Silversteri first 100 questions
A hospitalized client with allergic asthma has been started on cromolyn sodium inhaler. The nurse assists in preparing a plan of care and includes monitoring for undesirable side effects associated with the use of this medication. The nurse places the highest priority on monitoring for which side effect? 1. Cough 2. Bronchospasm 3. Throat irritation 4. Nasal congestion
2 Rationale: The most common undesired clinical responses associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.
Nifedipine has been prescribed for a client with Raynaud's disease, and the nurse reinforces medication instructions with the client about the medication. Which statement by the client indicates a need for further teaching? Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pharmacology: Cardiovascular Medications Integrated Process: Teaching and Learning Priority Concepts: Client Education, Safety Strategy(ies): Negative Event Query, Strategic Words 1. "I will contact my doctor if I get short of breath." 2. "I will call my doctor if I get headaches that worsen." 3. "Nausea and drowsiness are expected, and if they occur, I don't really need to worry about it." 4. "I need to get up slowly when I change positions because the medicine causes hypotension
3 Rationale: Nifedipine is a calcium antagonist that reduces smooth muscle contractibility by inhibiting the movement of calcium ions in slow channels. Its side effects include headache, flushing, peripheral edema, and postural hypotension. Overdose of the medication produces nausea, drowsiness, confusion, and slurred speech. If signs of overdose occur, the health care provider is notified.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Gastrointestinal Integrated Process: Nursing Process/Data Collection Priority Concepts: Elimination, Nutrition Strategy(ies): Strategic Words, Subject 1. Sweating and pallor 2. Dry skin and stomach pain 3. Bradycardia and indigestion 4. Double vision and chest pain
1 Rationale: Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth? Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Respiratory Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Safety Strategy(ies): Subject 1. Bite stick 2. Oral airway 3. Nasal airway 4. Padded tongue blade
2 Rationale: An oral airway may be used to keep the client from biting down, occluding an orotracheal tube. A nasal airway is not used in conjunction with an oral endotracheal tube. A padded tongue blade or a bite stick may be used initially to open the mouth for easier insertion of an oral airway.
A client is receiving phenytoin. Which findings would indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Neurological Medications Integrated Process: Nursing Process/Data Collection Priority Concepts: Intracranial Regulation, Safety Strategy(ies): Subject 1. Ataxia 2. Constipation 3. Bleeding gums 4. Decreased white blood cells 5. Decreased platelet count
2,3,4,5 Rationale: Phenytoin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily. Ataxia is a side effect of benzodiazepines.
A client who is receiving negative pressure wound therapy (NPWT) is scheduled for a dressing change. Identify the sequence the nurse should follow. (Place the steps in the selected order of performance. All steps must be used.)
A. Apply sterile or clean gloves and irrigate wound. B. Apply skin protectant/barrier film to skin around wound. C. Remove the soiled dressing and perform hand hygiene. D. Connect the tubing to transparent film and turn on the NPWT unit. E. Place prepared foam into wound bed and cover with transparent dressing. F. Place the NPWT in the "de vac" mode and administer the prescribed analgesic.
Signs of hyponatremia s a l t l o s s
Signs of hyponatremia s : Stupor / confusion a : Anorexa l : limp muscle t : Tendon reflex down l : Lethargy o : Ortho static hypotension s : Seizure s : Shallow breathing, stomach cramps
variance occurs when
expected outcome of critical pathway are not met The client has circular area of nonblenchable redness on her left heel
Which food sources should the nurse include in the discharge teaching plan of a client with vitamin B12 deficiency anemia? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Hematological Integrated Process: Nursing Process/Planning Priority Concepts: Client Education, Nutrition Strategy(ies): Subject 1. Eggs 2. Liver 3. Ice cream 4. Red meats 5. Citrus fruits
1,2,4 Rationale: Eggs, enriched grain products, and red meats, especially liver, are food sources high in vitamin B12. Ice cream (high in calcium and fat) and citrus fruits (high in vitamin C) are not food sources high in vitamin B12.
The nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Endocrine Integrated Process: Nursing Process/Data Collection Priority Concepts: Glucose Regulation, Infection Strategy(ies): Subject 1. Temperature 2. Blood glucose 3. Blood pressure 4. Pulse and respirations
1. Rationale: Elevated temperature may be indicative of infection, which is a leading cause of hyperglycemic hyperosmolar state (HHS) or diabetic ketoacidosis (DKA). Options 2, 3, and 4 are findings that are within a normal range.
wound irrigation steps
1. Ensure privacy 2. Introduce self 3. Place supplies near pt bedside 4. Hand hygiene 5. Use two identifiers to confirm pt 6. Verify doctors order and explain procedure 7. Raise bed to comfortable working height 8. Always assess pain before dressing change and administer pain meds at least 20 min before 9. Prepare supplies 10. Sterile normal saline solution is used for wound care irrigation 11. Don personal protective equipment per policy 12. Place absorbent pad underneath the pt 13. Use emesis basin to collect fluid beneath the wound 14. Remove the dressing being careful with pt underlying skin 15. If wound is dry and dressing has adhered to it, consider using saline to wet dressing to facilitate removal 16. Place used dressing materials in disposable bag 17. Remove something ask teacher 18. Assess wound prior to cleaning 19/ Measure dimensions to doc size and appearance of wound, odor, drainage 20. Dispose of applicator and measuring guide in disposable bag 21 Remove gloves 22. Hand hygiene 23. Open and prepare supplies 24. Using large volume syringe and large gauge needle or catheter draw up solution in syringe to irrigate 25. Use saline filled syringe to clean wound 26. Attempt to be made to maintain cleansing from top to bottom of wound 27. Solution will flow from the least contaminated area to the most contaminated 28. Minimizing risk of cross contamination 29. If you see addition debris in the wound use gauze pad to remove it 30. Can be painful 31. Use gauze pad to pat the area from top to bottom 33. Discard gauze and syringe in disposable bag 34. Open and prepare the remainder of your supplies 35. Don sterile gloves 36. Packing of wounds is for wounds that are deep or tunneling 37. Packing materials can be sterile gauze or gauze with solution present 38. Some dressing changes will not require the use of foam dressing and will need gauze dressing Info iconThis preview has intentionally blurred sections. Sign up to view the full version. View Full Document Right Arrow Icon
A client with endometrial cancer is receiving doxorubicin, an antineoplastic agent. The nurse should specifically collect data about which criteria? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Oncology Integrated Process: Nursing Process/Data Collection Priority Concepts: Cellular Regulation, Clinical Judgment Strategy(ies): Comparable or Alike Options, Data in the Question, Subject 1. Electrocardiogram 2. Level of orientation 3. Neuromuscular reflexes 4. Pupillary response to light 5. Hematological laboratory values
1.5 Rationale: Doxorubicin has adverse/side effects affecting the red and white blood cell counts and platelets. In addition, it is known to be cardiotoxic, causing dysrhythmias and electrocardiogram changes. Because of bone marrow suppression during therapy with antineoplastic agents, hematological laboratory values should be monitored closely. The incorrect options reflect neurological symptoms, which are not the concern with this medication.
A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Respiratory Integrated Process: Nursing Process/Data Collection Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Subject 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody with several clots
2 Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience significant clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.
The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Respiratory Integrated Process: Nursing Process/Data Collection Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words, Subject 1. Central cyanosis 2. Arterial Pao2 of 48 3. Arterial Pao2 of 81 4. Respiratory rate of 10 breaths per minute
2 Rationale: The most characteristic sign of ARDS is increasing hypoxemia with a Pao2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis.
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate? Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Postpartum Integrated Process: Nursing Process/Implementation Priority Concepts: Infection, Reproduction Strategy(ies): Subject 1. "The infection usually involves both breasts." 2. "The infection can occur at any time during breastfeeding." 3. "The infection usually is caused by wearing a supportive bra." 4. "The infection is most common for women who have breast-fed in the past."
