Extra Alternate-Format Practice
The nurse is assessing an infant with neonatal bronchopulmonary dysplasia (chronic lung disease). Which symptoms would the nurse expect to find? Select all that apply. tachypnea rapid weight gain bradypnea hyperexpansion on chest X-ray wheezing
tachypnea hyperexpansion on chest X-ray wheezing The physical exam of an infant with neonatal chronic lung disease often reveals tachypnea and wheezing. The chest X-ray shows hyperinflation as the disease becomes more severe. Infants often fail to gain weight.
The nurse is assessing a client with a hematoma and compartment syndrome in the same extremity. Which symptoms would the nurse anticipate? Select all that apply. decreased pain on movement edema increased venous pressure increased arterial circulation decreased venous circulation
edema increased venous pressure decreased venous circulation The hemorrhage in compartment syndrome would cause edema, increased venous pressure, and decreased venous and arterial circulation. Compartment syndrome would cause increased pain.
The nurse is caring for a child who has been diagnosed with a brain tumor. Which assessment findings are recognized as early signs of increased intracranial pressure? Select all that apply. headache irritability fixed and dilated pupils decerebrate posturing dizziness
headache irritability dizziness Headache, irritability, and dizziness are early signs; fixed and dilated pupils and decerebrate positioning are late signs.
A child with suspected infective endocarditis arrives at the emergency department. Which assessment findings would the nurse anticipate in this child? Select all that apply. malaise low-grade fever headache murmur weight gain
murmur low-grade fever malaise headache Symptoms may include a low-grade intermittent fever, decrease in hemoglobin level, tachycardia, anorexia, weight loss, malaise, headache, joint and muscle pain, and decreased activity level. Bacteremia leads to these signs of an infection. The murmur is due to damage to the cardiac valves or myocardium.
Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well. pulmonary edema croup pneumonia asthma
asthma Asthma frequently presents with wheezing and coughing. Airway inflammation and edema increase mucous production. Other signs include dyspnea, tachycardia, and tachypnea. Stridor is heard in croup. Rhonchi and rales are heard with pneumonia and pulmonary edema.
The nurse is assessing a newborn for incurvature of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
The nurse would place the infant in a horizontal prone position with one hand, and stroke the side of the newborn's trunk, from shoulder to buttocks with the other hand. If the reflex is present, the newborn's trunk will curve toward the stimulated side. Answer two illustrates the position to test a stepping response. Answer three illustrates positioning to test for a tonic neck reflex. Answer four illustrates the position to test for a Moro reflex.
The nurse is evaluating the external fetal monitoring strip of a client in labor. What condition is the nurse concerned about? cephalopelvic disproportion hydramnios oligohydramnios uteroplacental insufficiency
uteroplacental insufficiency This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins after the peak of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis. Cephalopelvic disproportion may cause early, not late, decelerations early in labor. Oligohydramnios be associated with variable decelerations. Hydramnios may be associated with uterine rupture.
A nurse is providing teaching to an adolescent who has been prescribed phenytoin for seizures. What information should the nurse include in this teaching? Select all that apply. "You can stop taking this medication when your seizures stop." "A rash is normal while taking this medication." "You should wear an ID bracelet indicating you are taking this drug." "You will need to have bloodwork done frequently." "Brush your teeth using a soft toothbrush."
"Brush your teeth using a soft toothbrush." "You will need to have bloodwork done frequently." "You should wear an ID bracelet indicating you are taking this drug." This drug can cause gingival hyperplasia, so proper dental care is important to prevent infection. This drug has a narrow therapeutic index and many drug interactions. A steady serum level is needed to maintain effectiveness without toxicity, so serum levels should be done frequently. An ID bracelet is necessary because of the numerous drug interactions. This drug should not be stopped abruptly as this may precipitate seizures. A measles-like rash may lead to Steven-Johnson syndrome. If this rash occurs, the drug should not be used.
A 7-year-old has just been admitted to the unit for excessive vomiting. Based on the available chart data, what is the nurse's most appropriate action? 10/150730Vital Signs RecordT: 104.9° F (40.5° C)P: 98RR: 30Lab ValuesSerum Potassium: 3.1 mmol/LSerum Sodium: 128 mmol/LNurse's NoteSkin flushed and warm to touch; good turgor; petechiae noted over entire trunk Cover the petechiae with dry sterile dressings. Suspect that the child has been abused. Assess the child's neurological status. Initiate extremity restraints as seizure precautions.
Assess the child's neurological status. Since fever, seizures, vomiting, and petechiae are signs of meningitis, the nurse should promptly assess the child's neurological status and report the findings to the provider. Petechiae does not require dry sterile dressings, nor are they signs of abuse. Restraints are not used as a seizure precautions and the finding of petechiae wouldn't be a reason to initiate seizure precautions. The lab values are just below normal, and would be expected if the child has been vomiting.
A two-year-old child is being monitored after cardiac surgery. Which assessment findings would represent a decrease in cardiac output? Select all that apply. capillary refill less than two seconds warm fingers and toes hypotension decreased urine output weak peripheral pulses
hypotension decreased urine output weak peripheral pulses Signs of decreased cardiac output include weak peripheral pulses, hypotension, low urine output, delayed capillary refill, and cool extremities.
A client asks the nurse what factors affect how long it will take for a hip to heal following hip replacement surgery. What are the best responses by the nurse? Select all that apply. the age of the client the height of the client the gender of the client the client's comorbidities the client's marital status
the client's comorbidities the age of the client The age and comorbidities of the client are important because they can affect the blood supply to the fracture, which can affect the healing process. An older client, or one with comorbidities such as hypertension and diabetes, will have slower bone healing due to a decrease in blood supply. The height of the client does not directly delay bone healing. The client's gender and marital status have no effect on healing.
Prioritize the steps needed to perform an electrocardiogram (ECG). Use all options.
wash hands explain the importance of lying still, breathing normally, and refraining from talking during the test apply conductive gel to the client's skin attach electrodes to the client's skin and obtain a reading disconnect the electrodes from the client clean the gel from the client's skin First, a nurse should wash their hands. Next, explain the importance of lying still, breathing normally, and refraining from talking during the test. Then, attach electrodes to the client's skin to obtain a reading. Once the reading is obtained, disconnect the electrodes from the client. Finally, clean the gel from the client's skin.
