Professional Nursing

A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
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Terms in this set (49)
The nurse identifies the client's needs and formulates the nursing problem of, "imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short term goal is best for this client?
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continue to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?A nurse with Marfan's syndrome who is post menopausal. (A nurse's ability to care for this client is not affected by Marfan's syndrome which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structure.)The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the health care provider?Recalls drinking a glass of juice after midnight. (risk of aspiration increased)The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which is information is best for the nurse to provide?Early adolescence is a developmental stage of normal experimentation ( change spurred by hormonal increases in pubescence and teenage experimentation with values, choices and peer acceptance)The nurse determines that a client's body weight is 105% above the standardized height/weight scale. Which related factor should the nurse include in the nursing problem, "imbalanced nutrition: more than body requirements?"Inadequate lifestyle changes in diet and exercise (best identifies factors that contribute to the formulation of the nursing diagnosis)During the physical assessment, which finding should the nurse recognize as a normal finding?Regular pulsation at the epigastric are when the client is supine.The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?Change in level of consciousness (is the first and most sensitive sign of change in cerebral function)When documenting assessment data, which statement should the nurse record in the narrative nursing notes?S 1 murmur auscultated in supine positionThe nurse is developing a series of child birth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?Participants can identify at least 3 coping strategies to use during labor.A female client makes routine visits to a neighborhood community center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?Secondary prevention. (attempts to halt the progression of the disease process by educating the client about prevention strategies)Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio?A self evaluation that identifies how the nurse has met professional objectives and goals.When engaging in planned change on the unit, what should the nurse-manager establish first?Staff members are aware of the need for changeA work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map?Multi disciplinary groupAn older client who has been bedridden for a month has been admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?Stage 3 (full thickness tissue loss with visible sub q fat that does not expose the bone, tendon or muscle)A client is admitted with medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?Hypotension, rapid weak pulse and rapid respiratory rate (manifestations of shock; the client is at risk for circulatory collapse and shock)Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?Encourage the usage of incentive spirometerThe nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?A pregnant womanA client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?Monitor for increased BP and pulse (clients with alcohol dependency experience withdrawal symptoms which include elevated BP, pulse and temperature)The nurse is preparing to administer a prescribed dose of acetylcysteine 600 mg PO. The 10mL vial is labeled 20g per 100mL. What volume of medication in mL should the nurse administer? (round to the nearest whole number)3 mL (20g = 20,000 mg. 20,000 mg/100 mL = 200mg/ 1 mL. Using desired/half X volume: 600mg/200 mg X 1 mL = 3mL)During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for 3 years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?Taking medication with community follow up.After eye drops are instilled, which instruction should the nurse provide to the client?Close your eyelidsThe nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?A Buretrol attachment (a buretrol attachment is used to restrict the total volume of fluid a client receives)Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?Describes working hard to develop musclesWhich instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?Increase daily intake of raw fruits and vegetables (constipation is a common side effect of antipsychotics)Prior to the discharge of a healthy 4 day old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test.Assess the newborn's feeding patterns of formula or breastmilk which has "come in" (PKU screening is mandatory in most states and requires that the newborn has ingested adequate amounts of milk proteins to detect metabolism errors)Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?Implements health programs for construction workersThe nurse is planning care for a client who is having abdominal surgery. To achieve desired post operative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?Administer analgesics prior to encouraging progressive activities and ambulation. (effective pain management post operatively promotes client participation in exercises that promote healing)To assess a client's pupillary response to accommodation, a nurse should perform which activity?Ask the client to look at a distant object and then add an object held 10 cm from the nose.A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?Administer isoniazid (INH) daily for 6-9 months (prevent transmission and development of clinical disease)A client who is 1 week post operative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the health care provider, which action should the nurse take?Keep the client in bed in the supine position.A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to 3 months of IV antibiotic therapy. The client asked the nurse why surgery is necessary. Which is the best response for the nurse to provide?The infection has walled off into an area of infected bone creating a barrier to antibiotics. (a sequestrum [dead bone] is separated from the living bone and has no blood supply, so neither antibiotics or white blood cells can reach the infected area)After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatiod arthritis returns to the clinic for a follow up visit. Which laboratory finding should the nurse review for a therapeutic response?Erythrocyte sedimentation rate (an elevated ESR is indicative of active inflammation so the nurse should determine if the ESR has normalized)The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the health care practices?Individual beliefs (the clients' beliefs are key to accepting health care practices and interventions)During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?Chlamydia is the most common and fastest spreading STI in American women2 hours after the vaginal delivery of a 7lb 3oz infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?Palpate above the symphysis for the bladder (2 hours after giving birth, the uterus should be firm, in the midline and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder)The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for?Preparing for other diagnostic testingPrenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?Diagnostic testing may indicate a fetal problem that could be treated prior to delivery.Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?Give one hour before or 2 hours after a mealA male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?When did the symptoms begin after the last dose of opiate analgesic? (moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea and muscle cramps and elevated BP)A child receiving maintainance IV fluids at a rate of 1000mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kg between 10-20. How many mL per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? Round to the nearest whole number61