Module 10-Physiological Health Problems

A nurse is caring for a child with newly diagnosed type 1 DM who is receiving insulin. The child suddenly exhibits tachycardia and begins to sweat and tremble and the nurse determines that the child is experiencing a hypoglycemic reaction. the nurse would immediately give the child

1/2 cup of fruit juice

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 CPR. How many compressions per min does the nurse deliver

100

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

2inches

a nurse notes that a client has ST segment depression on the ECG monitor. with which serum K reading does the nurse associate this finding

3.1 mEq/L

The nurse is adminstering CPR to an adult client. Which compression-ventilation ratio is correct

30:2

A nurse is assigned to care for 4 clients on the med-surg unit. Which client should the nurse see first on the shift assessment

A client with new-onset SOB and a hx of pulm edema

a nurse notes that a client's serum K level is 5.8. The nurse interprets this as an expected finding in the client with

Addison's Disease

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

BP and wt

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 cleint 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 OTC cortisone cream on the rad 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 RA about join 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 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 tx measures. Which statement by the father indicates a need for further instruction

I should put a steam vaporizer in her room

The nurses teaches a client with GERD about measures to prevent reflux during sleep. The nurse determines that the client needs additional instruction if the client states

I should sleep flat on my right side

A nurse provides home care instructions to a client with a 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 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 ECG. Which finding would the nurse expect to note in the event of an ischemic episode

ST-segment depression

A nurse is working in the ED. Which client should be assessed first

a client with new-onset a-fib with a rate of 118bpm

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. a) absence of FHR b) bradypnea c) severe chest pain d) increased BP e) increased frequency of uterine contractions

a) absence of FHR c) severe CP

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client SATA a) increased UOP b) hyperactive DTR c) muscle weakness d) paresthesias e) Chvostek sign

a, c

The ED nurse assesses a client who has a dx of left sided HF. Which findings does the nurse expect to note SATA a) dyspnea b) dependent edema c) crackles on auscultation of the lungs d) abdominal distention e) neck vein distention

a, c

a home care nurse is providing instructions to the mother of a 3 y/o with hemophillia regarding care of the child. Which statements by the mother indicate a need for further instructions SATA a) I will be so glad when my baby outgrows all of this bleeding b) I should move furniture with sharp corners out of the way and pad the corners of the furniture c) If he gets a cut, I should hold pressure on it until the bleeding stops d) I should check the house for any household items that could fall over easily e) I need to cancel all of the dental appts that I've made for him

a, e

An ED nurse receives a call from EMS 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 ED with reports of a headache, hives, itching and dysphagia. The client states that he took ibuprofen 1 hour earlier and believes that he is experiencing an allergic reaction to this med. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first

administration of a SQ injection of epi

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

alternating liquids with solids

a nurse is reviewing the medical records of the clients whom she is assigned on the 7a-7p shift. Which client will the nurse monitor most closely for excessive fluid vol

an 85 y/o client receiving IV therapy at a rate of 100mL/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 nurse attending a recertification course in BLS for healthcare professionals in 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 call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse advises the child's mother to immediately

apply ice to the affected area

A client who sustained a fx 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 at the ED for tx 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 dx 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 ox

A stepdectomy is performed on a client with otosclerosis. During the preparations for d/c, which home care instruction does the nurse give the client

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

A nurse is caring for a client experiencing hyponatremia who was admitted to the med-surg unit with FVO. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client SATA a) decreased UOP b) hyperactive bs c) skeletal muscle weakness d) hyperactive DTR e) slow HR

b, c

A nurse is caring for a client with Crohn disease whose mag level is 1.0. Which assessment findings does the nurse expect to note SATA a) hypotension b) Trousseau sign c) skeletal muscle weakness d) abdominal distention e) decreased DTR

b, d

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

begin chest compressions

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a dx of intussusception. Which occurrence 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 2-3 hours

