36 terms


A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?
Notify the physician that the client has no vital signs.
The resident has signed a document indicating a wish not to be resuscitated. The nurse should be aware of the resident's "do not resuscitate" status and should not need to go to the desk to confirm this. The nurse should notify the physician so that he or she can pronounce the death and notify the family.
A client is admitted with the following vital signs: temperature, 102° F (38.9° C); heart rate, 144 beats/minute and irregular; and respiratory rate, 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client's care?
Decreased cardiac output
A heart rate of 144 beats/minute indicates decreased diastolic filling time and a reduced blood volume ejected with each contraction, resulting in decreased cardiac output. The client's temperature and respiratory rate are elevated but not enough for a diagnosis of Ineffective thermoregulation or Ineffective breathing pattern to take precedence over one of Decreased cardiac output. The client's vital signs don't suggest a diagnosis of Ineffective renal tissue perfusion.
When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:
nothing abnormal.
High-pitched gurgles are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.
The physician asks the nurse to join him to discuss palliative care options with a terminally ill client and his family. Which statement by the nurse indicates an understanding of palliative care?
"I'll assist with the client with his total needs."
Providing palliative care involves taking care of the client's total needs, which include spiritual, emotional, and pain management and other physical needs. Options 1, 2, and 3 each describe only one aspect of palliative care.
The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
Current health promotion activities
Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, the current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:
left calf circumference 1" (2.5 cm) larger than the right.
Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.
A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:
higher systolic blood pressure reading.
Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.
The nurse can auscultate for heart sounds more easily if the client is:
leaning forward.
The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This enables the nurse to listen after exhalation without the sound of expiration interfering. The supine position is used to visually inspect the precordium, allowing the nurse to watch the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. A left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.
The nurse is preparing a transfusion for a client with type AB blood. Which of the following blood types is considered the universal donor?
Type O
Type O blood may be considered a universal donor, because it does not typically have the ABO antigens. Type AB blood may be considered a universal recipient because it has both A and B antigens, but does not have the anti-A or anti-B antibodies. In reality, blood needs to be correctly typed and crossmatched before transfusion.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat
A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
A nurse is classifying the pregnancy history of a woman who has had five pregnancies: three full-term, one preterm, and one abortion. How would the nurse document this information on the patient chart?
You selected: G5 P3114
G = gravida or the total number of pregnancies, which in this case equals five. P = para is the outcome of the pregnancies in the following order: full term, preterm, abortions, and living as of today. In this case, P3114.
Which disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode?
Dysthymic disorder
Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode. Cyclothymic disorder is characterized by 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for bipolar disorder. Seasonal affective disorder occurs in the winter or spring. Hypomania is a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days.
Which of the following personnel are legally responsible for obtaining the patient's informed consent for a surgical procedure?
The surgeon
The surgeon is legally responsible for obtaining the patient's informed consent.
Which type of evaluation occurs continuously throughout the teaching and learning process?
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative isn't a type of evaluation. (less)
When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following?
Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.
A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Data collection consists of the client's history, physical examination, and laboratory studies. Planning consists of considering collected data to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process during which the nurse puts the plan of care into action.
When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:
closing of the aortic and pulmonic valves.
The second heart sound (S2) results from closing of the aortic and pulmonic valves. The first heart sound (S1) is produced by closing of the mitral and tricuspid valves
Which reaction is a normal response to a corneal sensitivity test?
The normal response to a corneal sensitivity test is blinking. Sudden onset of seeing spots or flashing lights may indicate retinal detachment. Pupil dilation occurs when the eye is exposed to darkness. Pupil contraction normally occurs when the pupil is exposed to direct light.
The triage nurse's assessment of a girl who has been brought in by her frantic parents reveals that the girl is likely in anaphylaxis. After establishing a patent airway, what action should the emergency department care team prioritize?
