Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement?
Rationale:
Rapid weight gain indicates that the client with Addison's disease is receiving too much glucocorticoid replacement. Excess glucocorticoids can lead to fluid retention and increased appetite, resulting in significant weight gain, which is a hallmark of over-treatment. Monitoring weight is essential for adjusting glucocorticoid dosages appropriately to avoid complications associated with excess hormone levels.
A: Anorexia. This symptom typically suggests insufficient glucocorticoid levels rather than an excess, as individuals with Addison's disease often experience decreased appetite due to inadequate hormone production.
B: Dizziness. Dizziness is often linked to low cortisol levels in Addison's disease, reflecting adrenal insufficiency rather than an indication of excessive glucocorticoid replacement therapy.
D: Poor skin turgor. Poor skin turgor generally reflects dehydration or inadequate glucocorticoid levels, not an overabundance, as excess glucocorticoids usually promote fluid retention and improved skin elasticity.
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
Rationale:
C: I.V. rate increase. The client's indicators, including low blood pressure and inadequate urine output, signal hypovolemia, necessitating an increased intravenous fluid rate to enhance circulation and kidney perfusion, addressing the urgent need for fluid resuscitation.
A: Furosemide (Lasix) may exacerbate fluid volume depletion, counterproductive in this scenario where the client requires more fluids to stabilize blood pressure and improve renal function.
B: Fresh frozen plasma would not address the immediate fluid deficit or low blood pressure, as the priority is replenishing volume rather than correcting potential coagulopathy or protein deficiencies at this moment.
D: Dextrose 5% provides calories but lacks the necessary volume to correct hypotension and hypovolemia, failing to meet the critical requirement for effective fluid resuscitation in this burn patient.
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
Rationale:
B: Apply water-soluble jelly to lubricate the nares. This activity aids in maintaining moisture in the nasal passages, promoting healing and comfort after the removal of nasal packing, thus preventing crusting and irritation.
A: Avoid cleaning the nares until swelling has subsided. This approach can lead to increased discomfort and potential complications; gentle cleansing is often necessary to maintain hygiene even with swelling.
C: Keep a nasal drip pad in place to absorb secretions. While this may seem practical, it does not directly address the need for lubrication and can lead to unnecessary discomfort.
D: Use a bulb syringe to gently irrigate nares. This method might be too aggressive post-surgery, potentially causing trauma to sensitive tissues and delaying the healing process rather than facilitating it.
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
Rationale:
Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
Confirming the administration of morphine ensures the nurse has accurate information on the client's recent medication history, which is crucial for safe pain management and preventing potential overdose.
B: Assess the client for manifestations of pain. Pain assessment is essential but premature without verifying prior medication administration, as it could lead to unnecessary interventions or mismanagement of the client's condition.
C: Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom. While reviewing documentation is important, direct validation from the outgoing RN offers immediate clarity about the medication's administration status.
D: Check to ascertain if any discrepancy had been documented with accompanying reason/s. Investigating discrepancies is vital for safety, yet this step is secondary to confirming the actual administration of the narcotic.
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
Rationale:
C: A 50-year-old woman caring for a spouse with cancer should be prioritized for seasonal influenza vaccination. Her caregiving role places her at increased risk, as she may be exposed to infections while caring for an immunocompromised individual, making vaccination essential for both her and her spouse's health.
A: A 60-year-old man with a hiatal hernia does not represent a significantly higher risk for influenza compared to others. His condition does not necessarily compromise his immune system.
B: A 36-year-old woman with three children may be exposed to illness, but her age and lack of chronic conditions do not indicate a higher priority than caregivers of vulnerable patients.
D: A 60-year-old woman with osteoarthritis may have some risk factors, yet her condition does not elevate her priority for vaccination above those caring for immunocompromised individuals.
The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations?
Rationale:
D: Undergoing a root canal. In stressful situations such as dental procedures, individuals with Addison's disease may require an increased glucocorticoid dosage to manage stress and prevent adrenal crisis, ensuring adequate hormone levels during the event.
A: Completing the spring semester of school. While academic stress can be significant, it typically does not necessitate an adjustment in glucocorticoid dosage compared to physical stressors like surgery.
B: Gaining 4 pounds. Weight gain does not directly correlate with the need for glucocorticoid dose adjustments, as it may not reflect immediate physiological stress or adrenal insufficiency.
C: Becoming engaged. Although engagement can be emotionally significant, it generally does not induce the level of physical stress that would require an increase in glucocorticoid doses for Addison's patients.