2.vvRationale: Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breastfeeding. It is more common in mothers nursing for the first time and usually affects one breast at a time but can affect both breasts. Constriction of the breasts from a bra that is too tight may interfere with emptying of all the ducts and may lead to infection.
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Fundamentals of Care: Laboratory Tests Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Strategic Words, Subject 1. Prone in semi-Fowler's position 2. Supine with a pillow under the head 3. Prone with a pillow under the abdomen 4. Lateral with the head slightly higher than the rest of the body
3 Rationale: For 1 hour after the procedure, the client assumes a prone position 1 if able with a pillow under the abdomen to increase intra-abdominal pressure. 2 This position retards leakage of cerebrospinal fluid. Prone in semi-Fowler's position, supine with a pillow under the head, and lateral with the head slightly higher than the rest of the body are not the correct positions after a lumbar puncture.
The wife of a client with diabetes mellitus who takes insulin calls the nurse in a primary health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which action should the nurse tell the wife to do first? Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Endocrine Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Glucose Regulation Strategy(ies): Strategic Words 1. Call an ambulance. 2. Take his temperature. 3. Check his blood glucose level. 4. Drive him to the primary health care provider's office.
3 Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading that the nurse should then report to the primary health care provider. Option 1 or 4 may be done at a later time if required. Option 2 is unrelated to the client's immediate problem.
A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Musculoskeletal Integrated Process: Nursing Process/Data Collection Priority Concepts: Glucose Regulation, Tissue Integrity Strategy(ies): Subject 1. Pain 2. Hemorrhage 3. Edema of the stump 4. Separation of wound edges
4 Rationale: Clients with diabetes mellitus are at greater risk of wound infection and separation of wound edges leading to delayed wound healing. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.
A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury 1. Decreased heart rate 2. Increased urinary output 3. Decreased blood pressure 4. Elevated hematocrit levels
4. Rationale: The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit rises above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury but generally return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, reducing renal perfusion and glomerular filtration. This leads to a decreased urine output. Pulse rates are typically higher than normal; the blood pressure is normal or slightly elevated unless hypovolemia is severe.
An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. Which indicates that the treatment is effective? Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pediatrics: Throat/Respiratory Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words, Subject 1. The child no longer has a fever. 2. The child's bowel movements are firmer. 3. The child's skin is no longer high in sodium. 4. The child has a productive cough of thick sputum.
4. Rationale: Percussion treatments are intended to produce sputum. Thick sputum is characteristic of cystic fibrosis. Being afebrile is not necessarily reflective of the effectiveness of percussion treatments. Although a high sodium content in the skin is a sign associated with cystic fibrosis, percussion treatments will not help this characteristic. The percussion treatments will not help bowel movements.
Hyper kalemia which victim ?
BURN untreatedburn ketoacidosis who experiences shift in fluid The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. ** This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. ** ** Potassium is mostly intracellular so the cell destruction releases potassium into the blood. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis**. The body physiologically responds to acidosis by moving hydrogen ions intracellularly and potassium ions extracellularly to compensate and maintain a normal pH (7.35 to 7.45). The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Fundamentals of Care: Fluids and Electrolytes Integrated Process: Nursing Process/Data Collection Priority Concepts: Fluids and Electrolytes, Tissue Integrity Strategy(ies): Comparable or Alike Options, Subject
The nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which method as reliable for determining fluid loss? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pediatrics: Throat/Respiratory Integrated Process: Nursing Process/Data Collection Priority Concepts: Fluids and Electrolytes, Gas Exchange Strategy(ies): Subject 1. Intake 2. Output 3. Skin turgor 4. Body weight
Rationale: 4 Body weight is the most reliable method of measurement of body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. Although options 1, 2, and 3 may be used to determine fluid status, they are not the most reliable determinants.
