Nursing Assessment and Patient Care
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Questions and Answers

What type of care should be initiated for a client whose caregiver requests adult day care services?

PACE

Which of the following findings should the nurse identify as an adverse effect of captopril to report to the provider?

  • Blurred vision
  • Polyuria
  • Tinnitus
  • Cough (correct)
  • Which instruction should the nurse include for a client with a fracture of the right fibula?

  • Use a three-point gait. (correct)
  • Adjust the crutches for comfort as needed.
  • Wear leather-soled shoes.
  • Advance the affected leg first when walking upstairs.
  • What is the priority action for a nurse caring for a client who had abdominal surgery 24 hours ago?

    <p>Assist with deep breathing and coughing.</p> Signup and view all the answers

    Which prescription for a postoperative client is contraindicated?

    <p>Ondansetron 4 mg PO for nausea.</p> Signup and view all the answers

    What indicates a client's understanding of advance directives?

    <p>I can designate my partner as my health care surrogate.</p> Signup and view all the answers

    What should the nurse assess first for a client who is 48 hours postoperative following a laryngectomy?

    <p>Determine the client's reading skills.</p> Signup and view all the answers

    The client is at highest risk for developing _____ as evidenced by the _____ following a total thyroidectomy.

    <p>hypocalcemia; report of numbness around lips</p> Signup and view all the answers

    What statement indicates altruism by a client in therapy?

    <p>I told my doctor that I would like to start a support group for other women who are sick in my community.</p> Signup and view all the answers

    Which child should the nurse assess first?

    <p>10-year-old child awaiting appendectomy surgery with sudden pain relief.</p> Signup and view all the answers

    What should the nurse do when suspecting physical abuse in a child with scald burns?

    <p>Contact Child Protective Services.</p> Signup and view all the answers

    Which action should the nurse plan when administering an IM injection to an obese client?

    <p>Use the ventrogluteal site.</p> Signup and view all the answers

    Select the 4 client findings that indicate a thyroid storm.

    <p>Temperature</p> Signup and view all the answers

    Which newly licensed nurse action requires intervention?

    <p>Starts a task then determines what supplies are needed.</p> Signup and view all the answers

    Which finding should the nurse identify as an adverse effect of amitriptyline?

    <p>Blurred vision</p> Signup and view all the answers

    What indicates understanding of asthma management in a parent?

    <p>I will make sure my child receives a yearly influenza immunization.</p> Signup and view all the answers

    What behavior should the nurse expect in a child with autism spectrum disorder?

    <p>Strict adherence to routines.</p> Signup and view all the answers

    What action should the nurse take for a client with active pulmonary tuberculosis?

    <p>Assign the client to a private room with negative air pressure.</p> Signup and view all the answers

    The client is at risk for experiencing _____ due to the client’s _____ during pregnancy.

    <p>metabolic acidosis; weight loss</p> Signup and view all the answers

    Health care personnel can proceed with necessary life-saving care when a client is unable to give informed consent in an emergency due to implied consent.

    <p>True</p> Signup and view all the answers

    What is the nurse's priority activity for a client with a new diagnosis of type 1 diabetes mellitus?

    <p>Ensure that the client understands the medication regimen.</p> Signup and view all the answers

    Select the 3 findings that require immediate follow-up for a client in a mental health clinic.

    <p>Speech</p> Signup and view all the answers

    What is the priority step of the time management process that should be included when teaching newly licensed nurses?

    <p>Making a list of activities to complete.</p> Signup and view all the answers

    What action should the nurse take before performing a paracentesis?

    <p>Instruct the client to void.</p> Signup and view all the answers

    Which of the following statements by the client indicates an understanding of the teaching regarding common discomforts associated with pregnancy?

    <p>I will wear a supportive bra overnight.</p> Signup and view all the answers

    What action should the nurse take for a client recently started on risperidone?

    <p>Implement fall precautions for the client.</p> Signup and view all the answers

    What condition is the client most likely experiencing based on the symptoms?

