Physiological Adaptation

An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant?

"All of a sudden it does not hurt at all."

A 15-month-old client is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the caregivers indicates effective discharge teaching?

"We'll go to the physician if our child pulls on the ears or won't lie down."

A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

Acute pain

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug?

Client experiences a decrease in dystonia.

A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions.When planning this client's care, the nurse should include which intervention?

Teaching the client how to deep-breathe and cough

Which information should the nurse include in the teaching plan of a female client with bilateral adrenalectomy?

The client will need steroid replacement for the rest of her life.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation.

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

an irregular apical pulse

While performing cardiopulmonary resuscitation (CPR) on a 5-year-old child, the nurse palpates for a pulse. Which site is best for checking the pulse during CPR in a 5-year-old child?

carotid artery

A nurse is documenting a health assessment when the client states having problems with balance, as well as fine and gross motor function. When collaborating with the health team, which area on the illustration of the brain would the nurse highlight as an area of concern?

cerebellum

The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding?

circulatory collapse

Which action is most effective when a nurse is assessing the client suspected of developing diabetes insipidus?

measuring urine output hourly

When caring for a toddler with epiglottitis, the nurse should first:

place a tracheotomy tray at the bedside.

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for which problem?

puerperal infection

A nurse is caring for a 14-day-old neonate admitted for pyloric stenosis. The healthcare provider ordered an ultrasound to confirm the diagnosis. When instructing the parents, which area of the stomach would the nurse stress as the area of concern?

pyloric sphincter

A client newly diagnosed with primary Addison's disease asks the nurse about the cause of the disease. What should the nurse tell the client? "The disease is caused by:

idiopathic atrophy of the adrenal gland."

The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?

retina

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly?

The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated.

When completing a nursing assessment on a client admitted with a neck injury, which findings would indicate an incomplete spinal cord injury (SCI)?

evidence of voluntary motor and sensory function below the level of injury

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure?

insertion of a chest tube into the neonate

A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is mostindicative of infection?

red, warm, swollen, tender incision with foul drainage

A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation?

right lateral The client should be positioned on the right side because gravity contributes to increased blood flow to the right lung, thereby allowing for better gas exchange. Positioning the client prone, supine, or in the left lateral position doesn't allow for better gas exchange in this client.

A toddler is brought to the emergency department after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which intervention first?

securing the airway

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement?

"Antibodies are not usually formed until after exposure to an antigen."

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client?

"Do you wear glasses?"

A nurse is caring for a client diagnosed with herpes zoster. Place in chronological order the pathophysiological changes that the nurse would anticipate in assessing the progression of the disease. All options must be used.

Varicella-zoster virus is reactivated. Residual antibodies from the initial infection mobilize but are ineffective. The virus multiplies in the ganglia, causing deep pain, itching, and paresthesia or hyperesthesia. Vesicles appear, filled with either clear fluid or pus. Vesicles crust and scab. Client experiences post-herpetic neuralgia.

The nurse is establishing goals for the client with hepatitis A? Which goal is appropriate?

Verbalize the importance of reporting bleeding gums or bloody stools.

A client who had a splenectomy yesterday has a nasogastric (NG) tube. What should the nurse assess to determine the effectiveness of the NG tube?

absence of abdominal distention

Which clinical manifestation would be most indicative of complete arterial obstruction in the lower extremities?

coldness

At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next?

Evaluate the tube for patency.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include?

"Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."

A nurse is helping a pregnant caregiver devise a plan to help her 2-year-old child adjust to the birth of her second child. Which statement by the client indicates more instruction is needed?

"I'll tell my child that the new baby can be a playmate when the baby arrives."

The nurse teaches the family of school-age child with acute renal failure about continuous ambulatory peritoneal dialysis. Which statement indicates that the family needs more teaching about peritoneal dialysis?

"Our child should remain quite during dialysate dwell stage."

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next?

Assess for signs of increased intracranial pressure.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T tube. What should the nurse do to determine the effectiveness of the T tube?

Assess the color and amount of drainage every shift. A t-tube is inserted in the common bile duct to maintain patency when there is a likelihood of edema. The tube remains in place until edema from the duct exploration subsides. The bile color should be gold to dark green, and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?

Assess the vital signs and oxygen saturation levels.

A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take?

Increase fluids.

A client has massive bleeding from esophageal varices. In what order from first to last should the interprofessional team provide care for this client? All options must be used.

Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety.

When assessing a client's incision one day after surgery, the nurse sees redness and warmth around the incision site. What action by the nurse is best?

Note the wound edges in the client's chart.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next?

Notify the health care provider (HCP).

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priorityaction?

Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes.

A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take?

Obtain the child's blood pressure.

A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises?

The parent verbalizes the need to stay away from persons with known infections.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is greater than 35 mL/h.

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?

evaluation

A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action?

deep, rapid respirations with long expirations

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse?

hypothermia

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?

ineffective breathing pattern

A nurse is caring for a 12-month-old infant with dehydration with resulting metabolic acidosis. The infant exhibits lethargy and poor skin turgor. Which action by the nurse takes priority?

obtaining a patent intravenous site

An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure?

oxygenation prior to the procedure

Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer?

reassessing the client after administering pain medication

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?

shortening of the affected extremity with external rotation

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?

tachycardia

The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. When conducting a focused assessment, what should the nurse should assess the client for?

tachycardia

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

temperature instability

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

urine output of 20 ml/hour