What should the nurse do first for a client with a suspected spinal cord injury?
Rationale:
Immobilize the spine. Immediate immobilization is crucial to prevent further damage to the spinal cord in suspected injuries. This action stabilizes the patient and allows for safer transport to advanced medical care and diagnostic procedures.
B: Administer pain medication. While managing pain is essential, it should not precede stabilization, as movement during administration can exacerbate potential spinal injuries.
C: Check motor function. Assessing motor function is important but must occur after ensuring spinal stability to avoid causing additional harm to the spinal cord.
D: Obtain a CT scan. Imaging studies are vital for diagnosis but should be performed after spinal immobilization to prevent further injury during patient movement.
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
Rationale:
Insert a straight catheter.
Inserting a straight catheter is the most appropriate action to relieve urinary retention and facilitate bladder emptying. This procedure allows for immediate assessment of bladder volume and alleviates discomfort while preventing complications associated with prolonged distention following surgery.
B: Increase I.V. fluids. Increasing intravenous fluids may not address the immediate issue of urinary retention and could potentially exacerbate bladder distension rather than provide relief for the client.
C: Notify the surgeon. While notifying the surgeon may be necessary later, immediate intervention to relieve the distended bladder is crucial and should take priority over communication with the surgical team.
D: Assist the client to the bathroom. Assisting the client to the bathroom may not be effective if they are unable to void, as this does not address the underlying issue of urinary retention.
A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client?
Rationale:
Request that the client remove all metal objects on the day of the scan. Metal interference can distort the results of a bone-density scan, potentially leading to inaccurate readings. Ensuring the absence of metal allows for a precise assessment of bone health and density.
B: Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test. Calcium intake before a bone-density scan does not influence the accuracy of the results and may confuse the assessment of existing bone density.
C: Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. This requirement is unnecessary and irrelevant, as calcium supplementation does not impact the immediate results of a bone-density scan.
D: Tell the client that she should report any significant pain to her physician at least 2 days before the test. While reporting pain is important, it does not directly relate to preparations necessary for the bone-density scan itself.
A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Postoperative pain
B
Peripheral pulses
C
Urine output
D
Incision site
Rationale:
B: The nurse should assess peripheral pulses first to ensure adequate blood flow to the extremities after femoral-popliteal bypass grafting, as this is critical for identifying potential complications or graft failures.
A: Postoperative pain assessment follows peripheral pulses, as it provides insight into the client’s comfort level and may indicate complications, but it’s secondary to monitoring circulation.
C: Urine output assessment is less urgent than monitoring circulation and pain levels; while important, it does not provide immediate information on the effectiveness of the bypass.
D: Incision site evaluation, while necessary, is the final step in the assessment order; it is crucial but does not directly impact the client's immediate vascular status.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
Rationale:
Sit-ups. This exercise places undue strain on the lumbar region, potentially hindering recovery after a lumbar laminectomy. It can exacerbate pain and compromise the surgical site's stability, leading to complications.
A: Knee-to-chest lifts. This exercise promotes flexibility and is often recommended for spinal health, making it suitable for rehabilitation post-surgery when performed with caution.
B: Hip tilts. This gentle movement helps strengthen core muscles and improve stability, facilitating recovery while being low-impact and safe for patients following lumbar surgery.
D: Pelvic tilts. This exercise enhances abdominal strength and supports spinal alignment, providing beneficial stabilization for patients recovering from a lumbar laminectomy without risking injury.
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
Rationale:
Assisting the client out of bed to sit upright in a chair for 1 hour is the most appropriate intervention to decrease the risk of aspiration.
Sitting upright enhances swallowing mechanics and allows gravity to aid in digestion, significantly reducing the chance of aspiration during and after bolus tube feeding. This position promotes a safer feeding experience for clients with compromised health, such as those with cancer.
A: Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours. While elevation is beneficial, prolonged bed rest can hinder effective swallowing and digestion.
B: Place the client on the left side with the head of the bed at 45 degrees for 15 minutes. Lying on the side may not provide optimal airway protection and can increase aspiration risk during feeding.
D: Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes. This position lacks sufficient elevation, which may not adequately prevent aspiration during tube feeding.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Temperature 105° F (40.5° C)
B
Confusion
C
Perspiration
D
Tachycardia
E
Signs of dehydration
F
Hypotension
Rationale:
Temperature 105° F (40.5° C), confusion, perspiration, tachycardia, signs of dehydration, and hypotension are all consistent with the disease processes of heat exhaustion and heat stroke.