    <p>Intestinal obstruction</p> Signup and view all the answers

    Which action should the nurse take for a client receiving chemotherapy and has neutropenia?

    <p>Avoid including raw fruits in the client's diet.</p> Signup and view all the answers

    Select the statements that indicate understanding of newborn care.

    <p>I will use the bulb syringe first in her mouth and then in her nose.</p> Signup and view all the answers

    What should a nurse do when preparing to administer insulin via a pen device?

    <p>Hold the insulin pen device perpendicular to the client's skin to inject the medication.</p> Signup and view all the answers

    Which question should the nurse ask to assess for an adverse effect of ibuprofen in an adolescent with juvenile idiopathic arthritis?

    <p>Have you had any stomach pain or bloody stools?</p> Signup and view all the answers

    What intervention should a nurse plan for a client with a magnesium level of 2.7 mEq/L?

    <p>Initiate continuous cardiac monitoring.</p> Signup and view all the answers

    The client is at greatest risk for developing ________ as evidenced by electrolyte imbalance.

    <p>dysrhythmias</p> Signup and view all the answers

    Which finding indicates that the use of ginger tea is effective for a pregnant client?

    <p>The client reports a decrease in episodes of nausea.</p> Signup and view all the answers

    Which finding should the nurse report for a newborn after delivery?

    <p>Nasal flaring.</p> Signup and view all the answers

    What finding indicates the therapy of packed RBCs has been effective?

    <p>Hemoglobin 14.9 g/dL</p> Signup and view all the answers

    Which nutrient should a nurse instruct a client with Crohn's disease to decrease?

    <p>Fiber.</p> Signup and view all the answers

    Which variable should the nurse include as a risk factor for osteoporosis in older adults?

    <p>Sedentary lifestyle</p> Signup and view all the answers

    According to Nägele's rule, what is the estimated date of birth for a client with the LMP of May 8?

    <p>February 15.</p> Signup and view all the answers

    Which alteration in speech indicates the client with bipolar disorder is using?

    <p>Flight of ideas</p> Signup and view all the answers

    What task should a nurse delegate to an assistive personnel (AP)?

    <p>Arrange the lunch tray for a client who has a hip fracture.</p> Signup and view all the answers

    What action should a nurse take when transferring a stroke patient to a rehabilitation facility?

    <p>Facilitate an interdisciplinary conference at the new facility for the family.</p> Signup and view all the answers

    Which actions should the nurse take when caring for a postpartum client who indicates signs of hemorrhage?

    <p>Firmly massage the uterine fundus.</p> Signup and view all the answers

    The client is at risk for developing ____ due to ____.

    <p>spinal shock, autonomic dysreflexia.</p> Signup and view all the answers

    Which statement indicates that the family understands home hospice care?

    <p>We can expect the hospice nurse to provide support for us after our mother's death.</p> Signup and view all the answers

    Which action should the nurse take regarding the continuous passive motion (CPM) machine?

    <p>Turn off the CPM machine during mealtime.</p> Signup and view all the answers

    What finding should prompt a referral for occupational therapy for a stroke patient?

    <p>Difficulty performing ADLs.</p> Signup and view all the answers

    In which situation should the RN intervene when observing an LPN and AP moving a client?

    <p>The LPN and AP grasp the client under his arms to lift him up in bed.</p> Signup and view all the answers

    The nurse should first address the client's ____ followed by the client's ____.

    <p>oxygen saturation, urinary output.</p> Signup and view all the answers

    What should a nurse identify as an adverse effect of epinephrine?

    <p>Report of chest pain.</p> Signup and view all the answers

    Which task should the nurse assign to the member of the group functioning as the orienteer?

    <p>Noting the progress of the group toward assigned goals.</p> Signup and view all the answers

    What intervention should the nurse include in the care plan for a client with left-sided weakness after a stroke?

    <p>Support the client's left arm on a pillow while sitting.</p> Signup and view all the answers

    What action should the nurse take for a client with immunosuppression and a continuous IV infusion?

    <p>Monitor the client's mouth every 8 hr.</p> Signup and view all the answers

    Which client should the nurse assess first?