A middle-age adult has been identified as being in the stagnation stage of developmental conflict. What evidence would support this assessment? Select all that apply. increased nap and sleeping hours bought a new sports car recently became engaged withdrawn from family obligations started classes at the community college
withdrawn from family obligations increased nap and sleeping hours Clients in the stagnation stage of development will withdraw from activities and relationships. The remaining responses do not express stagnation.
Which electrocardiogram (ECG) strip would the nurse expect to see from a child with bradycardia?
Strip four shows sinus bradycardia in an ECG. Strip one shows atrial flutter. Strip two is a normal ECG tracing. Strip three shows heart block.
Which conditions or situations are most likely to result in difficulty sleeping? Select all that apply. shift work sleep apnea caffeine intake in the evening consistent bedtime routine excessive worry or anxiety reduction of external stimuli
shift work sleep apnea caffeine intake in the evening excessive worry or anxiety Shift work, such as working evenings/nights or working different shifts in different weeks, can disrupt the circadian rhythm, causing shift work sleep disorder. Sleep apnea can cause a reduction in oxygen to the brain, which can reduce the quality of rest. Caffeine is a stimulant and, if taken too close to bedtime, can interfere with falling asleep. Excessive worry or anxiety causes an increase in adrenaline, which enhances alertness and reduces sleepiness. A consistent bedtime routine and reduction of external stimuli promote good sleep.
After repeated office visits and diagnostic tests, the healthcare provider is unable to find a physical cause for the client's symptoms and recommends a psychiatric referral. The client states, "I can't imagine why I should see a psychiatrist." What statements by the nurse will help the client? Select all that apply. "All the diagnostic tests are negative, so we have to explore other explanations for your symptoms." "A psychiatrist is part of the medical team and can offer input into your overall plan of care." "Psychiatric treatment can best resolve your symptoms because they are psychosomatic." "There is a known correlation between physical symptoms and stress, and we should explore this." "Your care is being transferred to the psychiatrist because there is nothing medically wrong with you."
"All the diagnostic tests are negative, so we have to explore other explanations for your symptoms." "There is a known correlation between physical symptoms and stress, and we should explore this." "A psychiatrist is part of the medical team and can offer input into your overall plan of care." The healthcare provider is likely investigating the client for somatic symptom disorder, which involves a preoccupation with physical symptoms that do not have a physical cause. Repeated physical examinations, diagnostic tests, and reassurance from the healthcare provider won't allay the client's concerns about physiologic disease. Many clients falsely believe that there is no relationship between psychological and physiologic issues, so the nurse should explain that the relationship does exist and should be explored. The nurse should also explain the benefit of psychiatric care for medical illnesses because many clients are unaware of it. This client's symptoms may be psychosomatic, but many people misinterpret this to mean they are fabricated by the client. Therefore, making this statement without explaining that psychosomatic symptoms are real and are felt as physical manifestations may result in defensiveness.
A male client reports little or no sexual desire, causing marital discord over the past year. What priority questions will the nurse ask the client to explore lack of sexual desire? Select all that apply. "Did you experience this decreased desire before?" "What are your past sexual practices?" "What are the current medications you are taking?" "Do you have any medical conditions?" "How long have you been married?"
"Did you experience this decreased desire before?" "What are the current medications you are taking?" "Do you have any medical conditions? Clarifying the symptoms and their onset will provide an opportunity to gather useful information about the client's current condition. Many medications can have a profound effect on sexual desire as can some medical conditions. The client's sexual practices and marital history have no direct bearing on the client's lack of desire.
The nurse is providing support to the parents of a 15-year-old client who just underwent successful removal of a brain tumor. Which statements by the nurse are appropriate? Select all that apply. "Your child can resume usual activities, within tolerable limits, as soon as possible." "The tumor was successfully removed, and there is no chance of recurrence." "It's difficult, at this point, to accurately determine the residual deficits your child may have." "Any residual disabilities will decrease over time, and disappear in adulthood." "Your child will have to wear a helmet until the skull is fully healed if participating in physical activities."
"It's difficult, at this point, to accurately determine the residual deficits your child may have." "Your child will have to wear a helmet until the skull is fully healed if participating in physical activities." "Your child can resume usual activities, within tolerable limits, as soon as possible." Long-term survivors of brain tumors may have permanent disabilities in areas such as speech and mobility. A helmet will be necessary until the skull is fully healed. The goal for the client who undergoes the removal of a brain tumor is to return to full activities as soon as possible. It is inappropriate to give false reassurance that the tumor will not return.
The nurse is teaching a caregiver how to effectively interact with an older adult parent who suffers from impaired memory and judgment. What is the most important information for the nurse to provide? Select all that apply. "Approach your parent from the front when beginning a conversation." "Allow ample time for your parent to respond to a question." "Speak slowly and use understandable words and phrases." "Orient and re-orient your parent as needed throughout the day." "Perform all your parent's care and activities of daily living." "Keep music playing to promote environmental stimulation."
"Speak slowly and use understandable words and phrases." "Allow ample time for your parent to respond to a question." "Orient and re-orient your parent as needed throughout the day." "Approach your parent from the front when beginning a conversation." When interacting with a parent who has cognitive impairment, a person should speak slowly and use simple, understandable language, allow ample time for a reply, orient and re-orient as needed, and approach the parent from an angle where the speaker can be seen. The caregiver must not provide care and activities that the parent can perform. The caregiver should provide a low-stimulus environment, so continuous music would cause agitation.
A mother tells the nurse she understands breastfeeding is the best, but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell this mother about formula feedings? Select all that apply. "A brand-name formula should be used because it has the best nutritional value." "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding." "All babies on formula should have an iron-fortified formula to ensure healthy brain growth." "When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." "All babies should be started on soy-based formulas because of the risk of future allergic reactions."
"Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding." "When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." "All babies on formula should have an iron-fortified formula to ensure healthy brain growth." Many different brands of formula are available, but all must meet strict U.S. Food and Drug Administration and Health Canada requirements. The American Academy of Pediatrics and the Canadian Pediatric Society recommend that all babies be fed iron-fortified formula unless contraindicated. It is vitally important that parents follow the directions on the package when mixing powdered formula to ensure proper nutrition. The baby's primary care provider, and the parents, should decide which formula is best for the baby. There has been no proven association of allergies for babies who begin with a cow-milk-based formula.