The elevated temperature indicates a severe heat-related illness, while confusion suggests altered mental status commonly seen in heat stroke. Perspiration reflects the body's attempt to cool down, and tachycardia, dehydration, and hypotension signify the physiological stress caused by excessive heat exposure.
A: Temperature 105° F (40.5° C) Indicates a critical rise in body temperature typically associated with heat stroke, not heat exhaustion alone.
B: Confusion Reflects a severe level of heat-related illness, more indicative of heat stroke than heat exhaustion, which usually does not present with altered mental status.
C: Perspiration While present in both conditions, excessive sweating is more typical in heat exhaustion, as heat stroke often leads to diminished sweating.
D: Tachycardia This finding can be observed in both heat-related illnesses, but it may be more pronounced in heat stroke due to greater physiological stress.
E: Signs of dehydration Although relevant to both conditions, dehydration is often more severe in heat stroke, making it less defining for heat exhaustion alone.
F: Hypotension This symptom can indicate severe illness and is more characteristic of heat stroke, where circulatory collapse may occur, rather than heat exhaustion.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
Rationale:
B: Place each item of clothing in a separate paper bag. This action preserves the integrity of the forensic evidence by preventing contamination and degradation, ensuring that each piece of clothing can be analyzed accurately for traces of gunshot residue or other relevant materials. Proper handling is crucial in maintaining the chain of evidence.
A: Cut around blood stains to remove clothing. This action compromises the evidence by altering the original state of the clothing, potentially damaging vital forensic information that could be crucial during an investigation.
C: Allow clothing to dry. Drying clothing can lead to the loss of critical evidence, such as DNA or other biological material. It is essential to keep items in their original condition for accurate forensic analysis.
D: Refrain from documenting client statements. Failing to document statements denies investigators valuable context and information about the incident, which is essential for understanding the events surrounding the shooting.
E: Place bullets in a sterile container. While this may seem appropriate, it does not address the immediate need for preserving the context and evidence associated with the victims’ clothing and environment, which is paramount.
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
Rationale:
You can wear the pouch for about 4 to 7 days. This timeframe allows for optimal skin health and pouch integrity, helping to prevent irritation and ensuring the pouch functions effectively for the client after an ileostomy.
A: The pouch is changed only when it leaks. This approach could lead to skin complications and discomfort, as waiting for leaks may compromise the pouch's function and the client's skin health.
C: You can wear the pouch for about 4 to 7 days. This option is identical to the correct one; however, it does not provide the necessary context that reinforces the importance of skin care and pouch integrity.
D: It depends on your activity level and your diet. While activity and diet can influence pouch wear time, a general guideline of 4 to 7 days provides a more standardized recommendation for care.
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
Rationale:
Vital signs must be taken to monitor the client’s condition, while establishing an I.V. access site is crucial for potential fluid management and medication administration. Calling the admitting physician ensures timely orders for further assessment and intervention. These actions are essential in managing acute renal failure effectively.
A: Elevate the head of the bed 30 to 45 degrees. Positioning may provide comfort but does not address the immediate medical needs associated with acute renal failure.
E: Contact the hemodialysis unit. While hemodialysis may be necessary, it is premature to contact the unit without a physician's orders and further assessment of the client's condition.
Which of the following will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?
Rationale:
Loss of consciousness, body stiffening, and violent muscle contractions.
During the ictal phase of a generalized tonic-clonic seizure, the individual experiences significant loss of awareness, accompanied by intense muscle rigidity followed by rhythmic jerking movements, characteristic of this seizure type.
A: Linking in one extremity that spreads gradually to adjacent areas. This describes a focal seizure, which involves localized activity rather than the widespread effects seen in generalized tonic-clonic seizures.
B: Vacant staring and abruptly ceasing all activity. This behavior is typical of absence seizures, which involve brief lapses in awareness rather than the more severe manifestations of generalized tonic-clonic seizures.
C: Facial grimaces, patting motions, and lip smacking. These symptoms are indicative of complex partial seizures, which involve altered consciousness and specific motor behaviors, not the generalized symptoms present in tonic-clonic seizures.
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
Rationale:
Systolic blood pressure less than 90 mm Hg. This finding indicates significant hypotension, a critical sign of hypovolemic shock, as the body struggles to maintain adequate perfusion due to decreased blood volume.
A: Pulse rate less than 60 bpm. A pulse rate below 60 bpm suggests bradycardia, which does not typically indicate hypovolemic shock, as tachycardia is more common in such cases.
