Module 10: Physiological Health Problems

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease?

"Has he had a sore throat in the last few months?"

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction?

"I can dry the cast faster if I use a hairdryer on the hot setting."

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction?

"I can use over-the-counter cortisone cream on the radiation site if it gets red."

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:

"I don't need medication unless I'm having a severe attack."

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction?

"I should avoid all exercise when my joints are inflamed."

A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction?

"I should lie on my right side in bed."

A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction?

"I should put a steam vaporizer in her room."

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states:

"I should sleep flat on my right side."

A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which of these statements by the mother indicate a need for further instructions? Select all that apply.

"I will be so glad when my baby outgrows all of this bleeding." "I need to cancel all of the dental appointments that I've made for him."

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?

"I'll put lotion on my leg a few times a day."

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request?

"You need to stay in your room for now."

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will:

Have her child use a straw to make drinking easier.

A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client?

Headache and confusion.

A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which of the following findings would the nurse expect to note?

Hypertension.

A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client?

Pleuritic chest pain.

A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record?

Positive result on an acid-fast bacillus smear.

A nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beats does the nurse recognize?

Premature ventricular contractions (PVCs).

A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse?

Antecubital fossa of the arm.

A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. The nurse advises the child's mother to immediately:

Apply ice to the affected eye.

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver?

100

A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest by what depth?

2 inches.

A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding?

3.1 mEq/L.

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct?

30:2

A nurse is working in the emergency department. Which of the following clients should be assessed first?

A client with new-onset atrial fibrillation with a rate of 118 beats/min.

A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment?

A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema.

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply.

Abdominal distention, Trousseau sign.

A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with:

Addison disease.

An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first?

Administering 100% humidified oxygen.

A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?

Administration of a subcutaneous injection of epinephrine

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which of the following measures does the nurse plan to implement at mealtimes?

Alternating liquids with solids.

A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume?

An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr.

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client?

An ultrasound examination.

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves:

Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material.

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately:

Assesses the client.

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first?

Assessing the client's vision.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first:

Attaches the child to a pulse oximeter.

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client?

Avoid rapidly moving the head and bending over for at least 3 weeks.

A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication?

Ensure that the medication is diluted in an appropriate amount of normal saline solution.

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates what?

Expect to experience pain, nausea, and vomiting after the procedure.

A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant to:

Face the client when talking, keeping the hands away from the mouth.

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items:

B. Within the client's reach on the right side

A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first?

Beginning chest compressions.

The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, what does the nurse immediately do?

Begins cardiopulmonary resuscitation (CPR).

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective?

Blood pressure and weight.

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which of the following occurrences does the nurse expect the mother to report?

Bloody mucus stools and diarrhea.

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will:

Breastfeed the newborn every 2 to 3 hours.

The wife of a client with angina pectoris calls the physician's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. What does the nurse tell the client's wife to do?

Call Emergency Medical Services to take her husband to the emergency department (ED) immediately

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include?

Call the primary health care provider if the infant is lethargic.

A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first?

Check the system for kinks.

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care?

Checking the skin integrity of the right leg at least every 8 hours.

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately:

Checks the client's bladder for distention.

A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate?

Contacting the primary health care provider

A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately:

Contacts the client's primary health care provider

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately:

Contacts the primary health care provider

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which of the following assessment findings indicates to the nurse that the client may be experiencing hypotonic contractions?

Contractions that can be indented easily with fingertip pressure at their peak.

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.

Decreased urine output. Increased respiratory rate.

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect?

Dysphagia.

The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply.

Dyspnea Crackles on auscultation of the lungs

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to:

Eat small frequent meals that are low in fat and protein and high in carbohydrates.

A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition:

Indicates deterioration in neurological function.

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client?

Instituting measures to prevent infection in the client.

A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child?

Lethargy.

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to:

Limit sodium in the diet.

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion?

Limiting elevation of the head of the bed to 45 degrees.

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first:

Manually ventilate the client, using a resuscitation bag.

Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:

Moist heat will increase circulation and may be used before the breasts are emptied.

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply.

Muscle weakness Increased urine output

A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation?

Nonproductive cough.

A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?

Palpate for a vibrating sensation at the fistula site.

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately:

Places the client in the knee-chest position.

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately:

Places the infant in the knee-chest position.

A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then:

Prepares for reintubation.

A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which of the following interventions does the nurse include in the plan?

Providing a high-calorie, high-protein diet.

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately:

Records the findings.

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely?

Respiratory distress syndrome.

A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child's diet?

Rice.

A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to:

Rock back and forth to start movement.

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which of the following findings would the nurse expect to note in the event of an ischemic episode?

ST-segment depression.

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

Semi-Fowler.

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply.

Severe chest pain Absence of fetal heart tones.

A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn?

Short palpebral fissures and a flat midface.

A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for:

Signs of congestive heart failure (CHF).

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply.

Skeletal muscle weakness, Hyperactive bowel sounds.

A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside?

Sterile dressing.

A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. What does the nurse tell the client to do?

Take the prescribed insulin dose even if he is unable to eat.

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client:

That redness and swelling of the eyelids and conjunctiva are expected.

During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client:

That the intraocular pressure in both eyes is normal.

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist?

The traction ropes are unable to move over the pulleys.

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother:

To bring the newborn to the clinic.

A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse tells the client:

To plan to drain the reservoir every 2 to 3 hours initially.

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition?

Trace protein in the urine.

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to:

Turn the head to scan the lost visual field.

A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next?

Use the AED.

A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first?

Using long-handled forceps to place the implant in a lead container.

A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented?

Uterine tenderness.

A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm?

Ventricular tachycardia.

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan?

Visitors must be limited to one half-hour per day.

A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved?

Weight loss of 4 lb in 24 hours.

An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client?

With the knees drawn up to the chest.

A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. What should the nurse immediately give the child?

½ cup of fruit juice.