A 12-year-old client is 2 days postoperative from an open reduction, internal fixation procedure for a fractured femur. The client's chart reads: Breakfast:1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml)1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml)1 bowl of oatmeal (n/a)1 - 6 oz glass of orange juice (6 oz × 30 ml = 180ml)Additional information for 8-hour shift:I.V. of lactated Ringers is running at 125 ml/hr.A 1 g cefazolin injection was administered q8h.The pharmacy sent the cefazolin injection 1 g in 100 ml 50% dextrose.Calculate this client's intake for the 7 am to 3 pm shift. Record your answer using a whole number.
1520 Calculate the breakfast intake in milliliters: 1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml) 1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml) 1 bowl of oatmeal (n/a) 1 - 6 oz glass of orange juice (6 oz × 30 ml = 180 ml). Additional information needed: 1,000 (I.V. 125 ml/hr × 8 hr) plus 100 ml (cefazolin injection, one dose). 120 ml + 120 ml + 180 ml + 1,000 ml + 100 ml = 1,520 ml
The nurse is calculating intake and output for a client. Intake included 1750 ml of D5W, 500 ml of ceftriaxone, 8 oz of coffee, 4 oz of juice, and 800 ml of water. The client's output included 1560 ml of urine, and 45 ml of vomitus. What is the total output for this client? Record your answer using a whole number
1605 1560 ml + 45 ml = 1605 output
An IV of 1000 ml 5% dextrose in water is ordered to infuse over eight hours for a client who is dehydrated after receiving chemotherapy. The drop factor for the IV set is 10 gtt/ml. At what rate (in gtt/min) should the nurse start the infusion? Record your answer using a whole number.
21 8 h x 60 min/h = 480 min X=(1000 mL x 10 gtt/mL) ÷ (480 min) X = 21 gtt/min
A client is receiving 1 L of 0.9% sodium chloride IV to be infused for 12 hours. The IV infusion set has a drop factor of 15 gtt/ml. At how many drops per minute should the nurse set the IV to infuse? Record your answer using a whole number.
21 Here are the calculations: drops per minute= (ml/hr)/(60 min/hr) ×drop factor
The nurse is caring for a 1.2 kg neonate with anemia of prematurity. The health care provider orders a blood transfusion of 15 ml/kg red blood cells over 4 hours. At what rate (ml/hr) should the nurse set the infusion pump? Record your answer using one decimal place.
4.5 Neonatal blood transfusions, as with any blood transfusion, carry an increased risk. Smaller volumes are recommended to prevent complications. A maximum 5 ml/kg/h over a maximum time of 4 hours is recommended. Rate = (Volume to infuse)/(Time to infuse) Rate = (1.2 kg x 15 ml/kg)/4 hr = 4.5 ml/hr.
A client has given birth to an 8 lb 2.5 oz (3,700 g) infant. A newborn infant requires 110 to 120 cal/kg/day. What is the minimum number of calories per day this neonate requires? Record your answer using a whole number.
407 A newborn infant requires 110 to 120 calories/kg/day. It is important in newborns to calculate fluid and caloric requirements exactly, rather than rounding up or down. There are no differences in caloric requirements for males versus females. Because the question asks about the minimum, base the calculation on 110 calories/kg/day. First find the weight in kilograms: 3700 g = 3.7 kg. Now find the daily minimum calories: 3.7 kg × 110 calories/kg/day = 407 calories/day.
The pediatric nurse is caring for a 10-month-old infant. The health care provider orders an I.V. infusion of dextrose 5% in 0.45% NaCl solution to be infused at 7 ml/kg/hr. The infant weighs 22 lb (10 kg). How many ml/hr of the ordered solution should the nurse infuse? Record your answer using a whole number.
70 To perform this dosage calculation, the nurse should first convert the infant's weight to kilograms: (1 kg/2.2 lb) x 22 lb = 10 kg. Next, the nurse should multiply the infant's weight by the ordered rate: 10 kg x 7 ml/kg/hr = 70 ml/hr
A nurse is performing an assessment of a child who has been diagnosed with Wilms' tumor. What area of the body will the nurse avoid palpating?
A Wilms tumor can be on either side of the abdomen. To avoid trauma of the tumor and spread of the abnormal cells, the nurse should not palpate the abdomen when a Wilms' tumor is suspected or confirmed.
A child fell while playing basketball and sustained a greenstick fracture of the tibia. Which illustration represents a greenstick fracture?
A greenstick fracture occurs when the bone is bent beyond its limit, causing an incomplete fracture. The first illustration shows a plastic deformation or bend, with a microscopic fracture line where the bone bends. The second illustration shows a buckle fracture, which occurs when porous bone is compressed, causing a raised area or bulge at the fracture site. The fourth illustration shows a complete fracture in which the bone is broken into separate pieces.
A woman delivers a 3,250-g neonate at 42-weeks' gestation. Which physical finding is expected during an examination of this neonate's plantar creases?
A neonate born at 42-weeks' gestation is considered postmature, and would have creases over the entire sole. An infant born after 37 weeks would have creases over the anterior two-thirds of the sole. Very premature infants have no creases or only very faint red lines over the anterior aspect of the foot.
A young adult client who uses cannabis multiple times a day, has just participated in a family meeting at a community mental health center. The chart entry reads:2/100900The family meeting began by the client's family demanding that the client "stop using marijuana at once, or there will be severe consequences, including no support to attend college." The drug, and the problems associated with its use, were explained to the family.What educational topic should the nurse address with this family during the next teaching session? Talk about how things were prior to the client's substance use. Encourage the family to be more flexible with their thoughts and feelings. Discuss the possibility of the client developing violent tendencies. Address how the substance use has affected each member of the family.
Address how the substance use has affected each member of the family. As the client continues to use a substance, it is common for the family members to develop anxiety, depression, anger, and physical symptoms to help them to cope with the distress. Talking about how things were for this client in the past may, or may not, be effective. Clients who use cannabis do not tend to become violent. It is unrealistic to expect an immediate and dramatic shift in a person's thinking about substance use.