    <p>A client who is postoperative with abdominal distention and no bowel sounds</p> Signup and view all the answers

    Match the assessment findings with the appropriate disorder:

    <p>Intellectual impairment = Intellectual disability (ID) Interrupting others = Attention Deficit Hyperactivity Disorder (ADHD) Impaired language skills = ADHD Hyperreactivity to sensory input = ADHD Losing necessary things = ADHD</p> Signup and view all the answers

    Which statement indicates an understanding of isolation precautions?

    <p>A client who requires airborne precautions should be placed in a negative-pressure airflow room.</p> Signup and view all the answers

    What isolation precautions should be initiated for a client with pneumonia?

    <p>Droplet</p> Signup and view all the answers

    Which manifestation of ovarian cancer should the nurse include in teaching?

    <p>Abdominal bloating</p> Signup and view all the answers

    Identify the acid-base imbalance for a client with pH 7.2, PaCO2 60 mm Hg, and HCO3- 25 mEq/L.

    <p>Respiratory acidosis</p> Signup and view all the answers

    Which prescription should the nurse clarify for a client with type 1 diabetes and ankle pain?

    <p>Apply a cold pack to the client's ankle for 30 min every hour.</p> Signup and view all the answers

    What action should the nurse take to prevent TB transmission?

    <p>Have the client wear a surgical mask while being transported outside the room.</p> Signup and view all the answers

    Informed consent promotes which ethical principle?

    <p>Autonomy</p> Signup and view all the answers

    Which adverse effect should the nurse monitor for in a client taking valproic acid?

    <p>Jaundice</p> Signup and view all the answers

    Which potential provider prescription is anticipated for a client post-stroke?

    <p>Oxygen therapy to keep oxygen saturation above 95%.</p> Signup and view all the answers

    Calculate the manual IV infusion gtt/min for 1,500 mL at 50 mL/hr using 15 gtt/mL.

    <p>12.5</p> Signup and view all the answers

    Which statement about basal body temperature method of birth control is true?

    <p>Your body temperature might decrease slightly just prior to ovulation.</p> Signup and view all the answers

    What action should be included in the care plan for a child with cystic fibrosis?

    <p>Administer high-dose antibiotic therapy.</p> Signup and view all the answers

    What finding is expected in a client with pulmonary edema?

    <p>Pink, frothy sputum</p> Signup and view all the answers

    How should the nurse maintain sterile technique during a dressing change?

    <p>Maintain sterile objects within the line of vision.</p> Signup and view all the answers

    What action should the nurse take for a client with rheumatoid arthritis?

    <p>Allow for frequent rest periods throughout the day.</p> Signup and view all the answers

    In caring for a client with sickle cell disease, which interventions should be implemented? (Select all that apply)

    <p>Administer IV fluids.</p> Signup and view all the answers

    Which client should the nurse attend to first?

    <p>An older adult client who is anxious and attempting to pull out an IV line</p> Signup and view all the answers

    For which client should the home health nurse initiate a referral to PACE?

    <p>An older adult client with complex care needs.</p> Signup and view all the answers

    Why should the nurse turn off the CPM machine during meals?

    <p>To promote client comfort and dietary intake</p> Signup and view all the answers

    Which client should the nurse recommend for discharge?

    <p>A client who has cellulitis and is receiving oral antibiotics every 8 hr</p> Signup and view all the answers

    Which instructions should the nurse include in the teaching for a child's medication?

    <p>Report diarrhea to the provider immediately.</p> Signup and view all the answers

    What is an indication of potential violence in a client?

    <p>Pacing around the chair</p> Signup and view all the answers

    Which client should the nurse recommend for treatment first?

    <p>A middle adult client who has unstable vital signs</p> Signup and view all the answers

    When should the nurse initiate a request for a high-frequency chest compression vest?

    <p>When the client has only a small amount of mucus after percussion therapy</p> Signup and view all the answers

    Which client should the nurse intervene to prevent a potential food and medication interaction?

    <p>A client who is receiving an MAOI and is requesting a cheeseburger for dinner</p> Signup and view all the answers

    What is a potential adverse effect of PEEP?