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Postpartum Integrated Process: Nursing Process/Data Collection Priority Concepts: Pain, Tissue Integrity Strategy(ies): Subject 1. Less pain 2. Less blood loss 3. More difficult repair 4. More likely to extend with birth of LGA infant 5. More likely to become infected than other types of episiotomies
1 2 4 Rationale: Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater and the repair is more difficult and painful with the mediolateral episiotomy than the midline episiotomy. A midline episiotomy may extend more readily with a difficult delivery than the mediolateral episiotomy. This midline episiotomy is no more likely to become infected than another type of episiotomy.
A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Fundamentals of Care: Perioperative Care Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Health Policy Strategy(ies): Subject 1. The bulb container is fully compressed. 2. Bright red bloody drainage is present in the bulb container. 3. Bright red bloody drainage is present on the surgical dressing. 4. Bubbling is occurring in the collected drainage in the bulb container. 5. Movement of the fluid in the drain is observed with client respirations.
1,2 Rationale: A surgical drain is a device placed during surgery to collect fluid away from the surgical site. The Jackson-Pratt drain is a bulb collection device that is self-suction and is emptied by releasing the suction, removing the drainage, and then again compressing to apply suction. To check patency, the bulb should be compressed and contain drainage that is usually red bloody drainage on the day of surgery. There is no bubbling or tidaling of the fluid with respirations with a Jackson-Pratt drain. The drainage on the surgical dressing should be minimal if the drain is operating properly.
The nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Endocrine Integrated Process: Nursing Process/Data Collection Priority Concepts: Clinical Judgment, Fluids and Electrolytes Strategy(ies): Comparable or Alike Options, Subject 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain
2 Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration and the client would lose weight. Options 1, 3, and 4 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation).
The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Fundamentals of Care: Fluids and Electrolytes Integrated Process: Nursing Process/Data Collection Priority Concepts: Acid-Base Balance, Fluids and Electrolytes Strategy(ies): Subject 1. Dry flaky skin 2. Bleeding from the gums 3. Weakness in all extremities 4. Confusion with garbled speech 5. Diarrhea with abdominal cramping
Rationale: The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Thus the client is experiencing low sodium, or hyponatremia, as evidenced by the weakness in extremities, confusion, and diarrhea with abdominal cramping. Signs of hyponatremia include rapid and thready pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion, and apprehension. The neurological functioning of the client relates to the swollen brain cells that impair functioning. The gastrointestinal system is stimulated and hyperactive bowel sounds often occur. Dry skin and bleeding gums are not related to the low sodium level.
The nurse reinforces instructions to a client regarding the use of tretinoin. Which statement by the client indicates the need for further teaching? Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pharmacology: Integumentary Medications Integrated Process: Teaching and Learning Priority Concepts: Client Education, Tissue Integrity Strategy(ies): Negative Event Query, Strategic Words 1. "Optimal results will be seen after 6 weeks." 2. "I should apply a very thin layer to my skin." 3. "I should wash my hands thoroughly after applying the medication." 4. "I should cleanse my skin thoroughly before applying the medication."
2 Rationale: Tretinoin is applied liberally to the skin. The hands are washed thoroughly immediately after applying. Therapeutic results should be seen after 2 to 3 weeks but may not be optimal until after 6 weeks. The skin needs to be cleansed thoroughly before applying the medication.
The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body? Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pediatrics: Renal and Urinary Integrated Process: Nursing Process/Data Collection Priority Concepts: Cellular Regulation, Clinical Judgment Strategy(ies): Subject 1. Cystocopy 2. Abdominal x-ray 3. Urodynamic study 4. Computed tomography scan
4 Rationale: If the testis is not palpable, an ultrasonography, computed tomography scan, or magnetic resonance imaging can determine its location. The missing testis may be found at any point along the process vaginalis, may be located in the abdomen, or may follow an aberrant course and come to lie in the inguinal area, base of the penis, or perineum. A cystoscopy is an examination of the bladder and lower urinary tract. An abdominal x-ray would not show the presence of the testis in the abdominal cavity. A urodynamic study is done to determine voiding dysfunction and an abnormal urinary tract.