The nurse is assessing a client's respiratory pattern. Which illustration represents Cheyne-Stokes respirations?
In Cheyne-Stokes respirations, breaths gradually become faster and deeper than normal and then slower during a 30 to 170-second period with intermittent periods of apnea. Illustration one shows tachypnea, or shallow breathing with an increased respiratory rate. Illustration three shows Kussmaul breathing, or rapid, deep breathing without pauses. Illustration four shows bradypnea, or regular breathing at a decreased rate.
A nurse is caring for a client whose cultural background is different from the nurse's. Which actions are appropriate? Select all that apply. Understand that all cultures experience pain in the same way. Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures. Ask if there are cultural or religious requirements that should be considered in the client's care. Respect the client's cultural beliefs. Explain the nurse's beliefs so that the client will understand the differences.
Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures. Respect the client's cultural beliefs. Ask if there are cultural or religious requirements that should be considered in the client's care. Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect. In another culture, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs, and ask if there are cultural or religious requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture. It isn't the client's responsibility to understand the nurse's culture. Culture influences a client's experience of pain.
The note on the chart of a client with post traumatic stress disorder reads: "During the group therapy session, the client spoke about facts related to the train accident, but did not express their feelings related to the trauma experienced."Based on this chart entry, what is the best strategy for the nurse to use to prompt further discussion during the next group therapy session? Encourage the client to explore feelings of survivor guilt and self-blame. Discuss if the family or other people hold them responsible for what happened. Determine if a history of child abuse prevents discussion of concerns and life events. Address the client's struggle to develop coping skills and sources of support.
Encourage the client to explore feelings of survivor guilt and self-blame. The client needs to recognize that their survival may have been due to chance and not due to a personal action or inaction. Developing coping skills and sources of support do not assist this client with their feelings. Determining if the client has a history of being abused as a child is best asked in a one-on-one interaction, or done in an assessment session prior to a group session. Prior to discussing the involvement and feelings of other people, the client needs to express their feelings about the trauma.
A child's most recent diagnostic testing reveals elevated levels of T3 and T4. When assessing this child for exophthalmos, the nurse should inspect what region?
Exophthalmos is the abnormal protrusion of the eye globes that occurs when there is an overproduction of thyroid hormone, or hyperthyroidism.
A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads:10/151130The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members.Which priority action must the nurse group leader initiate? Arrange for a coach to be present with the client at each meeting. Obtain an order for medication to be given every morning. Role-play social skills with client before the next group meeting. Formulate an individual contract for appropriate behavior during the group.
Formulate an individual contract for appropriate behavior during the group. The documented client behavior indicates a need for limits during group. Formulating a contract that addresses the appropriate behavior, and the consequences for violating the contract, is the priority strategy. Medication for a client with antisocial personality disorder is only used to manage the symptoms of depression or disordered thinking. The first action to be taken is setting limits on inappropriate behavior, not role playing skills and arranging for a coach.
The nurse is caring for an infant with a heart defect that involves increased pulmonary blood flow. Which illustration shows a congenital heart disorder with increased pulmonary blood flow?
In patent ductus arteriosus, an accessory fetal structure that connects the pulmonary artery to the aorta fails to close at birth. This allows blood to shunt from the aorta on the left side to the pulmonary artery on the right side. Illustration one depicts aortic stenosis, and illustration three shows pulmonic stenosis. Both disorders obstruct blood flow. Illustration four shows tricuspid atresia, a decreased pulmonary blood flow disorder.
The nurse is assisting with the delivery of a fetus where the mentum is the presenting part. Which illustration shows this fetal presentation?
In the cephalic, or head-down, presentation, the position of the fetus may be classified by the presenting skull landmark: mentum or chin (illustration one), brow (illustration two), sinciput (illustration three), or vertex (illustration four).
The emergency department healthcare provider diagnoses a middle-aged adult client with a small peri-tonsillar abscess. The client's chart entry reads:Discharge notes10/15/161400The client is being discharged following a needle aspiration of the peri-tonsillar abscess. Clindamycin 600 mg/bid is ordered, and the client is to take ibuprofen 400 mg/bid as needed for pain. Instructions were given to keep the follow-up appointment.Based on this discharge note, what is the nurse's priority intervention? Tell the client there is a high risk for developing a second abscess. Schedule an X-ray in the next 24 hours after the needle aspiration. Instruct the client to report frequent swallowing or coughing up blood. Give the client a prescription for a follow-up lab test for mononucleosis.
Instruct the client to report frequent swallowing or coughing up blood. Hemorrhage and airway obstruction are the most common complications and must be reported and treated immediately. X-rays are not frequently used in this situation. A culture would be performed on the exudate extracted from the abscess. If symptoms such as multiple swollen lymph nodes, fatigue, or an enlarged spleen are present, a test for mononucleosis would be performed. The risk of developing a second peri-tonsillar abscess is low.
A nurse is monitoring a 3-year-old child who is experiencing muffled heart sounds after cardiac surgery. What action(s) will the nurse include in the client's plan of care to help prevent cardiac tamponade? Select all that apply. Report a decrease in urine output. Monitor vital signs frequently. Notify the health care provider of the muffled heart sounds. Ensure emergency medical equipment is available. Provide supplemental oxygen therapy.
Monitor vital signs frequently. Notify the health care provider of the muffled heart sounds. Ensure emergency medical equipment is available. Provide supplemental oxygen therapy. Reporting early signs of cardiac tamponade including muffled heart sounds, hypotension, a narrowing pulse pressure, tachycardia, dyspnea, and apprehension will prevent cardiac tamponade. The nurse will need to continue to monitor vital signs frequently, notify the health care provider of the muffled heart sounds, ensure medical equipment is available, and provide supplemental oxygen therapy. Cardiac tamponade occurs when a large volume of fluid or clots interferes with ventricular filling and pumping, and then collects in the pericardial sac, decreasing cardiac output. The decreased urine output is not associated with cardiac tamponade.
