Lecture Exam 2
The nurse is obtaining a history from a client who states recurrent breast tenderness. The client inquires if there is something wrong with her breasts. Which question by the nurse is a priority?
"Does the tenderness occur around the same time each month?"
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?
"Increase your carbohydrate intake."
A patient is post a retroperitoneal lymph node dissection for metastatic testicular cancer. The patient states "I will never be able to have another orgasm again". Which of the following is the best statement from the nurse?
"This does not usually change a manʼs ability to have an orgasm"
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
1 to 3 days
A nurse is teaching a client about peritoneal dialysis. The nurse should tell the client the dwell time is:
20 minutes
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps:1. Change in pH2. Blood flow decreases3. A switch to anaerobic respiration4. Membrane pumps fail5. Cells cease to function6. Lactic acid is generated
236145
Atypical hyperplasia increases a women's risk for breast cancer about how many times compared with that of the general population?
4
A child with leukemia received chemotherapy about 10 days ago. She presents today with a temperature of 100.4°F, an absolute neutrophil count of 500, and mild bleeding of the gums. What is the priority nursing intervention?
Administer IV antibiotics as ordered
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
Advanced age
A nurse is providing an educational event to a local mens group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group?
African Americans
A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
Age 38
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
Keeping the client in one position to decrease bleeding
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side
An early sign of Paget's disease includes which of the following?
Nipple erythema
A client is receiving adjuvant chemotherapy for breast cancer. Which is most likely her node status and tumor size?
Node negative, tumor size 1.2 cm
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
Palpate the area for a breast mass.
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?
Placing food on the affected side of the mouth
The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?
Polycystic kidney disease (PKD)
After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following
Positioning to avoid hypoxia
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection?
Positive Kernigs sign
After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action?
Prepare to administer 3% NaCl by IV as ordered
A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders?
Preprocedure hydration and administration of acetylcysteine
A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply.
Promotion of HPV immunization, Encouraging young women to delay first intercourse, Smoking cessation, Using safer sex practices
55 year old man presents with painful ejaculaGon, frequent urinaGon, sGffness in lower back and hips and blood in urine. the nurse suspects
Prostate cancer
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
Protecting the safety of the patient, family, and staff
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication?
Provide a board of commonly used needs and phrases.
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.
The cuffs are made of Dacron polyester., The cuffs stabilize the catheter, The cuffs prevent the dialysate from leaking, The cuffs provide a barrier against microorganisms
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure?
The kidneys can improve over a period of months
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?
The patient should be approached on the side where visual perception is intact.
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?
The patient should be placed in a prone position for 15 to 30 minutes several times a day.
A nurse is performing an admission assessment on a 40-year-old man who has been admitted for outpatient surgery on his right knee. While taking the patients family history, he states, My father died of prostate cancer at age 48. The nurse should instruct him on which of the following health promotion activities?
The patient should have PSA levels drawn regularly.
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
The patient should mobilize as soon as she is physically able.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The patients activities immediately prior to the seizure.
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
The patients average urine output has been 10 mL/hr for several hours.
A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?
The patients disease is incurable and the nurses interventions will be supportive
A client with breast cancer is scheduled to undergo chemotherapy with aromatase inhibitors. Which of the following best reflects the rationale for using this group of drugs?
They lower the level of estrogen in the body blocking the tumor's ability to use it.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
Three hours
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?
Tissue plasminogen activator (tPA)
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
To remove atherosclerotic plaques blocking cerebral flow
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse?
Turn the client from side to side.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension
Which clinical finding should a nurse look for in a client with chronic renal failure?
Uremia
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
cardio embolic
a female patient with HIV & genital warts, what information is most appropriate for this patient?
condition increases risk for cervical cancer, therefore she should have a papanicolaous test annually.
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
A vein and an artery in your arm will be attached surgically.
One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:
restricting sources of potassium usually found in fresh fruits and vegetables.
A man tells the nurse that his father died of prostate cancer and he is concerned about his own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurses response?
A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer.
A man tells the nurse that his father died of prostate cancer and he is concerned about his own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurses response?
A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer.
A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?
Dehydration
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urine output of 250 ml/24 hours
A nurse is giving preoperative instructions to a client who is scheduled for a breast biopsy. Which medication should the nurse instruct the client to stop 1 week before the procedure?
Vitamin E
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
aspirin.