Parenteral administration of epinephrine
Simultaneously with airway management, aqueous epinephrine is administered as prescribed to provide rapid relief of the hypersensitivity reaction. Epinephrine may be administered again, if necessary and as prescribed. Bronchodilators, corticosteroids, and nitroglycerin do not directly relieve the acute signs and symptoms of anaphylaxis
A group of nursing students are reviewing the components of the endocrine system. The students demonstrate understanding of the review when they identify which of the following as the primary function of this system?
You selected: Hormonal secretion
The endocrine system consists of various glands, tissues, or clusters of cells that produce and release hormones. Hormones are chemical messengers that stimulate and/or regulate the actions of other tissues, organs, or endocrine glands that have specific receptors to a hormone. Along with the nervous system, the endocrine milieu influences all physiologic effects such as growth and development, metabolic processes related to fluid and electrolyte balance and energy production, sexual maturation and reproduction, and the body's response to stress. The release patterns of the hormones vary, but the level in the body is maintained within specified limits to preserve health.
A client with metastatic cancer is experiencing neuropathic pain. Which alternative therapy is most beneficial in treating this type of pain?
Transcutaneous electrical nerve stimulation (TENS)
TENS alters the client's perception of pain by blocking painful stimuli traveling over nerve fibers. This treatment is believed to help treat cancer pain because it reduces muscle spasm, decreases edema, and raises the pain threshold. This therapy appears to be the most effective in treating neuropathic pain. Cryotherapy is used for acute injuries, such as an ankle sprain, because it reduces inflammation. Biofeedback has been found to reduce cancer pain through the client's learned conscious control of the body's responses to pain. However, this method of pain control isn't the most beneficial in treating neuropathic pain. Herbal therapy isn't the most effective alternative therapy for treating neuropathic pain.
What is the most appropriate nursing diagnosis for a client with acute pancreatitis?
Deficient fluid volume
Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock will cause a decrease in cardiac output. Tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.
A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Option 1 is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option 2 is inappropriate because no evidence suggests that this client has a excessive fluid volume. Option 3 may be warranted but is secondary to ineffective tissue perfusion.
The nurse assists in developing a list of nursing diagnoses for a client. This list should include:
factors influencing the client's problem.
A nursing diagnosis is a written statement of the client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
After a stroke, a client develops aphasia. Which data collection finding is most typical in aphasia?
Inability to speak clearly
Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a stroke, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
The nurse should include which instruction in the teaching plan for a client who is scheduled to undergo an ultrasound of the gallbladder and biliary system?
Avoiding smelling greasy foods before the test
Smelling greasy foods such as popcorn can cause the gallbladder to empty. The client should be instructed to eat a fat-free meal on the evening before the test. Then, the client should fast for 8 to 12 hours before the test. These measures promote bile accumulation in the gallbladder and enhance ultrasonic visualization. The client must keep fasting to prevent bile excretion in the gallbladder.
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
"The client remains free of signs and symptoms of phlebitis."
"The client remains free of signs and symptoms of phlebitis" is an appropriate expected outcome for this client. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Option 4 is a nursing diagnosis.
One aspect of implementation related to drug therapy is:
documenting drugs given.
Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis?
You selected: Deficient fluid volume
Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to fluid volume deficit, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.
For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the data collection?
"Is the pain worse when your toes are pointed toward your knee?"
The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT.
A client with
INTERMITTENT CLAUDICATION experiences pain that increases during activity and decreases with rest
The nurse is collecting data on a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs
Which of the following is the most common source of airway obstruction in an unconscious victim?
The tongue
In many cases, the muscles controlling the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw- thrust maneuver must be performed. A foreign object, saliva or mucus, and edema are less common sources of airway obstruction in an unconscious adult
When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?
Circumscribed, elevated, and filled with serous fluid
A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.
A client comes to the clinic for diagnostic allergy testing. Why is an intradermal injection used for such testing?
Intradermal drugs diffuse slowly.
Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapid introduction of an allergen into a sensitive client could cause a life-threatening allergic reaction. Intradermal injections aren't necessarily less painful or easier to administer.
The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?
Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release
The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The other options aren't used to elicit rebound tenderness.