A nurse is teaching a client about withdrawal from the excessive use of caffeine. What will the nurse include in the teaching? Select all that apply. Drink fluids to help with the withdrawal. One of the first symptoms of withdrawal will be a headache. Try to stop the caffeine all at once to lessen the withdrawal symptoms. Nausea and muscle pain may occur with withdrawal. The only problem will be drowsiness.
Nausea and muscle pain may occur with withdrawal. One of the first symptoms of withdrawal will be a headache. Drink fluids to help with the withdrawal. The symptoms of caffeine withdrawal are headache, fatigue, drowsiness, irritability, and depression. Nausea and muscle pain can also occur. Drinking fluids during the withdrawal can prevent dehydration. Stopping the caffeine abruptly will not lessen symptoms.
A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply. Allow the client to skip meals until the antidepressant levels are therapeutic. Encourage the client to keep a journal. Encourage the client to eat three substantial meals per day. Monitor weight gain. Provide small, frequent meals.
Provide small, frequent meals. Monitor weight gain. Encourage the client to keep a journal. Due to self-starvation, clients with anorexia can rarely tolerate large meals three times per day. Small, frequent meals may be tolerated better by the anorexic client, and they provide a way to gradually increase daily caloric intake. The nurse should monitor the client's weight carefully because a client with anorexia may try to hide weight loss. The client may be emotionally restrained and afraid to express feelings; therefore, keeping a journal can serve as an outlet for these feelings. An anorexic client is already underweight and should not be permitted to skip meals.
The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states:Progress notes10/15/160245Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision.How can the nurse best determine this client's glycemic control since the last assessment? Review the results of the client's HbA1c. Ask the client to describe recommended diet and glucose monitoring routine. Ask the client to complete a 24-hour food recall. Arrange assessment of the client's fasting glucose level.
Review the results of the client's HbA1c. An HbA1c provides an overview of a person's blood glucose level over the previous 2 to 3 months. Glycosylated hemoglobin values are reported as a percentage of the total hemoglobin within an erythrocyte. The time frame is based on the fact that the usual life span of an erythrocyte is 2 to 3 months. The client's description of health maintenance will not determine adherence to the prescribed schedule. Fasting glucose gives a point-in-time result. A 24-hour food recall is subjective, and does not help the nurse gauge the client's overall adherence.
A nurse is caring for a client with the visual field deficit depicted above. What is the most important information for the nurse to teach this client? Plan for adequate rest. Use memory aids such as pictures. Scan the environment on the affected side. Make simple, non-risky decisions.
Scan the environment on the affected side. Scanning the environment can help a client with homonymous hemianopia overcome a loss in visual perception and prevent injury. Clients with other types of perceptual or memory loss may benefit from the interventions, nonspecific for a visual field loss, in the remaining answer choices.
A 40-year-old client who has completed radiation therapy for testicular cancer tells the nurse that he is unable to achieve an erection. Which responses are appropriate? Select all that apply. Impotence can result from improper nutrition after radiation. Sexual dysfunction can be a side effect of radiation therapy. Impotence is the body's way of avoiding sex to allow healing. Preoccupation and worry about sexual function can cause impotence. Impotence after testicular cancer is permanent.
Sexual dysfunction can be a side effect of radiation therapy. Preoccupation and worry about sexual function can cause impotence. Radiation or chemotherapy may cause sexual dysfunction. Libido may only be temporarily affected, and the client should be provided with emotional support. The client has not verbalized fear or concern related to the cancer. Impotence after cancer is not necessarily permanent. Impotence is not associated with imbalanced or improper nutrition. Impotence is not related to the body's capacity for healing.
The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure? 2/10/2017190056-year-old, right-handed client presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity. Suspected increased intracranial pressure (ICP) Blood in the cerebrospinal fluid (CSF) Severe vomiting Client requires mechanical ventilation
Suspected increased intracranial pressure (ICP) Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.
A client is admitted with hemophilia A. Which sports should the nurse recommend as safe for the client to participate? Select all that apply. Swimming Soccer Golf Basketball Baseball
Swimming Golf Hemophilia A or classic hemophilia is a bleeding disorder that results from a deficiency or abnormality of clotting factor VIII. A client with hemophilia should avoid contact sports like soccer, baseball, and basketball because of the risk of bleeding with injury. The client can safely participate in noncontact sports such as swimming and golf.
A 6-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made by the nurse regarding the infant's room assignment? Select all that apply. The infant's parents will not be allowed in the room. The child will need to be on droplet precautions. There must be a window in the door to view the child. The room should be near the nurses' station. A private room is required.
The child will need to be on droplet precautions. A private room is required. The room should be near the nurses' station. An infant diagnosed with bacterial meningitis should be placed on droplet precautions in a private room until that child has received I.V. antibiotics for 24 hours. This infant would be contagious. Bacterial meningitis can be quite serious; therefore, the infant's room should be near the nurses' station for close monitoring and easier access. The infant's parents would be permitted to visit as long as they wear the proper PPE. Although a window in the door is ideal, it is not a requirement.
How should the nurse position a preschooler with right lower lobe pneumonia?
The child with right lower lobe pneumonia should be placed on the left side. This places the unaffected left lung in a position so that gravity will promote blood flow to the healthy lung tissue, improving gas exchange. Placing the child on the right side, the back, or the stomach doesn't promote circulation to the unaffected lung.
When reviewing a client's chart, the nurse reads the progress note below. 10/151130Client, age 28, admitted to unit with diagnosis of antisocial personality disorder and suicide attempt after cutting his right wrist. Right wrist dressing appears dry and intact. Client states, "I don't want to be here and I'm not following your treatment plan or any of your rules. I'm going to tell everyone here not to follow your rules."—Barbara Jones, RNWhich statement, about the client's condition, is most accurate? The client is not motivated to change his behavior or his lifestyle. The client can quickly make behavior changes if motivated The client is refusing the required psychotropic drugs used to treat his condition. The client manipulates others, but not his family.
The client is not motivated to change his behavior or his lifestyle. Clients with antisocial personality disorder feel nothing is wrong with their behavior, and they have no desire to change. These clients don't benefit from psychotropic drug therapy. They attempt to manipulate the people around them. A quick behavior change isn't a realistic expectation for clients with this disorder.
