DUNNO

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to circumferential eschar Related to fat emboli Related to infection Related to femoral artery occlusion

"It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment.

The parent of a child diagnosed with chickenpox asks when the child can go to play group again. What is the best response by the nurse? "When the fever disappears." "When the vesicles and pustules have crusted." "When the rash is changing into vesicles, and pustules appear." "Two days after the rash appears."

"When the vesicles and pustules have crusted."

A male client presents with symptoms of bronchospasm that occurred during a birthday party for his grandson. What medication would the nurse expect the health care provider to give the client? Omalizumab Asthmacort Albuterol Theophylline

Albuterol

A client returned to the recovery room after a dilatation and curettage has the postoperative medication prescriptions shown in the medical record. What should the nurse do next? Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain. Administer the acetaminophen first, and if it does not relieve the pain in 2 hours, administer the meperidine. Administer the ibuprofen first, and if it does not relieve the pain, administer the meperidine. Administer the meperidine first because the client had surgery today.

Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain.

Which characteristic differentiates conversion disorder from malingering disorder? Conversion disorder is normally permanent, while malingering disorder is transient in response to stress. Conversion disorder has no pathophysiological cause, while malingering disorder has a neurological or endocrine basis. Conversion disorder produces reward, while malingering disorder normally results in punishment or difficulty. Conversion disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms.

Conversion disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? PCO2 HCO3 pH PaO2

PaO2

The nurse is caring for a client that has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. What is the nurse's first response? Take a blood pressure and pulse. Call the physician. Return the client to his back. Place saline-soaked sterile dressings on the wound. SUBMIT ANSWER Exit quiz

Place saline-soaked sterile dressings on the wound.

vdrl

Question 9 of 10 A client is at 24 weeks' gestation. The nurse is reviewing the report of laboratory tests. The nurse should report which of these results to the health care provider? blood type rubella titer VDRL blood glucose

A patient comes to the emergency department with complaints of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing? Normal sinus rhythm Sinus bradycardia Ventricular tachycardia Sinus tachycardia

Sinus tachycardia

A parent brings a teenaged child, who is complaining of having a severe headache, to the clinic. The teenager is groaning with pain. During assessment, the client asks the nurse for a note to excuse the absence from school. After further assessment, the nurse suspects that the client is malingering. What leads the nurse to come to this conclusion? Choose the best answer. The client was not found to have any underlying cause of headache on assessment. The client's symptoms may have been a result of stress caused by studying all night for an exam. The client reported having signs related to raised intracranial pressure, such as nausea. The client's symptoms disappeared after getting the medical note.

The client's symptoms disappeared after getting the medical note.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to circumferential eschar Related to fat emboli Related to infection Related to femoral artery occlusion

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request a prescription for: an x-ray with orogastric catheter placement. a serum blood glucose level. a blood gas analysis. a lactation consultation.

an x-ray with orogastric catheter placement.

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? bronchodilator antibiotic cardio tonic antihistamine

antihistamine Explanation: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period.

The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? applying a cooling blanket raising the room temperature applying a blanket providing warm fluids SUBMIT ANSWER

applying a blanket

The 47-year-old client is experiencing chest pain and has taken three sublingual nitrogylcerin tablets, but the pain remains. What should the client do next? Call 911. Notify his healthcare provider. Have someone take him to the emergency department. Take another nitroglycerin and call 911.

call 911

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: allow the client to remain in the chair but move all objects out of his way. carefully move the client to a flat surface and turn him on his side. place an oral airway in the client's mouth to maintain an open airway. hold the client's arm still to keep him from hitting anything.

carefully move the client to a flat surface and turn him on his side.

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first: prepare protamine sulfate for intravenous administration. don gloves and apply direct pressure over the site. notify the health care provider (HCP). observe and document the bleeding.

don gloves and apply direct pressure over the site.

Which is a classic sign of hypovolemic shock? High blood pressure Bradypnea Dilute urine Pallor SUBMIT ANSWER

pallor