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a dx of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client SATA a) increased BP b) decreased resp depth c) increased resp rate d) decreased HR e) decreased UOP

c, e

The wife of a client with angina pectoris calls the HCP's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 SL nitro tabs 5 min apart with no relief. The nurse tells the client's wife to

call EMS to take her husband to the ED immediately

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shift. which instruction does the nurse plan to include

call the HCP 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 fx. Which intervention should the nurse include in the plan of care

checking the skin integrity of the right leg at least q8h

A client with a SCI suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his BP has increased and that his HR has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the HOB and immediately

checks the client's bladder for distention

A nurse is monitoring a client after a TURP procedure for BPH. The clietn has a bladder irrigation infusing and the urine output is a light cherry color. The nurse performs a f/up assessment 1 hour later and notes that the UOP is now bright red in color with clots and that the client's BP has dropped. Which action by the nurse is appropraite

contacting the HCP

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's BP has dropped from 132/84 to 90/50 and that the HR has increased from 78 to 96bpm. On the basis of these findings, the nurse immediately

contacts the HCP

A home care nurse visits a pregnant client with a dx of mild preE. During the assessment, the client tells the nurse taht she has had an upset stomach and pain in the epigastric area. The nurse most appropraitely

contacts the client's HCP

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 assessment finding 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 cancer of the larynx is receiving extenal radiation therapy of the neck. Which s/e related specifically to the site of irradiation does the nurse tell the client to expect

dysphagia

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 carbs

a HCP writes a rx for the administration of IV KCL to a client with hypokalemia. What does the nurse plan to do when preparing and administering this med

ensure that the med is diluted in an appropriate amount of NS sltn

A nurse is providing d/c instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will

expect to experience pain, N&V after the procedure

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

face the client when talking, keeping the hands away from the mouth

A client with CKD is undergoing his first hemodialysis tx, and the nurse is monitoring the clients for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client

h/a and confusion

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

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 is she indicates that she will

have her child use a straw to make drinking easier

A nurse is reviewing the assessment findings and lab results of a child with a dx of new onset of glomerulonepritis. which finding would the nurse expect to note

hypertension

A nurse is assessing a child with increased ICP 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 neuro fxn

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 Meniere 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 HOB 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 assessing a client with AIDS for signs of Pneumocystitis jiroveci infection. Which sign of infection is the earliest manifestation

nonproductive cough

A client has an AV 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 resp; 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 monitoring a client with DVT for signs of pulmonary embolism. For which most common sign of DVT, does the nurse assess the client

pleuritic chest pain

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

positive result on an acid-fast bacillus smear

A nurse is caring for a client in the ICU who is being mechanically ventilated. As the nurse prepares meds, the client suddenly becomes anxious and pulls out the ET 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 dx of Graves disease. Which intervention does the nurse include in the plan

providing a high calorie, high protein diet

A nurse assessing a client in the 4th 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 appropraite

records the findings

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?

resp distress syndrome

A nurse provides dietary instructions to the mother of a child with celiac disease. Which food 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 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 nurse is assessing a newborn for fetal alcohol syndrome. 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 dx of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for

signs of congestive HF

A nurse in a newborn nursery receives a 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 DM who requires insulin about methods of preventing DKA when the client is ill. The nurse tells the client to

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 exam, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12mmHg and the left eye is 19mmHg. The nurse tells the client that

the IOP in both eyes is normal

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

the traction ropes are unable to move 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 2-3 hours initially

A nurse is conducting an assessment of a client with mild PreE. 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 defecit. The nurse tells the client to

turn the head to scan the lost visual field

A nurse is having dinner at a resturant 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 inititates CPR immediately and the resturant manager rushes to the scene with and 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 rad 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 places the implant in a lead container

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

uterine tenderness

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

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

within the client's reach on the right side

a nurse is caring for a client who is being treated for congestive HF and has been assigned a nursing dx of excessive fluid vol. Which assessment finding causes the nurse to determine that the client's condition has improved

wt loss of 4lbs in 24 hours

A female client who has undergone placement of a sealed rad 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