the client to cough and then take deep breaths between coughs

Which statement indicates a client understands transmission of the human immunodeficiency virus?

I can contract HIV by participating in oral sex HIV is contracted by using contaminated needles babies can contract HIV because of contact with maternal blood during birth

Which statement by the client who has major depressive disorder would alert the nurse to the possibility of a suicide attempt?

I feel much better; today is a lovely day

What are early symptoms of HIV?

malaise swollen lymph glands

Which parent is expressing anticipatory grief?

my son was diagnosed with terminal cancer 2 months ago and they can't stop my son from dying

Which question is the most therapeutic to ask the parents of a 3 year-old child who has just died?

can i be of any help with traditional practices that important to you?

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner?

1 to 2 L via nasal cannula to keep SaO2 above 90%

Which complication would the nurse expect if a client with addisons disease receiving cortisone therapy abruptly stops the medication?

shock circulatory collapse

A mood stabilizing medication is prescribed for a client's bipolar disorder. Which client comment would indicate to the nurse that further teaching is needed?

I know I wont have to stay on this medication for too long

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent by placing pillows around the injured area?

abduction

Which outcome would be expected after a client received treatment for cushing disease?

decreased blood glucose levels

Which nursing intervention is appropriate to include in the plan of care for a client with DKA?

intravenous administration of regular insulin

Which finding would the nurse expect when completing an admission physical for a client with Parkinson disease?

muscle rigidity blank facial expression

Which reason would the nurse provide for the gradual reduction in dosage to a client who recently started receiving oral corticosteroids for a severe allergic reaction and is instructed that the dosage will be reduced gradually until all medication is stopped at the end of 2 weeks?

Slow reduction of the medication will prevent a physiological crisis because the adrenal glands are suppressed

the nurse is completing an assessment on an older adult who fell and fractured the left hip. Which clinical indicator would the nurse identify as typical with a fractured left hip?

left leg is noticeably shorter than the right

The nurse is caring for a client with addison disease. Which dietary instruction would the nurse provide?

add extra salt to food

A client with COPD is breathing rapidly and using accessory muscles of respiration. the nurse asculates the lungs and hears crackles and wheezes. Which action would the nurse take?

raise the head of the bed to a high fowlers position and administer 2 L/min oxygen per nasal cannula.

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestations?

respiratory paralysis and cessation of diaphragmatic contractions

Which outcome is the main focus of treatment for a client with Addison disease?

restoration of electrolyte balance

Which disorder would the nurse suspect in a client who reports hair loss, joint pain and a facial rash and has a medical record showing the presence of a butterfly rash?

systemic lupus erythematosus

Which assessment finding after an open reduction and internal fixation of a fractured hip would cause the nurse to suspect and monitor for signs and symptoms of a fat embolism?

tachycardia and petechiae over the chest

The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care?

administer IV levothyroxine Give IV normal saline

Which action will the nurse take when a client's chest x-ray show atelectasis?

encourage incentive spirometer use

The nurse would monitor a client for which manifestation indicating a thyroid storm?

increased heart rate increased temperature

Which unique response is associated with diabetic ketoacidosis that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome?

kussmaul respirations

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?

metabolic acidosis

which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm?

escalating pain in the fingers

Which manifestations of surgically induced hypothydroidism might the client exhibit after a thyroidectomy?

fatigue dry skin

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries?

incontinence; inability to move independently

Which clinical manifestation would the nurse observe in an older client diagnosed with major depressive disorder?

decreased appetite neglect of personal hygiene "i don't know" answers to questions "I can't remember" answers to questions

A client reports unexplained weight gain and back pain from a compression fracture of the vertebrae. On assessment, the nurse notes truncal obesity with excessively thin extremities, a moon shaped face, a buffalo hump, thin hair, and adult acne. Which disease process would the nurse anticipate incorporating into the plan of care?

cushing disease