Physiological Adaptation 1
A college student who was diagnosed with mononucleosis 2 weeks ago arrives at the clinic. Which of the following should be the greatest concern to the nurse?
Abdominal pain in the left upper quadrant?
A nurse is assessing a client who has presented to the emergency department with reports of vision loss. The client describes the loss as having begun with a "flash" of light followed by a "curtain" across the field of vision. The nurse should interpret the reports as being related to
Retinal detachment
A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse observe closely for involvement?
Respirations
A nurse is preparing a client for an intravenous pyelogram (IVP). Which of the following findings should be reported to the provider?
Vomiting and diarrhea for the last 6 hours
A nurse is caring for a client who has a history of alcohol addiction and is attempting to leave the mental health unit against medical advice. Which of the following is an appropriate action by the nurse?
Call the nursing supervisor and discuss the situation.
A nurse is caring for a client who is 1 day postoperative following a craniotomy and notes a weight increase of 4 lb from the preoperative weight and a urine output of 75 ml/3hr. Which of the following actions should the nurse take FIRST?
Auscultate breath sounds?
A nurse provided teaching to the parent of a child diagnosed with celiac disease. Which of the following statements by the parent at the child's next appointment indicates a need for additional teaching?
"I have started making the soups my child eats with bouillon cubes."
A nurse is caring for a client who is 2 days postoperative following gastric surgery. Which of the following assessments should concern the nurse most?
200 mL of bright red drainage via the NG tube
A nurse is caring for a client who has Meniere's disease. Which of the following structures of the ear should the nurse identify as the origin of the dizziness experienced during a flare?
Cochlea
A nurse is conducting a home visit of an older adult client who has diabetes mellitus who is taking NPH insulin subcutaneously every morning. The client's partner asks the nurse why the client acts fine at lunch, but is disoriented and confused prior to dinner. The nurse should explain that a likely cause of this behavior is
Hypoglycemia
A client who has an ileostomy tells a nurse that her spouse wants to help with the bag change. Which of the following is an appropriate response to the client by the nurse?
"It seems that your spouse wants to feel needed."
The nurse is caring for a client who has pancreatitis. Select the part of the body where the nurse would assess for a positive Cullen's sign.
Periumbilical area
When assessing a child who is receiving IV chemotherapy, a nurse discovers extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions in this situation? (All steps must be used.)
Stop the infusion
Elevate the extremity
Notify the provider
Remove the IV line
A nurse is obtaining a guaiac test from a client. Which of the following assessment findings by the nurse provide the appropriate rationale for the prescription?
Blood in stool
A nurse should intervene if which of the following actions were observed?
A nurse discards an empty blood bag and tubing in the client's bedside trashcan.
A nurse is admitting an adult client to the emergency department who experienced a head injury from a fall. The client was carried in by coworkers. Which of the following actions is the HIGHEST priority?
Immobilize the client's cervical spine.
A nurse is caring for an older adult client. Which of the following signs may indicate the need for an additional assessment of osteoporosis?
Lower back pain
A nurse is caring for a client who has a cerebral lesion who develops hyperthermia. Based on the knowledge of physiology, the nurse understands that which of the following areas of the brain may be affected?
Hypothalamus
A nurse is caring for a client who is exhibiting symptoms of delirium. The nurse should understand that a laboratory value that can be associated with a diagnosis of delirium is
BUN 68 mg/dL.
A nurse is triaging clients during a mass casualty event. The nurse correctly labels a young woman who has a visible head trauma and fixed, dilated pupils as
Expectant Category (Class IV)
A nurse is assessing a client who has cholecystitis. The nurse expects to find discomfort in which of the following areas of the abdomen?
Right hypochondriac
A nurse is preparing to administer medication to a client whose order reads "Milk of Magnesia 1 and 1/2 oz PO." Which of the following amounts in milliliters should the nurse administer?
45 mL
A nurse is providing care to a client who has a diagnosis of neutropenia and a new onset of fever. Which of the following actions are appropriate for the nurse to take? (Select all that apply)
Obtain a set of blood cultures.
Administer a broad spectrum IV antibiotic.
Screen all visitors entering the client's room.
Ensure fresh flowers are not allowed in the client's room.
A nurse is instructing a client recently diagnosed with Addison's disease. The nurse correctly states that the disease results from inadequate production of which of the following hormones from the adrenal cortex?
Glucocortocoids
A nurse is discussing chemotherapy options with a client. Which of the following actions should have the greatest influence on increasing the client's participation in his care?
Allow the client to make decisions regarding his treatment.