B: Respiratory rate of 4 breaths/minute. A respiratory rate this low signals severe respiratory distress or failure, which is not a primary indicator of hypovolemic shock, making it misleading in this context.
C: Pupils unequally dilated. Unequal pupil dilation often points to neurological issues, such as head injury or increased intracranial pressure, rather than being a direct sign of hypovolemic shock.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
Rationale:
B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can lead to elevated potassium levels in the blood. Monitoring for hyperkalemia is crucial, especially in clients with liver dysfunction, as it can cause serious cardiac complications.
A: Constipation. Spironolactone does not commonly cause constipation; its primary action is fluid removal rather than affecting bowel function, making this option less relevant in this scenario.
C: Irregular pulse. While electrolyte imbalances can affect heart rhythm, spironolactone specifically poses a risk for hyperkalemia rather than directly causing an irregular pulse in this context.
D: Dysuria. Spironolactone does not typically induce dysuria; this symptom is more associated with urinary tract conditions rather than the medication's pharmacological effects in treating ascites.
A client with vasospastic disorder (Raynaud's phenomenon) is scheduled for sympathectomy. This surgery is performed:
Rationale:
A: In the early stages of the disease to prevent further circulatory disturbances. This procedure is typically reserved for severe cases, not for early-stage treatment where other interventions may be effective.
B: When the disease is controlled by medication. Sympathectomy is not indicated when medication effectively manages the symptoms, as this surgical option is meant for more resistant cases.
C: When the client is unable to control stress-related vasospasm. While stress can exacerbate symptoms, sympathectomy is not primarily indicated for stress-related triggers but rather for refractory cases that do not respond to other treatments.
The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
Rationale:
Epigastric pain and hematemesis indicate potential complications following a gastroscopy. Epigastric pain may suggest perforation or irritation of the gastrointestinal tract, while hematemesis points to possible bleeding, both requiring immediate evaluation and intervention.
A: The client has a sore throat. Sore throat is a common, benign outcome after gastroscopy due to the procedure's nature and typically resolves without further complications.
B: The client appears drowsy following the procedure. Drowsiness can result from sedation during the procedure, which is a normal response and not an indication of complications.
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
Rationale:
Send freshly-collected urine samples to the laboratory and return the remainder of the blood component unit to the blood bank. These actions are essential for appropriate investigation and management of transfusion reactions.
C: Return the intravenous administration set to the blood bank. While necessary for documentation, it does not directly support the investigation of the transfusion reaction.
D: Alert Risk Management about the incident. Although important for broader safety protocols, this step does not address immediate clinical actions required after a transfusion reaction.
E: Report the incident to the Infection Control Manager. This action may be relevant in some contexts but is not a standard immediate response following a transfusion reaction.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
Rationale:
The rehabilitation plan will be guided by it. Understanding the client’s functional status prior to the stroke allows the nurse to tailor the rehabilitation approach, focusing on restoring abilities and setting realistic goals based on individual needs and previous capabilities. This personalization enhances the effectiveness of the care plan and promotes better recovery outcomes.
B: Functional status before the stroke will help predict outcomes. While prior functional status may offer insights into potential recovery, it does not directly inform the specific rehabilitation strategies necessary for optimal care.
C: It will help the client recognize his physical limitations. Although awareness of limitations is valuable, the primary focus is on creating a rehabilitation plan tailored to the client’s previous functional abilities.
D: The client can be expected to regain much of his functioning. This assumption lacks substantiation; recovery varies greatly among individuals and should not dictate the rehabilitation strategy or expectations without thorough assessment.
Which assessment finding is expected in the oliguric phase of acute renal failure?
Rationale:
Weight gain. During the oliguric phase of acute renal failure, fluid retention occurs due to decreased urine output, leading to an increase in body weight as excess fluids accumulate in the tissues.
B: Hypotension. The oliguric phase typically results in fluid overload, which often elevates blood pressure rather than causing hypotension, contradicting the expectations in this phase of renal failure.
C: Clear urine. Oliguria is characterized by scant, often concentrated urine, not clear urine, as the kidneys struggle to filter waste effectively during this phase of acute renal failure.
D: Low BUN levels. Blood urea nitrogen (BUN) levels typically rise during the oliguric phase due to impaired kidney function and decreased excretion, contradicting the notion of low BUN levels in this context.
After pituitary surgery, the nurse should assess the client for which of the following?
Rationale:
Urine specific gravity less than 1.010.