A child on the pediatric unit has morning laboratory results of Hgb 10.0, Hct 30.2, WBC 24,000, and platelets 20,000. What is the priority nursing assessment?
assess for bruising or bleeding
The nurse is providing health education regarding disorders that affect breast tissue. Which symptom is least suggestive of a breast disorder?
differences in breast size
A client has been diagnosed with breast cancer and is awaiting cytology results of a biopsy. During client education, the nurse discusses the possible types of breast malignancies. Which is the most common type?
ductal
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
fatigue and weakness.
A nurse is caring for a paGent who has undergone a hysterectomy. Physical assessment findings indicate BP 80/50, pulse 130, Respirations 22, urinary output 24 hours 750 mL, pain 3/10, temp oral 99.9. Which of the following interventions would the nurse perform?
hook them up with fluids first, get them to use the tri-flow to work off anesthesia and lower temp, want to make sure they're peeing, assess pain
Which is inconsistent as a risk factor for breast cancer?
Multiparity
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?
6.3 mg
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
Alteration in level of consciousness (LOC)
The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States?
13%
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m.
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
5.4
Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?
6
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?
A dysrhythmia in the nerve cells in one section of the brain
A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?
A GFR of 30-59 mL/min/1.73 m2
A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
A nonmobile mass with irregular edges
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
A patient with diabetes mellitus and poorly controlled
A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint?
A thrombus formation at the site of the endarterectomy
A 33-year-old female client is recovering from a modified radical mastectomy with immediate reconstruction. This is the client's fourth day postoperatively. Her vital signs are temperature 99°F, pulse 82, respirations 18, and blood pressure 152/90. She continues to complain of considerable pain, with a pain rating of 9 on a scale of 1 to 10, with 10 being the worst possible pain. The client was discharged home with a prescription for oxycodone and acetaminophen and has been taking the drugs as prescribed. Which assessment finding would cause the nurse to phone the physician?
A well-defined oval area near the incision site
A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
Fine-needle aspiration
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
First 2 to 12 hours
A nurse is reviewing a client's history for possible risk factors associated with breast cancer. Which of the following would the nurse identify as increasing the client's risk?
First full-term pregnancy at age 34 years
A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis?
Hemodialysis is a treatment option that is usually required three times a week.
The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician?
Absence of drain output
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?
Absence seizure
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
Absolute bed rest in a quiet, nonstimulating environment
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
A patient who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. During the nurses admission assessment, the nurse observes that the patient is distracted and tense. What is it important for the nurse to do?
Acknowledge the fear the patient is likely experiencing.
A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.
Adherence to the exercise plan, Overall psychological functioning, Integrity of surgical drains
An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply.
Age-related physiologic changes, Chronic systemic disease
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan?
Inspection and care of the incision
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?
Anticoagulant therapy
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke?
Aspirin 81 mg PO o.d.
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
Assess for a thrill or bruit over the vascular access site each shift.
The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.
Assess for the presence of peripheral edema , Assess the patients BP.
A child with leukemia has the following AM laboratory results: Hgb 8.0, Hct 24.2, WBC 8,000, platelets 150,000. What is the priority nursing assessment?
Assess for valor fatigue and tachycardia
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response?
Assess the patient for signs of bleeding and inform the physician.
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
Assessment of the quantity of the patients urine output
Which interventions would be recommended for a client with dysphagia? Select all that apply.
Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
Atrial fibrillation
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?
Auditory agnosia
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting.
A 5-year-old has been diagnosed with Wilms tumor. What is the priority nursing intervention for this child?
Avoid palpating the child's abdomen.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
Cardiogenic emboli
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?
Carotid endarterectomy
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
Excess fluid volume related to generalized edema
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
Bilateral mastectomy
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?
Cerebral aneurysm
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
Bleeding
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?
Brachytherapy
The nurse is educating a group of women at the YMCA about breast cancer. What does the nurse understand is the current trend that should be focused on rather than BSE?
Breast self-awareness
A patient has just been told she needs to have an incisional biopsy of a right breast mass. During preoperative teaching, how could the nurse best assess this patient for specific educational, physical, or psychosocial needs she might have?
By encouraging her to verbalize her questions and concerns
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke?
Exercise the affected extremities passively four or five times a day.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
Call the physician immediately.
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?
Cardiac and respiratory status
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation.
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?
Cocaine use
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
Confusion
A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate?
Continuous venovenous hemodialysis (CVVHD)
A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic?
Current medication use
A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
Disturbed Body Image Related to Effects of Surgery
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
Facial droop
A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys
A woman is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the patient is aware of what potential consequence?
Decreased nipple sensation
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply.