    <p>Tension pneumothorax</p> Signup and view all the answers

    Why should the nurse assess the amount of vaginal bleeding in a client in the fourth stage of labor?

    <p>To identify potential hemorrhage</p> Signup and view all the answers

    Which discharge instructions are recommended for a client with hyperemesis gravidarum?

    <p>Alternate eating solid foods and liquids</p> Signup and view all the answers

    What food recommendations should the nurse make for a client taking phenelzine?

    <p>Yogurt</p> Signup and view all the answers

    What information should the nurse include in the change-of-shift report?

    <p>The time of the client's last dose of pain medication</p> Signup and view all the answers

    What is the first action the nurse should take in an emergency situation?

    <p>Survey the scene for potential hazards</p> Signup and view all the answers

    What task should the nurse delegate to an assistive personnel (AP)?

    <p>Measure the client's daily weight</p> Signup and view all the answers

    What is the priority intervention for a client with a fever and fluid-filled vesicles?

    <p>Initiate transmission-based precautions</p> Signup and view all the answers

    What is the risk for the client with a history of seizure activity?

    <p>Seizures</p> Signup and view all the answers

    What is the characteristic of a client with borderline personality disorder?

    <p>Emotional instability and self-harming behaviors</p> Signup and view all the answers

    What is the amount of mannitol the nurse should administer?

    <p>18g</p> Signup and view all the answers

    Which site should the nurse select for IV access in an older adult client?

    <p>Radial vein of the inner arm</p> Signup and view all the answers

    What is the nurse's response to the client's statement about their family?

    <p>How does this make you feel?</p> Signup and view all the answers

    What is the indication that the medication is effective?

    <p>Decreased hallucinations</p> Signup and view all the answers

    What information should the nurse include in the teaching for a client with total parenteral nutrition?

    <p>I will need to measure your weight daily</p> Signup and view all the answers

    What should the nurse do in an emergency situation when unable to locate the client's family?

    <p>Proceed with provision of medical care</p> Signup and view all the answers

    Study Notes

    Change-of-Shift Report

    • Prioritize assessment of postoperative clients with abdominal distention and absent bowel sounds, indicating potential paralytic ileus.
    • Stable clients, like those with blood glucose levels of 105 mg/dL, may be assessed later.

    ADHD vs Intellectual Disability

    • Key indicators for ADHD include hyperreactivity, disorganization (losing items), and interrupting others.
    • Intellectual disability may encompass similar deficits, particularly in cognitive function and language skills.

    Infection Control Education

    • Understanding that airborne precautions must be followed for clients with conditions like tuberculosis requires a negative-pressure room.
    • Droplet precautions are necessary for clients with measles or pneumonia, using surgical masks as needed.

    Ovarian Cancer Signs

    • Abdominal bloating is an early sign of ovarian cancer; other signs include changes in bowel habits and urinary symptoms.

    Acid-Base Imbalances

    • A pH of 7.2, PaCO2 of 60 mm Hg indicates respiratory acidosis, necessitating recognition of these abnormalities in acid-base balance.

    Type 1 Diabetes Management Post-Injury

    • Cold therapy is contraindicated in clients with diabetes due to impaired circulation risks.
    • Regular neurovascular checks and blood glucose monitoring are critical after injuries.

    Tuberculosis Precautions

    • Clients with active TB should wear masks when outside their rooms to minimize transmission risks to others.
    • Informed consent promotes client autonomy, giving them the right to make informed decisions regarding their treatment plans.

    Valproic Acid Adverse Effects

    • Monitor for signs of jaundice as a potential indicator of liver damage in clients taking valproic acid for seizures.

    Neurological Assessment and Care

    • Anticipate monitoring oxygen saturation and blood glucose levels in patients exhibiting signs of increased intracranial pressure.
    • Cluster nursing care is contraindicated due to risks of exacerbating increased ICP.

    IV Infusion Calculations

    • Calculate and set IV drip rates accurately, ensuring proper adjustments for patient needs.

