Physiological Adaptation
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement?
"Antibodies are not usually formed until after exposure to an antigen."
A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response?
"Babies need comforting and cuddling; meeting these needs will not spoil him."
The nurse is conducting a comprehensive assessment on a school-age child. Which parent statement would suggest to the nurse that a child may have celiac disease?
"His stools are large and smelly."
A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement?
"It's possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other."
A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding?
"My child can't eat wheat, rye, oats, or barley."
The mother of a preschool child with juvenile idiopathic arthritis (JIA) is worried that her child will have to stop attending preschool because of the illness. Which response by the nurse would be most appropriate?
"Your child should be encouraged to attend school, but he will need extra time to work out early morning stiffness."
A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
Assess the vital signs and oxygen saturation levels.
A nurse is assessing the skin of a client that is receiving a warm compress applied to a wound. The nurse notes slight maceration and excessive redness of the surrounding skin. What should the nurse do, in order from first to last? All options must be used.
Stop the heat application. Remove the compress. Apply new sterile dressing. Assess client for other manifestations. Report findings to healthcare provider.
A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first?
Elevate the affected arm and apply ice to the injury site.
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
NPO
A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?
Notify the health care provider (HCP) of the client's breathing pattern
The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply.
a client who underwent cholecystectomy today a client with pain related to pancreatitis
A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the priority for the nurse?
administering IV fluids
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an
anticoagulant
The nurse enters the hospital room and finds the client unresponsive to verbal stimulation. What would be the next action by the nurse?
apply physical stimulation
When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?
at the base of the wound
Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
auscultate bowel sounds
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's
blood pressure
A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?
hypokalemia
The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding?
circulatory collapse
A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement?
decreased hematuria
The nurse assesses a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest?
dry skin & constipation
A child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage?
frequent swallowing
The nurse is assessing a middle-aged client with cancer who has lost 1 lb (0.5 kg) in 4 weeks. The client is taking ondansetron for nausea and now has a temperature of 101°F (38.3°C). The nurse judges that the fever is a sign of what?
infection
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
inspecting the skin for petechiae once every shift
A client is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?
intercostal retractions
A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting which finding?
less dyspnea
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube on low continuous suction. Which acid-base imbalance is most likely to occur?
metabolic alkalosis
The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which finding should be reported to the health care provider (HCP)?
neonatal central cyanosis
An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?
notify HCP
The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to:
observe client performing varied activities of daily living.
The nurse diagnoses a client with acute pancreatitis. The client is being transferred to another facility. The nurse completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the nurse's diagnosis?
recent weight loss and temperature elevation
A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?
round and movable
After being admitted to the emergency department for severe lower right quadrant pain, a child reports that the pain has suddenly resolved. Which finding would the nurse suspect?
ruptured appendix
A client is brought to the emergency department in respiratory distress caused by acute epiglottitis. Which assessment finding is most concerning for the nurse?
severe sore throat, drooling, and inspiratory stridor
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/µl. What term should the nurse use to describe this low platelet count?
thrombocytopenia
A child is admitted to the emergency department and diagnosed with a suspected ruptured appendix. The parents are anxious about the child's condition and ask the nurse what to expect for immediate treatment. What is the best response by the nurse?
we will be prepping your child for emergency surgery
A 60-year-old female is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment?
weight gain.
