Quizlet n524 Health Assessment

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1 Inflammation of the synovial membrane rarely occurs. 2 Bony ankylosis of a joint is irreversible and causes immobility. 3 Complete immobility is desired during the acute phase of inflammation. 4 Redness and swelling of a joint signify that irreversible damage has occurred.

Bony ankylosis of a joint is irreversible and causes immobility. Ossification of cartilage, particularly of the spine, causes fixation of the involved joints. Inflammation and thickening of the synovial membrane are characteristics of arthritis. Although rest is essential, complete immobility will result in loss of joint motion. Redness and swelling are symptoms of local inflammation; they do not indicate irreversible damage.

A client with a history of chronic kidney disease is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Before the institution of CAPD, the nurse meets with the client to formulate a plan of care. Primarily, the nurse should assess the client for the presence of: Motivation 2 Dysrhythmias 3 Lability of mood 4 Respiratory problems

Motivation Lack of motivation is the most serious impediment to successful CAPD. Also, CAPD is contraindicated for clients who are blind or have a colostomy, a psychosis, or peripheral vascular disease. The presence of a dysrhythmia is not a contraindication for CAPD if the client is receiving medical supervision. Emotional lability is not a contraindication for CAPD if the client is receiving medical supervision. A pulmonary problem is not a contraindication for CAPD if the client is receiving medical supervision.

The nurse is assessing the pulse of a client with an on-demand pacemaker. What should the nurse identify when a client's on-demand pacemaker is functioning effectively? 1 Regular rhythm 2 Palpable at all pulse sites 3 At least at the demand rate 4 Equal to the pacemaker setting

At least at the demand rate

A nurse is assessing a client whose mouth is drawn over to the left. The nurse should consider damage to which cranial nerve to be the most likely explanation for this clinical finding? 1 Left facial nerve 2 Right facial nerve 3 Left abducent nerve 4 Right trigeminal nerve

Left facial nerve The facial nerve (seventh cranial) has motor and sensory functions. The motor function is concerned with facial movement, including smiling and pursing the lips. Nonconduction of the facial nerve will cause drooping on the side of the problem. Nonconduction of the facial nerve on the right side will cause that side of the face to droop. Nonconduction of the left abducent nerve will prevent abduction of the left eye. Nonconduction of the trigeminal nerve will cause problems in mastication.

A client with cancer of the bladder is admitted to the hospital for diagnostic tests to determine the extent of the disease. While the nurse is caring for the client, the client asks, "If they remove my bladder, how will I be able to urinate?" Which is the best response by the nurse? 1 "You can still function normally without a bladder." 2 "I am sure this is very upsetting to you, but it will be over soon." 3 "I know you're upset, but there are alternatives to removing your bladder." 4 "The tests will help to determine whether your bladder has to be removed."

"I know you're upset, but there are alternatives to removing your bladder." The response "I know you're upset, but there are alternatives to removing your bladder" offers the best combination of factual information and emotional support. The response "You can still function normally without a bladder" disregards the client's feelings; it is inaccurate information because if the bladder is removed, bladder function will not be normal. Although the response "I am sure this is very upsetting to you, but it will be over soon" identifies the client's feelings, further communication is cut off by the second part of the response. The response "The tests will help to determine whether your bladder has to be removed" is factual but does not answer the question or offer emotional support; it may increase anxiety

A client is discharged the same day after ambulatory surgery for a laparoscopic cholecystectomy. The nurse is providing discharge teaching about how many days the client should wait to engage in certain activities. Place in order the activities from the first to the last in which the client may engage 1) Getting out of bed in a chair 2) Performing light exercise 3) Showering 4) Driving a car 5) Lifting objects of more than 10 pounds

1) Getting out of bed in a chair 2) Performing light exercise 3) Showering 4) Driving a car 5) Lifting objects of more than 10 pounds Getting out of bed is the activity that should be implemented first. It allows the client to adjust to the upright position before ambulating. Light exercise, such as walking, can begin after tolerating sitting in a chair. A client may shower or bathe one to two days after surgery. A client may drive three to four days after surgery. Objects exceeding 10 lb may be lifted one week after surgery.

A nurse is weighing a client with heart failure. The client weighed 175 lb on the last visit and has had a 5% weight gain since then. The nurse suspects that the client is retaining fluid. How many liters of fluid has the client retained? Record your answer using a whole number. ___ liters

4 Multiply the client's weight by 5% (175 × 5% = 8.75 lb). Each liter of fluid is equal to 2.2 lb. Round 8.75 lb to 8.8 lb and divide by 2.2; this equals 4 liters.

The nurse is reviewing the plan of care for a client who is scheduled for a barium swallow. The plan will include: 1 Giving clear fluids on the day of the test 2 Asking the client about allergies to iodine 3 Administering cleansing enemas before the test 4 Administering a laxative after the procedure

Administering a laxative after the procedure Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium. The client must be kept nothing by mouth. Iodine is not used with barium. Administering cleansing enemas before the test is not part of the preparation; feces in the lower gastrointestinal (GI) tract will not interfere with visualization of the upper GI tract.

A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain on a level 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do? 1 Determine when the pain medication was last given. Correct2 Verify the pain medication prescription in the clinical record. 3 Employ nonpharmacological measures initially to relieve the pain. 4 Explain that the primary nurse will be back from lunch in a few minutes.

Before administering any medication for the first time the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription in the client's medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain associated with recent major abdominal surgery. The client's pain must be immediately addressed. The covering nurse is capable of verifying the pain medication prescription and administering it safely at the correct time

When making a differentiation between myasthenic and cholinergic crises, the nurse understands that the clinical manifestations of cholinergic crisis include: 1 Blurred vision 2 Muscle weakness 3 Respiratory distress 4 Difficulty swallowing

Blurred vision The client in cholinergic crisis usually is overmedicated with an anticholinesterase medication that intends to reduce excessive cholinergic activity in the brain (prevents the decrease of Ach by the enzyme ChE). Muscle weakness occurs with both myasthenic and cholinergic crises. Respiratory distress occurs with both myasthenic and cholinergic crises. Difficulty swallowing occurs with both myasthenic and cholinergic crises.

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply. Correct 1 Iced tea 2 Red meat 3 Club soda 4 Hot cocoa 5 Chocolate pudding

Iced Tea Hot cocoa chocolate pudding Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition

A nurse is concerned that a client with a diagnosis of cirrhosis of the liver may experience the complication of hepatic coma. For which clinical indicator should the nurse assess this client? 1 Icterus 2 Urticaria 3 Uremic frost 4 Hemangioma

Icterus Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.