    Basal Body Temperature Method

    • Educate clients that body temperature may drop slightly before ovulation, assisting them in tracking fertility cycles.

    Cystic Fibrosis Care

    • High-dose antibiotics are essential due to the metabolic needs of children with cystic fibrosis facing infections.

    Recognizing Pulmonary Edema

    • Expect pink, frothy sputum in clients with pulmonary edema due to fluid accumulation in the lungs.

    Maintaining Sterile Technique

    • Keep sterile items within the direct line of vision to uphold aseptic conditions during procedures.

    Rheumatoid Arthritis Pain Management

    • Encourage rest periods interspersed with activity to manage joint pain effectively in rheumatoid arthritis clients.

    Sickle Cell Crisis Management

    • Administer IV fluids rapidly to alleviate crisis symptoms and utilize humidification with oxygen therapy to ensure comfort.

    Client Prioritization in Nursing

    • Address safety concerns first, prioritizing clients who are anxious and attempting to remove IV lines.

    Referral to PACE Program

    • Initiate PACE referrals for older adults needing adult day care services, which align with comprehensive elder care objectives.

    Captopril Adverse Effects

    • A persistent cough is a significant side effect of captopril that requires communication to the healthcare provider.

    Crutch Training for Fracture Management

    • Instruct clients to use a three-point crutch gait to ensure mobility without pressure on the injured limb.

    Postoperative Care Priorities

    • Encourage deep breathing exercises post-abdominal surgery to prevent complications such as pneumonia and promote lung expansion.### Postoperative Care
    • Deep breathing and coughing exercises reduce the risk of postoperative pneumonia.
    • Key assessments post laparoscopic cholecystectomy include alertness, incision site status, and auscultation of lung sounds.
    • Dressings should be clean, dry, and intact; change when soiled.
    • Educate on symptoms to report: swelling, redness, drainage, or warmth at the incision site.

    Provider Prescriptions

    • Apply heat for abdominal pain related to carbon dioxide retention.
    • Encourage deep breathing exercises hourly to aid recovery.
    • Ondansetron for nausea should be provided as needed, not on a scheduled basis.

    Advance Directives Education

    • Client can designate a partner as their health care surrogate, showcasing understanding of advance directives.
    • Younger clients may underestimate the importance of planning for future health care.

    Postoperative Laryngectomy Care

    • Assess reading skills first to tailor communication methods for a patient unable to speak after a laryngectomy.

    Risk Assessment Post Thyroidectomy

    • Watch for hypocalcemia indicated by muscle cramps and numbness around the lips following thyroid surgery.
    • Immediate treatment with calcium gluconate required to prevent complications.

    Altruism in Cancer Care

    • Proactive behavior, such as starting a community support group, illustrates altruism in patients coping with breast cancer.

    Pediatric Assessment Prioritization

    • Sudden relief of pain in a child awaiting appendectomy can signal a serious condition like peritonitis; assess this patient first.

    Suspected Child Abuse Protocol

    • Legally required to report suspected physical abuse to Child Protective Services—do not confront the parents directly.

    Intramuscular Injection Guidelines

    • Opt for the ventrogluteal site for IM injections in obese clients, as it avoids large nerves and vessels.

    Indicators of Thyroid Storm

    • Monitor for increased temperature, heart rate, blood pressure changes, and alterations in mental status after thyroid surgery.

    New Nurse Performance Evaluation

    • Interventions needed when a new nurse starts a task without adequate preparation, compromising time management.

    Adverse Effects of Amitriptyline

    • Blurred vision should be monitored as an adverse effect of amitriptyline.

    Asthma Management Education

    • Ensure annual influenza vaccination to reduce infection risk in children with asthma.

    Autism Spectrum Disorder Characteristics

    • Expect strict adherence to routines and rituals in children on the autism spectrum.

    Tuberculosis Infection Control

    • Assign clients with active pulmonary tuberculosis to a private room with negative air pressure to prevent disease transmission.
    • Monitor for metabolic acidosis in pregnant clients experiencing significant weight loss and inadequate nutritional intake.