Monitoring urine specific gravity is crucial after pituitary surgery as it helps identify potential diabetes insipidus, a common complication characterized by excessive urination and dilute urine output.
B: Urine output between 1 and 2 L/day.
Normal urine output does not specifically indicate complications following pituitary surgery, making it an insufficient measure for assessing the client’s condition postoperatively.
C: Blood glucose level higher than 300 mg/dL.
Elevated blood glucose levels are not typically a direct concern after pituitary surgery and do not specifically relate to the postoperative assessment of the client’s condition.
D: Urine negative for glucose and ketones.
While urine composition can provide insights, the primary focus after pituitary surgery should be on urine specific gravity to detect possible complications like diabetes insipidus.
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
Rationale:
Tamsulosin relaxes ureter muscles. This action facilitates the passage of renal calculi, alleviating pain and discomfort associated with urinary obstruction, thereby enhancing urinary flow and reducing complications from kidney stones.
A: Dissolves stones. Tamsulosin does not chemically alter or dissolve stones but rather aids in their passage through relaxation of ureter muscles.
C: Reduces urine output. Tamsulosin does not influence urine production; its primary role is to alleviate obstruction rather than diminish urinary output.
D: Prevents infection. The medication primarily focuses on muscle relaxation and does not have antibacterial properties or a role in infection prevention related to renal calculi.
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
Rationale:
Turn the client every 2 hours.
Repositioning the client every two hours significantly reduces pressure on vulnerable areas, promoting blood circulation and preventing prolonged pressure on bony prominences, which is essential for avoiding pressure ulcers in individuals with spinal cord injuries.
A: Reposition the client every 4 hours. This interval is too lengthy, allowing potential pressure buildup that increases the risk of ulcer development in susceptible clients.
B: Use a foam mattress without a cover. A foam mattress provides some support, but lacking a cover can lead to moisture accumulation, increasing the likelihood of skin breakdown and pressure ulcer formation.
C: Apply lotion to bony prominences daily. While moisturizing helps skin integrity, it does not address the critical need for regular repositioning, which is vital for preventing pressure ulcers.
The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication?
Rationale:
Acetazolamide
Acetazolamide effectively alleviates symptoms of acute mountain sickness (AMS) by enhancing respiratory drive and promoting bicarbonate excretion, which helps correct the metabolic alkalosis associated with altitude changes. This medication aids in acclimatization, reducing headaches and nausea commonly experienced during AMS.
A: Sodium bicarbonate This medication does not address the physiological changes caused by altitude and could potentially worsen metabolic imbalances rather than alleviate AMS symptoms.
C: Tamsulosin Primarily used for urinary issues, tamsulosin has no role in treating altitude-related conditions and does not impact the symptoms of acute mountain sickness.
D: Dutasteride This medication treats benign prostatic hyperplasia and has no relevance to acute mountain sickness, failing to provide any therapeutic benefit for altitude-related symptoms.
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
Rationale:
Risk for injury related to vertigo.
Prior to labyrinthectomy, the client’s recurrent vertigo poses a significant threat of falls or accidents. Addressing this nursing diagnosis ensures safety measures are implemented to minimize potential harm during this vulnerable time leading up to surgery.
A: Deficient diversional activity related to inability to participate secondary to vertigo. While diversional activities may be limited, the immediate concern is the client’s safety due to vertigo’s unpredictable nature.
C: Powerlessness related to inability to influence effects of disease process. Although feelings of powerlessness may be present, the priority is ensuring the client remains safe from injury caused by vertigo.
D: Social isolation related to hearing loss. Social isolation is a concern, yet it is secondary to the urgent need for addressing immediate physical safety risks associated with vertigo.
The nurse should assess a client with Addison's disease for which of the following?
Rationale:
B: Orthostatic hypotension. Clients with Addison's disease often experience adrenal insufficiency, leading to decreased aldosterone levels. This condition results in impaired blood volume regulation, causing orthostatic hypotension when standing or changing positions.
A: Weight gain. Addison's disease typically results in weight loss due to decreased appetite and metabolic changes, not weight gain, which is more characteristic of conditions like Cushing's syndrome.
C: Lethargy. While lethargy can occur, it is a nonspecific symptom that can arise from numerous conditions, making it less directly associated with Addison's disease compared to orthostatic hypotension.
D: Muscle spasms. Muscle spasms are not a primary symptom of Addison's disease; they are more frequently linked to electrolyte imbalances, which may not be the predominant concern in this condition.