Decreased protein intake, Decreased sodium intake, Fluid restriction,
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
Dehydration
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?
Depression
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern?
Difficulty swallowing
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care?
Disturbed sensory perception
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
Elevation of the head of the bed
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?
Emotional lability is common after a stroke, and it usually improves with time
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
A nurse is caring for a 33-year-old male who has come to the clinic for a physical examination. He statesthat he has not had a routine physical in 5 years. During the examination, the physician finds that digital rectal examination (DRE) reveals stoney hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what?
Evidence of a more advanced lesion
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
Evidence of hemorrhagic stroke
A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?
Excess fluid volum
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words and comprehend spoken words
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
Frustration around changes in function and communication
A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
Generalized seizure
A 30-year-old client whose mother died of breast cancer at age 44, and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic?
Genetic counseling
Which of the following causes should the nurse suspect in a client is diagnosed with intrarenal failure?
Glomerulonephritis
Most important risk factor for cervical cancer?
HPV
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action?
Have a colleague follow the patient closely with a wheelchair.
A nurse is teaching a 53-year-old man about prostate cancer. What information should the nurse provide to best facilitate the early identification of prostate cancer?
Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it?
Heart failure
A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply.
Heart rate greater than 120 bpm, Older age, Low Glasgow Coma Scale
The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem?
Hematuria
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?
Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.
The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client?
Hemodialysis
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take?
Hold the medications until after dialysis
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include?
How to correctly modify the home environment
A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?
Hyperkalemia
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
Hyperkalemia
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
Hypertension
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Impaired Swallowing
A client is demonstrating breast self-examination while the nurse is observing the woman's technique. The nurse stops the client and provides reinstruction when the nurse observes the client palpating in which manner?
In a horizontal pattern across each quandrant of the breast from the inner edge outward
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Increased BUN
A pt with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the health history. What clinical manifestation would the nurse expect to assess?
Increased abdominal girth, Flatulence and feeling full after a light meal
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action?
Inform the physician and assess the patient for signs of infection.
A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
Instructions about breast self-examination (BSE)
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
Intravenous diazepam (Valium)
A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
Is there someone you trust to help you make treatment choices?
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Ischemic
A public health nurse has been asked to provide a health promotion session for men at a wellness center. What should the nurse inform the participants about testicular cancer?
It is highly responsive to treatment.
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
It will help to observe for dimpling more closely.
The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client?
Keep the dialysis supplies in a clean area, away from children and pets
A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make?
Kidney transplants in patients your age are as successful as they are in younger patients.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal)
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.
Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?
Less than 400 mL
The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?
Leukopenia
The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate?
Level of consciousness
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the patients restrictive clothing.
A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
Lumpectomy and radiation
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?
Maintain and improve cerebral tissue perfusion
The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
Maintain aseptic technique when administering dialysate.
cerebral perfusion. A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
Maintain the patient on complete bed rest.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway
A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient?
Managing postoperative pain
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
Meningitis
Which term is used to describe removal of breast tissue and axillary lymph node dissection leaving muscular structure intact as surgical treatment of breast cancer?
Modified radical mastectomy
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
Most cases of ovarian cancer are considered to be random, with no obvious causation.
The nurse recognizes which statement as accurately reflecting a risk factor for breast cancer?
Mother affected by cancer before 60 years of age
During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
National Institutes of Health Stroke Scale (NIHSS) score, LOC at time of admission, Age
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis?
Neck flexion produces flexion of knees and hips
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?
Oliguria
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI?
Oliguria
The nurse is completing the admission history for a client who is admitted for a reduction mammoplasty. Which of the following client statements is uncommon when explaining the rationale for the procedure?
Others disapprove
During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patients signs and symptoms are suggestive of what health problem?
Pagets disease
Which of the following occurs late in chronic glomerulonephritis?
Peripheral neuropathy
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
Phenytoin
A 76-year-old with a diagnosis of penile cancer has been admitted to the medical floor. Because the incidence of penile cancer is so low, the staff educator has been asked to teach about penile cancer. What risk factors should the educator cite in this presentation? Select all that apply.
Phimosis, Increasing Age, Lack of circumcision
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
Place a pillow in the axilla when there is limited external rotation.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
Place the patient in a side-lying position
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
Place the patients extremities where she can see them.
The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply.
Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order.
The nurse is caring for a patient who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this patient at this time?
Provide emotional support to the patient and her family.