    Common Pregnancy Discomforts

    • Wearing a supportive bra overnight can alleviate discomfort associated with breast changes during pregnancy.

    Intestinal Obstruction Identification

    • Signs include abdominal distension, hypoactive bowel sounds, and prolonged absence of bowel movements; requires IV fluids and semi-Fowler's positioning for relief.### Bowel Sounds and Urine Output Monitoring
    • Assess bowel sounds a minimum of twice daily to check for peristalsis return.
    • Monitor urine output closely in clients receiving IV fluids.
    • Dehydration is a key manifestation of intestinal obstruction.

    Hip Joint Abduction

    • Hip joint abduction occurs when the leg moves away from the body's midline during assessment.

    Chemotherapy and Neutropenia Care

    • Exclude raw fruits and vegetables from the client's diet to minimize bacterial infection risk.
    • Limit visits from young children to reduce exposure risk.
    • Measure client’s temperature per shift.

    Ibuprofen Adverse Effects

    • Assess for stomach pain or bloody stools to identify potential gastrointestinal bleeding caused by ibuprofen.

    Postoperative Risk Assessment

    • Client post CABG at risk for dysrhythmias due to hypokalemia evidenced by lab results showing low potassium levels and muscle cramping.
    • Monitor electrolyte levels closely following CABG surgery.

    Ginger Tea Effectiveness

    • A decrease in episodes of nausea indicates the effectiveness of ginger tea in pregnant clients.

    Effectiveness of Packed RBC Therapy

    • A hemoglobin level of 14.9 g/dL indicates that packed RBC therapy was successful in elevating low hemoglobin.

    Osteoporosis Risk Factors

    • Sedentary lifestyle recognized as a significant risk factor for osteoporosis; encourage weight-bearing exercises in older adults.

    Alterations in Speech in Bipolar Disorder

    • Flight of ideas is characterized by continuous speech with rapid and frequent topic switching.

    Neuroleptic Malignant Syndrome Management

    • Conditions likely indicating neuroleptic malignant syndrome include muscle rigidity, diaphoresis, and altered vital signs.
    • Hold antipsychotic medications and provide cooling interventions; monitor hydration status and temperature.

    Intracranial Pressure Mitigation

    • Keeping the client's environment quiet helps reduce the risk of increased intracranial pressure.

    Hospice Care Understanding

    • Expect ongoing support from hospice services post-death; importance of bereavement care.

    Advocacy in Nursing

    • Advocacy empowers clients to self-actualize; view it as a leadership role encouraging personal growth.

    Postpartum Hemorrhage Interventions

    • Immediate actions include massaging the uterine fundus, administering methylergonovine, weighing perineal pads, providing emotional support, and administering oxygen.

    Continuous Passive Motion Machine Use

    • The CPM machine should be switched off during meal times to enhance comfort while eating.

    Client Discharge Decisions

    • Clients receiving oral antibiotics for cellulitis can be safely discharged, whereas others may need continued hospital care.

    Discharge Instructions for Amoxicillin/Clavulanate

    • Shake the medication well before administering, store it in the refrigerator, and report diarrhea to the provider.

    Monitoring for Violence in Mental Health

    • Pacing around a partner during a visit can indicate potential for violent behavior; closer assessment and de-escalation are needed.

    Triage Prioritization in Emergency

    • Clients with unstable vital signs require immediate treatment due to the risk of severe complications or death.

    Cystic Fibrosis and Airway Clearance

    • Recommend a high-frequency chest compression vest for children who achieve inadequate results with standard therapies.

    Preventing Food and Medication Interactions

    • Clients on MAOIs should avoid tyramine-rich foods like cheeseburgers to prevent hypertensive crises.

    Adverse Effects of PEEP

    • Tension pneumothorax is a potential adverse effect of positive end-expiratory pressure (PEEP); monitoring lung sounds for warning signs is crucial.

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    Description

    This quiz assesses nursing knowledge on postoperative care, ADHD and intellectual disability, infection control, ovarian cancer signs, and acid-base imbalances.

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