A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:
Rationale:
In cases of acute renal failure with elevated potassium levels, IV insulin and glucose are critical for driving potassium back into cells, thus reducing serum potassium levels and preventing complications like cardiac dysrhythmias.
B: Oral potassium supplements would exacerbate hyperkalemia, further increasing the potassium level instead of managing it, which is counterproductive in acute renal failure.
C: Fluid restriction does not directly address hyperkalemia and may be necessary for other reasons, but it won't reduce potassium levels in this scenario.
D: Diuretic administration can help with fluid overload but is ineffective in managing hyperkalemia in acute renal failure when potassium levels are critically elevated.
Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide?
Rationale:
B: Increased urine output.
Furosemide is a loop diuretic that promotes diuresis, leading to an increase in urine production. This effect is expected as the medication is administered intravenously, enhancing its efficacy in fluid management.
A: Increased blood pressure.
Furosemide typically reduces blood volume, which can lead to decreased blood pressure rather than an increase. The primary action of this diuretic is to eliminate excess fluids.
C: Decreased pain.
Furosemide does not have analgesic properties. Its primary function is to manage fluid retention and edema, rather than addressing pain relief in clients.
D: Decreased premature ventricular contractions.
Furosemide does not directly influence cardiac arrhythmias. Its purpose is focused on diuresis rather than stabilizing heart rhythm or reducing premature ventricular contractions.
A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse?
Rationale:
The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered. Elevated CRP levels signal increased cardiovascular risk, making statins and aspirin necessary for managing this patient's health.
A: The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet. LDL levels are elevated but not severe enough to justify this explanation.
B: The triglycerides are elevated and will be lowered to normal with these medications. Triglyceride levels are only mildly elevated, making this rationale insufficient for starting treatment.
D: The medications are not indicated since your lab values are all normal. Multiple lab values are elevated, particularly CRP, indicating a need for intervention despite some values appearing acceptable.
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
Rationale:
The 'ringing' may be related to the aspirin. Aspirin can cause tinnitus, a condition characterized by persistent ringing in the ears, particularly in older adults or those taking higher doses.
A: Aging can lead to various sensory changes, but attributing tinnitus solely to aging overlooks potential medication side effects. Aspirin usage is a more plausible cause in this scenario.
B: A hearing test might provide insights, but it does not address the immediate concern of possible aspirin-related side effects. Understanding the medication's impact is more pertinent.
C: Audiometric testing may offer useful information about hearing loss but does not directly address the client's reported symptom. The focus should be on potential medication effects.
The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia?
Rationale:
Restlessness. Early signs of hypoxemia often manifest as restlessness, indicating the body’s increased need for oxygen and a response to inadequate oxygenation, particularly during the immediate recovery phase from anesthesia.
A: Somnolence. This symptom typically suggests excessive sedation or drowsiness rather than hypoxemia, making it less relevant in assessing oxygen levels post-anesthesia recovery.
C: Chills. Chills are generally related to temperature regulation issues and do not directly indicate a lack of oxygen in the bloodstream, thus not serving as an early hypoxemia sign.
D: Urgency. Feelings of urgency pertain to the need to void or act quickly, which does not correlate with hypoxemia and is not a recognized indicator of oxygen deficiency.
A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:
Rationale:
Dyspnea. Given the patient's history of COPD and metastatic lung carcinoma, assessing for dyspnea is crucial as it directly impacts his quality of life and may require immediate management in hospice care.
A: Ascites. While ascites can occur in cancer patients, it is not directly related to the immediate respiratory concerns associated with COPD or metastatic lung disease in this scenario.
B: Pleural friction rub. This sign suggests pleuritis or pleural effusion, which may not be the primary focus for a patient with advanced COPD and lung cancer in hospice settings.
D: Peripheral edema. Although peripheral edema can arise from various conditions, it does not address the immediate respiratory issues prevalent in this patient’s COPD and metastatic lung cancer context.
A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following stress interventions will be most helpful to the client?
Rationale:
Reviewing her current coping mechanisms and developing alternatives empowers the client to actively manage stress, fostering resilience and adaptability in her high-pressure career while addressing her ulcerative colitis concerns effectively.
B: Suggest a less stressful career in which she would still use her education and experience. Transitioning careers may not directly enhance her coping skills or effectively manage existing stressors related to her condition.
C: Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases. Relying on colleagues for easier cases does not address underlying coping strategies or the client's personal management of stress.