A client is seen in the health care clinic and acute pyelonephritis is suspected. The nurse reviews the client's record and should expect to note which associated signs and symptoms documented? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Renal and Urinary Integrated Process: Nursing Process/Data Collection Priority Concepts: Clinical Judgment, Elimination Strategy(ies): Subject 1. Chills 2. Low-grade fever 3. Pale, dilute urine 4. General weakness 5. Nausea and vomiting 6. Flank pain on the unaffected side
1,4,5 Rationale: Typical signs and symptoms of acute pyelonephritis include high fever, chills, nausea, vomiting, flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache. The client often exhibits the typical signs and symptoms of cystitis with production of urine that is foul smelling and cloudy or bloody and that has an increased white blood cell (WBC) count.
The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which clients? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Renal and Urinary Integrated Process: Nursing Process/Data Collection Priority Concepts: Fluids and Electrolytes, Safety Strategy(ies): Subject 1. The client with cataracts 2. The client with varicose veins 3. The client with type 2 diabetes mellitus 4. The client with chronic obstructive pulmonary disease (COPD)
4. Rationale: Peritoneal dialysis requires instillation of approximately 2 L of a dialysate solution into the peritoneal space. This solution remains in the peritoneal space for a prescribed amount of time usually from 4 to 10 hours. This is known as the "dwell time." Although this fluid remains in the peritoneal space, it causes upward displacement of the diaphragm resulting in decreased lung expansion. A client with COPD would be at high risk for developing respiratory distress if the respiratory system were to be further compromised by the instillation of the dialysate solution and the resulting upward displacement of the diaphragm. The conditions in options 1, 2, and 3 are not contraindications for peritoneal dialysis.
A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Subject 1. Serum sodium level 2. Cerebral angiography 3. Lumbar puncture (LP) 4. Oculovestibular reflex 5. Electroencephalogram 6. Computed tomography
2,3,6 Rationale: Bell's palsy can be caused by inflammation or a lesion of the facial nerve, and when the client presents with both Bell's palsy and increasing clumsiness, the health care team suspects more diffuse central nervous system lesions. The client should be referred to a neurologist or otolaryngologist as soon as possible to exclude other neurologic conditions. The most sensitive and specific tests that provide relevant diagnostic information for these types of pathology are cerebral angiography, LP, and computed tomography (options 2, 3, 6). The imaging studies illustrate central nervous system lesions, and the LP enables the care provider to analyze cerebrospinal fluid for immunoglobulins (antibodies) and other components. Because the client's neurological problem is unlikely to be metabolic, the sodium level is unlikely to be helpful (option 1). Usually electroencephalogram and oculovestibular reflex are tests reserved to evaluate electrical activity of the brain in seizure disorders and to determine brain death (option 4 and 5). In addition, the oculovestibular reflex is not performed on a client who is conscious.
The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the primary health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding? Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Pediatrics: Neurological Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Subject 1. Damage to the midbrain 2. Dysfunction of the pons 3. Damage to the diencephalon 4. Dysfunction in the cerebral hemisphere
4. Rationale: Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons.
The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance? Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Fundamentals of Care: Acid-Base Integrated Process: Nursing Process/Data Collection Priority Concepts: Acid-Base Balance, Clinical Judgment Strategy(ies): Subject 1. Drowsiness, headache, and tachypnea 2. Tachypnea, dizziness, and paresthesias 3. Disorientation, hypotension, and dyspnea 4. Decreased respiratory rate and depth and cardiac irregularities
1 Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours after overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 2 and 3 indicate respiratory acidosis and alkalosis, respectively.
The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Postpartum Integrated Process: Nursing Process/Data Collection Priority Concepts: Addiction, Reproduction Strategy(ies): Data in the Question, Subject 1. Tremors 2. Irritability 3. Bradycardia 4. Hypertension 5. Flaccid muscles 6. Exaggerated startle reflex
1,2,5,6 Rationale: Clinical signs/symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.