What information should a nurse include when teaching post-circumcision care to the parents of a neonate prior to discharge from the hospital? Select all that apply. The infant can take tub baths while the circumcision heals. Petroleum jelly should be applied to the glans with each diaper change. The infant must void before being discharged. The circumcision will require care for 2 to 4 days after discharge. Any blood noted on the front of the diaper should be reported.
The infant must void before being discharged. Petroleum jelly should be applied to the glans with each diaper change. The circumcision will require care for 2 to 4 days after discharge. It is necessary for the infant to void prior to discharge to ensure that the urethra isn't obstructed. Petroleum jelly is appropriate, and is applied with each diaper change. Typically, circumcision care is required for 2 to 4 days while the penis heals. To prevent infection, sponge baths should be given while the penis heals. A small amount of bleeding is expected following a circumcision. Parents should only report a large amount of bleeding.
The nurse is caring for a child with tricuspid atresia who develops polycythemia. Which statement most accurately describes this manifestation? The viscosity of the blood is unchanged. The red blood cell count is normal. There is an increased ability for the oxygen to carry blood. There is an increased risk of developing a thrombus.
There is an increased risk of developing a thrombus. Polycythemia is an increased number of red blood cells, thereby increasing the ability of the blood to carry oxygen to the cells. It is the body's attempt at compensating for the chronic hypoxia associated with this heart defect. Due to this clinical manifestation, the viscosity of the blood increases, which leaves the child at risk for developing a thrombus, particularly when dehydrated. There is also not as much room for clotting factors, which can leave the child at risk for blood clotting disorders.
The nurse is evaluating a 5-year-old client's response to clindamycin being given I.V. for osteomyelitis. Which findings are important for the nurse to monitor in this client? Select all that apply. random blood sugar level of 90 mg/dl WBC count of 17,000 mm³ tinnitus and hearing loss creatinine level of 1.2 mg/dl BUN level 10 mg/dl
WBC count of 17,000 mm³ creatinine level of 1.2 mg/dl BUN level 10 mg/dl tinnitus and hearing loss The length of therapy for osteomyelitis is determined by the duration of the symptoms, the client's response to treatment, and the organism's sensitivity. Because of the prolonged duration of high-dose antibiotic therapy, the nurse should monitor for hematologic, renal, hepatic, ototoxic, and other potential side effects. When a client is on aminoglycoside therapy, the nurse should monitor for tinnitus and hearing loss, which could indicate ototoxicity. Nephrotoxicity is indicated by rising BUN levels, and increasing creatinine levels. A WBC count of 17,000 mm3 is above the normal range of 5.5 to 15.5. A decrease would indicate the clindamycin is being therapeutic. Normal creatinine ranges from 0.3 to 0.7 mg/dl. Normal BUN ranges from approximately 5.0 to 18.0 mg/dl for children up to 12 years of age. A random blood sugar level of 90 mg/dl is within normal limits
A child, just been admitted to the emergency department, has the following chart entry:Progress notes10/15/161800Parents describe recent weight loss and lack of energy. Client's ears and cheeks are flushed; acetone-smelling breath noted. Blood glucose 324 mg/dl (18.0 mmol/L), BP: 104/60 mm Hg; P: 88/bpm; RR: 16 breaths/min.What intervention would the nurse should anticipate? administration of I.V. fluids in boluses of 20 ml/kg subcutaneous administration of glucagon administration of I.V. regular insulin by continuous infusion pump administration of regular insulin subcutaneously Q4H as needed per sliding scale
administration of I.V. regular insulin by continuous infusion pump Weight loss, lack of energy, acetone odor to breath, and a blood glucose level of 324 mg/dl (18.0 mmol/L) would indicate diabetic ketoacidosis. Insulin would be given I.V. by continuous infusion pump. Glucagon is administered for mild hypoglycemia. Sliding scale insulin isn't as effective as the administration of insulin by continuous infusion pump. Administration of I.V. fluids in boluses of 20 ml/kg is recommended for the treatment of shock.
The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily:2/101700The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that."What health problem is this client experiencing because of extended cannabis use? vascular dementia delirium tremens amotivational syndrome cognitive distortions
amotivational syndrome Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.
The nurse is gathering data on a client with pernicious anemia. Which data would support this diagnosis? Select all that apply. dyspnea on exertion angular cheilitis sensitivity to cold hemoglobin of 14 g/dl (140g/L) smooth, bright-red tongue
angular cheilitis smooth, bright-red tongue sensitivity to cold dyspnea on exertion Pernicious anemia is a vitamin B12 deficiency due to lack of the intrinsic factor produced by gastric mucosa. Intrinsic factor is necessary for the absorption of vitamin B12. Clinical manifestations include pallor, fatigue, dyspnea on exertion, angular cheilitis (scaling of the surface of lips and fissures in the corner of the mouth), and sensitivity to cold. The client will also have a smooth, sore, bright red tongue because of the atrophy of the papillae of the tongue due to vitamin B12 deficiency. Hemoglobin of 14 g/dl (140 g/L) is normal.
The nurse is assessing breath sounds of a child admitted to the unit. Based on the following progress notes, which respiratory illness would the nurse suspect?Progress notes10/152030Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well. pulmonary edema croup pneumonia asthma
asthma Asthma frequently presents with wheezing and coughing. Airway inflammation and edema increase mucous production. Other signs include dyspnea, tachycardia, and tachypnea. Stridor is heard in croup. Rhonchi and rales are heard with pneumonia and pulmonary edema.
A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply. eat a large meal and drink fluids before bedtime schedule bedtime when you feel tired prepare the room for sleep and turn off distracting noise avoid caffeine, alcohol, and nicotine before bedtime participate in a bedtime routine keep the room very warm
avoid caffeine, alcohol, and nicotine before bedtime prepare the room for sleep and turn off distracting noise participate in a bedtime routine Caffeine, alcohol, and substances such as nicotine act as stimulants, avoiding them should help promote sleep. Maintaining a cool temperature in the room will facilitate optimal sleep. Excessive fullness or hunger can disrupt or interfere with sleep. A regular sleep-wake time facilitates physiologic patterns, rather than waiting until an individual begins to feel tired. The room should be conducive to sleep. Eliminate distractions such as a television or radio. Participation in a relaxation, prayer, or meditation routine can help prepare an individual for a restful night.