D: Prepare family members for the fact that she will have to work part-time. Working part-time might limit her professional fulfillment and does not directly equip her with necessary stress management techniques for her current role.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
Rationale:
Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. These medications are effective pain relievers that can help alleviate the headache caused by nitroglycerin, which is known to induce such symptoms in some patients.
B: Nitroglycerin should be avoided if the client is experiencing this serious side effect. This choice misrepresents the situation, as nitroglycerin is essential for angina and headaches can often be managed.
C: Taking the nitroglycerin with a few glasses of water will reduce the problem. This option suggests an ineffective remedy; water does not address the pharmacological causes of headaches associated with nitroglycerin.
D: The client should lie in a supine position to alleviate the headache. While lying down may provide comfort, it does not specifically treat the headache resulting from nitroglycerin use.
The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
Rationale:
The client experiences disturbed body image related to neck surgery.
This diagnosis is appropriate as the client expresses feelings of disgust toward the stoma, indicating significant distress about his altered appearance and self-perception post-surgery. Acknowledging these feelings is crucial for effective emotional support and rehabilitation.
A: Deficient knowledge about the care of a stoma. The client’s concerns are centered on appearance, not a lack of understanding about stoma care or management.
B: Disturbed personal identity related to change in appearance. While personal identity may be affected, the primary focus here is the client’s immediate distress about body image rather than his overall identity.
D: Hopelessness related to irreversible changes in body functioning. The client’s focus is on his appearance, not on feelings of hopelessness regarding his overall health or functionality after the procedure.
A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works?
Rationale:
The radioactive iodine destroys thyroid tissue and thyroid hormones are no longer produced. This method effectively treats hyperthyroidism by selectively targeting and eliminating overactive thyroid cells, leading to decreased hormone levels and resolution of symptoms associated with Graves' disease.
A: The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy. This statement misrepresents the purpose of RAI, which aims to permanently reduce hormone production rather than merely stabilizing levels.
B: The radioactive iodine reduces uptake of thyroxine and thereby improves your condition. This explanation inaccurately simplifies RAI's action, as it primarily destroys thyroid tissue rather than just limiting thyroxine absorption.
C: The radioactive iodine slows your body's production of thyroid hormones. This oversimplification fails to convey RAI's mechanism, which involves the destruction of thyroid cells responsible for hormone production rather than merely slowing it down.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
Rationale:
Insert a gauze wick into the stoma. This action helps absorb urine and minimizes leakage during the appliance change, providing a barrier that protects the surrounding skin and maintains hygiene.
B: Close the opening temporarily with a cellophane seal. This method does not effectively prevent urine leakage and may lead to skin irritation or discomfort during the appliance change process.
C: Suction the stoma before changing the appliance. Suctioning is not a standard procedure for managing urine leakage and could potentially harm the stoma or the surrounding tissue.
D: Avoid oral fluids for several hours before changing the appliance. Limiting fluid intake does not address the immediate concern of urine leakage during the appliance change and could lead to dehydration.
A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?
Rationale:
Deep, rapid respirations with long expirations indicate a potentially life-threatening condition, such as diabetic ketoacidosis, requiring immediate medical intervention to prevent severe complications and stabilize the patient's respiratory status.
B: Shallow respirations alternating with long expirations suggest a possible respiratory issue but do not immediately indicate a critical state requiring urgent intervention. Monitoring may be sufficient in this scenario.
C: Regular depth of respirations with frequent pauses could indicate fatigue or another non-critical respiratory pattern, lacking the urgency necessary for immediate action in a diabetic emergency situation.
D: Short expirations and inspirations may reflect anxiety or discomfort but do not signify the critical respiratory distress seen in diabetic emergencies, thus not necessitating immediate intervention.
A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?
Rationale:
D: Cleaning the rectal area with unscented soap and water after each bowel movement helps maintain skin integrity by removing irritants and preventing further skin breakdown from diarrhea-related moisture.
A: Discourage sitz baths because they can lead to excessive moisture and irritation, which would further compromise skin integrity rather than providing beneficial cleansing or relief.
B: Apply zinc oxide ointment to the rectal area after each bowel movement may be helpful, but it doesn't address the fundamental need for thorough cleansing to prevent irritation.
C: Apply a skin-barrier dressing daily to the rectal area to form a protective barrier does not sufficiently address the need for regular, gentle cleaning and drying to avoid skin damage.
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included?
Rationale:
Taking a deep abdominal breath, bending forward, and coughing three or four times on exhalation helps to effectively clear secretions and enhances lung expansion in clients with chronic obstructive pulmonary disease. This method promotes optimal airflow and facilitates effective airway clearance, which is critical for managing symptoms and improving respiratory function in these patients.