A 22-year-old male is being discharged home after surgery for testicular cancer. The patient is scheduled to begin chemotherapy in 2 weeks. The patient tells the nurse that he doesnt think he can take weeks or months of chemotherapy, stating that he has researched the adverse effects online. What is the most appropriate nursing action for this patient at this time?
Provide empathy and encouragement in an effort to foster a positive outlook.
A 52-year-old woman has just been told she has breast cancer and is scheduled for a modified mastectomy the following week. The nurse caring for this patient knows that she is anxious and fearful about the upcoming procedure and the newly diagnosed malignancy. How can the nurse most likely alleviate this patients fears?
Provide the patient with relevant information about expected recovery.
The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply.
Providing emotional support for the family, Monitoring for complications, Participating in emergency treatment of fluid and electrolyte imbalances, Providing nursing care for primary disorder (trauma)
The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply.
Quantity of output, Color of the output, Visible characteristics of the output
A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?
Radical trachelectomy
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
Recent intracranial pathology, Current anticoagulation therapy, Symptom onset greater than 3 hours prior to admission
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?
Report this to the physician as a possible sign of clinical deterioration.
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?
Restrict fluids before surgery.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis.
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection
The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patients analgesic regimen be best managed?
Scheduled analgesia should be administered around-the-clock to prevent pain.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
Severe headache
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are
Severe headache and early change in level of consciousness
A 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client?
She should eat a low-fat diet to further decrease her risk of breast cancer.
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Smoking
The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma?
Smoking cessation
What is used to decrease potassium level seen in acute renal failure?
Sodium polystyrene sulfonate / Kayexalate
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage?
Stage 3
A child with cancer is receiving chemotherapy, and his mother is concerned that the nausea and vomiting associated with chemotherapy are reducing his ability to eat and gain weight appropriately. What is the most appropriate nursing action?
Start antiemetic at the first hint of nausea
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer?
Stop smoking as soon as possible
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?
Streptococcal infection
Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care?
Supervise the patients activities of daily living closely.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
Take antihypertensive medication as ordered.
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a BP reading on the affected arm can damage the fistula.
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
Tall, peaked T waves
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?
Teaching the patient to perform deep breathing and coughing exercises
A public health nurse is teaching a health class for the male students at the local high school. The nurse is teaching the boys to perform monthly testicular self-examinations. What point would be appropriate to emphasize?
Testicular cancer is a highly curable type of cancer.
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.
The client arrives at a public health clinic worried that she has breast cancer since finding a lump in her breast. When assessing the breast, which assessment finding is characteristic of fibrocystic disease?
The lump is round and movable.
The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patients risk for breast cancer?
The patient gave birth to her first child at age 38.
A patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis?
The patient has a 15% chance of 5-year survival
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
The patient should avoid close contact with his daughter for 2 months.
. A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care?
The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
The nurse is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure to be completed before the surgery can be done?
Tissue expansion
The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?
Wash hands carefully and frequently.
During a follow-up visit, a female client who underwent a mastectomy asks the nurse if she can work in her backyard or at least do some household work. Which suggestion would be most appropriate?
Wear gloves and protective clothing to avoid any injuries
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?
When symptoms cease, the client will return to presymptomatic state.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
White blood cell (WBC) count of 20,000/mm3
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?
White male, age 60, with history of uncontrolled hypertension
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?
With each meal
The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?
With food
for which of the following population groups would an annual clinical breast examination be recommended?
Women over age 40
A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?
Womens knowledge of how their breasts normally look and feel
A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?
bruit
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?
impaired cerebral circulation
A nurse is caring for a paGent who received a hysterectomy. The nurse notes the paGent has been tearful for the last 24 hours staGng "Who is going to love me". The paGent has been refusing visitors. Which of the following problems would the nurse consider a priority?
isolation is the priority because she is refusing visitors
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
left visual field deficit
75 year old woman complains of bloaGng, abdominal pain, urinary urgency and feeling full quickly... the nurse suspects
ovarian cancer
A client has been diagnosed with acute glomerulonephritis. This condition causes
proteinuria.
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action?
reposition the patient to facilitate drainage
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
rovide thickened commercial beverages and fortified cooked cereals.
55 year old woman undergoes a hysterectomy. The cervix is spared. The nurse suspects the patient underwent what type of hysterectomy?
she just wants us to know how to take care of a hysterectomy
25 year old male presents with a painless lump and swelling in testicle. The patient complains of heaviness. The nurse suspects
testicular cancer
A patient undergoes a TURP. The nurse notes that 72 hours post op the patient has amber colored urine. The nurse performs which of the following actions.
this is concerned normal
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