A child is undergoing testing to rule out a diagnosis of Kawasaki disease. Which test results would support this diagnosis? Select all that apply. leukocytosis hematuria elevated C-reactive protein levels decreased erythrocyte sedimentation rate thrombocytopenia
leukocytosis elevated C-reactive protein levels Inflammation of the small vessels, along with pancarditis, leads to an elevated leukocyte count, increased platelet count, increased erythrocyte sedimentation rate, and elevated C-reactive protein levels. Urinalysis would show proteinuria or sterile pyuria.
The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which laboratory studies should the nurse order to evaluate myocardial damage? Select all that apply. hemoglobin and hematocrit myoglobin serum glucose troponin T and troponin I blood urea nitrogen (BUN) creatinine phosphokinase (CK-MB)
creatinine phosphokinase (CK-MB) troponin T and troponin I myoglobin Levels of CK-MB, troponin T, and troponin I rise because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. Neither hemoglobin, hematocrit, serum glucose, nor BUN levels provide information related to myocardial ischemia.
A chart entry reads:2/10/20171700The client presents with a sad affect, stooped posture, limited eye contact, and slow, but clear speech. The client is oriented and stays away from peers. During a one-to-one interaction the client stated," I'm not worth it. It won't do me any good to talk about it."Based on the progress note shown here, which is the best intervention for the nurse to initiate? gently question the negative self-statements made by the client talk about community resources that may be of use to the client address how building social skills will prevent escalation of anxiety have the client identify spiritual needs to develop comfort and strength
gently question the negative self-statements made by the client Gently challenging the client's negative self-statements will help this client begin to look at self-criticism and negative feelings. Talking about community resources is premature when the client sees little value in addressing personal issues and feelings. Identifying spiritual needs can lead to obtaining spiritual support to assist with this anxiety. Obtaining resources is premature until the client starts to acknowledge self-worth. Building social skills is a premature action when the client isolates, feels unworthy and lacks self-acceptance.
After interviewing a client diagnosed with major depressive disorder, the nurse determines the client's potential to commit suicide. What factors contribute to the client's suicide potential? Select all that apply. substance use impulsive behaviors decreased physical activity chronic, debilitating illness psychomotor retardation criminal involvement
impulsive behaviors criminal involvement chronic, debilitating illness substance use Impulsive behavior, criminal activity and involvement with a law enforcement agencies, chronic illness, and substance use are factors that contribute to suicide potential. Psychomotor retardation and decreased activity are symptoms of depression, but don't typically lead to suicide because the client doesn't have the energy to harm themselves.
The nurse is teaching a client about the risk factors for developing osteoporosis. What is the most important information for the nurse to include? Select all that apply. smoking blood pressure medications inadequate dietary intake of calcium oral hypoglycemics family history
inadequate dietary intake of calcium family history smoking Inadequate dietary intake of calcium, family history, and smoking are risk factors of osteoporosis. There is no evidence that blood pressure medications or oral hypoglycemics are risk factors.
The nurse suspects that a client, with a recent fracture, has developed compartment syndrome. Which assessment finding would be most concerning to the nurse? Select all that apply. intense, throbbing pain unresponsive to analgesics an overall decrease in bone mass the inability to perform passive movement a palpable growth in and around the bone tissue absent pulses distal to the fracture site the inability to perform active movement
intense, throbbing pain unresponsive to analgesics absent pulses distal to the fracture site the inability to perform active movement When compartment syndrome is present, the client will not be able to perform active movement, and pain will occur with passive movement. Osteoporosis brings an overall decrease in bone mass. A bone tumor will show growth in and around the bone tissue. Symptoms of compartment syndrome include pain, decreased movement, and absent pulses distal to the fracture site.
During the admission assessment, the nurse focuses on the client's reflexes, muscle strength, coordination, eye movements, and mental status. What symptoms would the nurse identify as suggestive of vascular dementia? Select all that apply. aching joint deformities laughing inappropriately shuffling gait hyperextending the head swinging leg losing bladder control
losing bladder control laughing inappropriately shuffling gait The typical symptoms of vascular dementia are confusion, memory deficits, wandering, shuffling gait, loss of bladder and bowel control, and inappropriate laughter.
2/10/2017210018-year-old college student presents to the emergency department with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104° F (40° C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis.What is the most important action by the nurse? administer the meningitis vaccination per order obtaining I.V. access in preparation of antibiotic administration administer an analgesic per order prepare this client for endotracheal intubation
obtaining I.V. access in preparation of antibiotic administration This client's rapid course, and petechiae suggest that they are at risk for a fulminant presentation of meningitis, which can include circulatory collapse. Intravenous access may be needed, not only for immediate antibiotics to address the infection, but also for fluids and vasopressors. The client does not currently require intubation. Immunization will not prevent disease in persons who have already been exposed. An analgesic may be given, but I.V. access is the top priority.
A nurse is caring for a client with delirium. Which nursing interventions are important to implement after establishing a safe client environment? Select all that apply. offering recreational activities providing a structured environment instituting measures to promote sleep talking about self-care needs distracting the focus away from others
offering recreational activities providing a structured environment instituting measures to promote sleep After providing a safe environment for the client with delirium, it would be appropriate for the nurse to offer recreational activities, provide a structured environment, and institute measures to promote sleep.
A 5-year-old client was admitted to a pediatric unit 4 hours ago with reports of pain in the right ankle. Upon assessment, the nurse documents the following findings: VS: 102.8° F (39.3° C), P 112, R 16 BP 96/55, O2 99% on RA, moderate amount of erythema and +2 edema over the lateral aspect of the right ankle, warm to touch, limited range of motion noted. The nurse also reviews the laboratory values. Based on the assessment findings and laboratory data in the chart below, for what is this client at risk? CBC:WBC: 17.8 x 103/µlRBC: 4.8 million/mm3Hgb: 13.5 gm/dlHCT: 38%Bands: 13 PMN%CRP: 2.8 ng/dlBlood Culture: Gram positive: Staphylococcus aureus developmental dysplasia of the hip (DDH) aplastic anemia osteogenesis osteomyelitis
osteomyelitis Systemic symptoms such as fever and irritability, and localized symptoms such as edema, swelling, and tenderness over the bone are often precursors to osteomyelitis. This child's physical examination should focus on identifying common findings, such as erythema, soft tissue swelling or joint effusion as well as decreased joint range of motion, and tenderness over the bone.