B: Lie flat on the back, splint the thorax, take two deep breaths, and cough. This position may hinder diaphragm movement and limit lung expansion, reducing the effectiveness of the cough.
C: Take several rapid, shallow breaths and then cough forcefully. Rapid, shallow breathing can lead to inadequate lung expansion and ineffective coughing, compromising the ability to clear mucus effectively.
D: Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing. While this may provide some comfort, it does not optimize airflow or clearance as effectively as the correct method.
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?
Rationale:
Bran muffin, skim milk, stir-fried broccoli. This combination provides high fiber from the bran muffin and broccoli, both of which are beneficial for promoting digestive health and potentially lowering colon cancer risk.
A: Croissant, granola and peanut butter squares, whole milk. This choice lacks sufficient fiber and includes high-fat items that may contribute to unhealthy dietary patterns, increasing cancer risk.
C: Granola, bagel with cream cheese, cauliflower salad. While granola and cauliflower are nutritious, the bagel with cream cheese adds unnecessary saturated fats, diluting cancer-preventive benefits of fiber-rich foods.
D: Oatmeal, raisin cookies, baked potato with sour cream, turkey sandwich. Though some items are healthy, the sour cream and raisin cookies introduce excessive sugars and fats, which counteract colon health benefits.
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
Rationale:
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid coughing. Coughing can increase intraocular pressure, potentially compromising the surgical outcome and causing complications.
A: Lying supine. This position is typically not contraindicated and can be safe post-surgery, allowing for comfort and proper healing without significantly affecting intraocular pressure.
C: Deep breathing. Engaging in deep breathing exercises generally promotes relaxation and oxygenation, which are beneficial for recovery and do not elevate intraocular pressure significantly.
D: Ambulation. Moving around is encouraged after surgery to promote circulation and prevent complications, and it does not inherently increase intraocular pressure or pose risks to recovery.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
Rationale:
C: Use a printed checklist with information individualized for the client. This method ensures that all critical details specific to the patient's condition and care needs are systematically conveyed, minimizing the risk of miscommunication.
A: Give the report face-to-face with both nurses in a quiet room. While this allows for direct communication, it may overlook the comprehensive documentation needed for effective handoff.
B: Audiotape the report for future reference and documentation. This approach lacks immediate engagement and may miss real-time clarification of concerns or questions that arise during the report.
D: Document essential transfer information in the client's electronic health record. Although important, this option does not facilitate immediate verbal communication, which is crucial for ensuring thorough understanding during handoff.
What is a goal of care for a client with acute renal failure?
Rationale:
Maintain urine output of 30 mL/hour. Monitoring and maintaining an adequate urine output is crucial in acute renal failure to assess kidney function and prevent complications such as fluid overload and electrolyte imbalances.
B: Keep potassium above 5.5 mEq/L. Elevated potassium levels can lead to serious cardiac issues; thus, the goal is to manage potassium levels within a safe range, not to increase them.
C: Increase protein intake. In acute renal failure, high protein intake can exacerbate kidney stress and worsen metabolic waste accumulation, making it counterproductive to the goals of care.
D: Limit ambulation. Promoting mobility is essential for overall health and recovery; limiting ambulation can lead to complications such as muscle atrophy and decreased circulation, hindering recovery.
A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply.
Rationale:
Aerobic activity, weight control, and stress management should be the focus of the discharge plan. These activities will enhance cardiovascular health, promote weight loss, and reduce stress, which are essential for recovery.
B: Strength training does not adequately address immediate concerns related to circulation and recovery from a blood clot, making it less suitable for this client at this stage.
The client with rheumatoid arthritis tells the nurse, 'I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?' Which of the following responses by the nurse would be most appropriate?
Rationale:
Every person is different. What works for one client may not always be effective for another.
D emphasizes the individuality of treatment responses, acknowledging that while gold shots may have benefitted the friend, the client's unique medical circumstances dictate a different approach. This fosters understanding and reinforces the importance of personalized healthcare decisions.
A: It's the physician's prerogative to decide how to treat you. This response dismisses the client's concerns without fostering dialogue or understanding about their treatment options.
B: Tell me more about your friend's arthritic condition. This shifts focus away from the client's own experience, failing to address their specific concerns about treatment choices effectively.
C: That drug is used for cases that are worse than yours. This undermines the client's situation and could create feelings of inadequacy or frustration regarding their condition and treatment plan.