The chart entry for a client with chronic pharyngitis readsProgress notes10/150945A 37-year-old client, who works in a textile factory, has returned to the clinic with symptoms of a persistent sore throat which makes swallowing uncomfortable and congestion that causes frequent episodes of coughing to expel mucous.Based on this chart entry, how should the nurse teach this client how to manage these symptoms? instruct this client to ask the primary care provider for a complete cardiac evaluation address the need to monitor for infection by taking a daily temperature reading recommend decreasing exposure to environmental irritants by wearing a mask suggest that the client increase the frequency of performing oral hygiene
recommend decreasing exposure to environmental irritants by wearing a mask Clients with chronic pharyngitis are often exposed to environmental irritants. Minimizing exposure, by wearing a disposable face mask, is a helpful intervention. A cardiac evaluation is not warranted for chronic pharyngitis. Good oral hygiene will decrease the symptoms, but will not address the underlying cause. Daily monitoring of this client's temperature is not warranted.
A nurse begins their shift by reading the following shift report. The nurse interprets these results as indicating which of these?H.B. age 78Hyperventilating, RR 36Bpm. C/O dizziness, shortness of breath, tingling in hands and feet, weakness. Anxious.ABG: pH 7.48PaCO2: 33 mmHg anxiety reaction acute respiratory failure metabolic acidosis respiratory alkalosis
respiratory alkalosis Respiratory alkalosis is defined by a pH greater than 7.45 and PaCO2 less than 35 mmHg, and generally is associated with deep, rapid breathing; light-headedness or dizziness; circumoral and peripheral paresthesia; and carpopedal spasms, twitching, and muscle weakness as it progresses. Metabolic acidosis is defined as a pH less than 7.3, PaCO2 less than or equal to 34 mmHg depending on respiratory compensation, and HCO3 less than 22 mEq/L and is caused by an underlying non-respiratory disorder. Acute respiratory failure is characterized by a pH less than 3, PaCO2 greater than 50 mmHg, and markedly diminished oxygen saturation levels. Although the client may be anxious, the abnormal blood gas levels and corresponding symptoms indicate that treatment of respiratory alkalosis is the primary concern and may greatly reduce the client's anxiety level.
2/10/2017 0800 A client was admitted for intracranial hemorrhage four days ago. Morning laboratory results demonstrate a low serum sodium of 121 mEq/L, a low serum osmolality of 256 mOsm/kg, a high urine osmolality of 588 mOsm/kg, and a high urine sodium of 89 mmol/L. Vital signs are stable. Urine output is high, averaging greater than 100 cc/hr. Which nursing interventions should the nurse include when planning care for a client with cerebral salt wasting (CSW) syndrome? synthetic vasopressin replacement fluid restriction sodium and fluid replacement sodium restriction
sodium and fluid replacement Cerebral salt wasting syndrome is a volume-depleted and sodium-wasting state, requiring fluid replacement with isotonic solutions to prevent further deterioration. Its presentation is similarly to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is treated with free water restriction. Synthetic vasopressin replacement is used to treat central diabetes insipidus.
A college student visited the health center almost daily during the second half of the semester, before course examinations. Physical causes for these visits have been eliminated. Based on the following progress note entry in the client's chart, the nurse should suspect2/10/20171600Throughout the semester, this student presented at the walk-in clinic an average of twice per week reporting a variety of symptoms. A full work-up was done to rule out mononucleosis, influenza, colitis, pregnancy, kidney infection, and chronic fatigue. The student presented in a dramatic and worried manner with each new complaint. She did not question any of the findings, seeming to simply suffer a repeat of a previous malady or present with a new set of symptoms. It is recommended that the client have a consult to mental health services. somatic symptom disorder depersonalization-derealization disorder generalized anxiety disorder functional neurologic symptom disorder
somatic symptom disorder Somatic symptom disorder, in this case, is shown by the client's belief that she has a serious illness, although pathologic causes have been eliminated. The disturbance usually lasts at least six months, and the gastrointestinal system is commonly affected. Exacerbations are usually associated with identifiable life stressors, in this case the client's examinations. Functional neurologic symptom disorder is characterized by one or more neurologic symptom. Depersonalization-derealization disorder refers to persistent, recurrent episodes of feeling detached from one's self or body. Generalized anxiety disorder presents with persistent, overwhelming anxiety unrelated to life stressors.
A client is started on steroid therapy after an adrenalectomy. Which information is most important to share with this client? Select all that apply. notify your healthcare provider if you experience increased urination take the prescribed dose daily, and do not miss a dose discontinue steroid therapy after two weeks take this medication for the rest of your life take two doses if you miss a dose
take this medication for the rest of your life take the prescribed dose daily, and do not miss a dose notify your healthcare provider if you experience increased urination take this medication for the rest of your life Steroid therapy following an adrenalectomy will continue for the rest of the client's life. It is important to take the dose daily, and not miss a dose. The client should be instructed about potential side effects such as hyperglycemia, which could manifest as symptoms such as increased urination. Clients should take the medication as soon as they remember the missed dose, but should not double the dose the next day.
A nurse is admitting a child to the unit. Based on the history, what illness would the nurse suspect?History and physical10/151030Nine-year-old child admitted with frequent cough and fever of > 100.5° F (38.1° C) for the past month. Child lives with parents and with grandparents who recently emigrated from SE Asia. Weight = 20 kg. Parent reports significant weight loss in child. Child reporting fatigue and poor appetite. Denies vomiting/diarrhea. Does have some nausea. No problems with voiding or stooling. Child does well in school. pneumonia tuberculosis asthma HIV
tuberculosis Tuberculosis often presents with a chronic, unremitting cough and fever lasting more than 3 weeks. Weight loss and fatigue are common symptoms. Risk factors include visiting or living with persons from endemic areas. Pneumonia typically does not produce significant weight loss. Asthma is not usually accompanied by fever. HIV symptoms are varied, nonspecific, and seen with specific risk factors such as a mother with HIV at birth.