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Questions and Answers
In what position should the nurse place a client diagnosed with gastric reflux?
In what position should the nurse place a client diagnosed with gastric reflux?
What statement by the client would indicate to the nurse that further teaching is needed regarding a gluten-free diet?
What statement by the client would indicate to the nurse that further teaching is needed regarding a gluten-free diet?
Which food items would indicate to the nurse that the UAP understands a clear liquid diet? (Select all that apply)
Which food items would indicate to the nurse that the UAP understands a clear liquid diet? (Select all that apply)
Which electrolyte imbalance would be the nurse's priority concern for a client with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism?
Which electrolyte imbalance would be the nurse's priority concern for a client with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism?
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Following three days of treatment, what information should the nurse include in discharge teaching for a client with encephalopathy secondary to cirrhosis? (Select all that apply)
Following three days of treatment, what information should the nurse include in discharge teaching for a client with encephalopathy secondary to cirrhosis? (Select all that apply)
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What actions should the nurse take for a client who reports dizziness and weakness while walking? (Select all that apply)
What actions should the nurse take for a client who reports dizziness and weakness while walking? (Select all that apply)
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Which finding would indicate a possible complication after an endoscopic retrograde cholangiopancreatogram (ERCP)?
Which finding would indicate a possible complication after an endoscopic retrograde cholangiopancreatogram (ERCP)?
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What is the first nursing action for a client with suspected tuberculosis?
What is the first nursing action for a client with suspected tuberculosis?
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After a heart catheterization, what should be the nurse's first action for a client with severe foot pain on the side of the femoral insertion site?
After a heart catheterization, what should be the nurse's first action for a client with severe foot pain on the side of the femoral insertion site?
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Which interventions would help control a client's pain following an acute abdominal situation? (Select all that apply)
Which interventions would help control a client's pain following an acute abdominal situation? (Select all that apply)
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What priority action should the nurse perform after a lumbar puncture when the client reports a headache on a pain scale of 8 out of 10?
What priority action should the nurse perform after a lumbar puncture when the client reports a headache on a pain scale of 8 out of 10?
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Which action by a UAP should the nurse interrupt while caring for a client with a skull fracture?
Which action by a UAP should the nurse interrupt while caring for a client with a skull fracture?
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Why is metoprolol likely to decrease chest pain episodes for a client with a history of CHF switching from hydralazine?
Why is metoprolol likely to decrease chest pain episodes for a client with a history of CHF switching from hydralazine?
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What additional findings would make the nurse suspect pancreatitis in a client with a history of alcoholism? (Select all that apply)
What additional findings would make the nurse suspect pancreatitis in a client with a history of alcoholism? (Select all that apply)
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What statement by a client indicates successful teaching for preventing urinary tract infections? (Select all that apply)
What statement by a client indicates successful teaching for preventing urinary tract infections? (Select all that apply)
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Which statement indicates understanding of the nurse's teaching about an upper GI series?
Which statement indicates understanding of the nurse's teaching about an upper GI series?
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What nursing interventions would be appropriate for a client with end-stage chronic renal failure exhibiting dry, itchy skin and uremic halitosis? (Select all that apply)
What nursing interventions would be appropriate for a client with end-stage chronic renal failure exhibiting dry, itchy skin and uremic halitosis? (Select all that apply)
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What early warning signs of Alzheimer's Disease (AD) should the nurse include in teaching? (Select all that apply)
What early warning signs of Alzheimer's Disease (AD) should the nurse include in teaching? (Select all that apply)
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Which signs or symptoms would indicate a client needs further investigation during a cancer risk screening? (Select all that apply)
Which signs or symptoms would indicate a client needs further investigation during a cancer risk screening? (Select all that apply)
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What intervention should the nurse initiate first for a post-operative client who becomes anxious and reports acute chest pain?
What intervention should the nurse initiate first for a post-operative client who becomes anxious and reports acute chest pain?
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Which risk factors for influenza complications would be included in a session about influenza? (Select all that apply)
Which risk factors for influenza complications would be included in a session about influenza? (Select all that apply)
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What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? (Select all that apply)
What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? (Select all that apply)
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Which potential side effect should the nurse educate the client regarding while receiving spironolactone?
Which potential side effect should the nurse educate the client regarding while receiving spironolactone?
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Which teaching points should the nurse include about foot and leg care for a client diagnosed with peripheral vascular disease (PVD)?
Which teaching points should the nurse include about foot and leg care for a client diagnosed with peripheral vascular disease (PVD)?
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What assessment finding would the nurse expect to see in a client diagnosed with Guillain-Barre' Syndrome?
What assessment finding would the nurse expect to see in a client diagnosed with Guillain-Barre' Syndrome?
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When dressing a severe burn on the right hand, what is important for the nurse to do?
When dressing a severe burn on the right hand, what is important for the nurse to do?
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What statement indicates that the client understands the edrophonium (Tensilon) test?
What statement indicates that the client understands the edrophonium (Tensilon) test?
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Following burns to the chest and legs, which assessment should the nurse perform immediately?
Following burns to the chest and legs, which assessment should the nurse perform immediately?
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What is the priority nursing action for a client with tingling of the toes and feet following the flu who begins to have numbness in the legs and hips?
What is the priority nursing action for a client with tingling of the toes and feet following the flu who begins to have numbness in the legs and hips?
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A client reports excruciating paroxysmal facial pain. What disorder does the nurse suspect?
A client reports excruciating paroxysmal facial pain. What disorder does the nurse suspect?
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In the case of critical lab results, which body system requires immediate notification of the healthcare provider?
In the case of critical lab results, which body system requires immediate notification of the healthcare provider?
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What is the priority action by the nurse for a client with a bypass graft of the left femoral artery who develops left leg pain and coolness?
What is the priority action by the nurse for a client with a bypass graft of the left femoral artery who develops left leg pain and coolness?
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What should be included in the discharge teaching plan for a client with lymphedema post right mastectomy?
What should be included in the discharge teaching plan for a client with lymphedema post right mastectomy?
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Which dietary changes should be included in teaching for a client with iron deficiency anemia?
Which dietary changes should be included in teaching for a client with iron deficiency anemia?
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What should the nurse advise a 68-year-old client experiencing tremors?
What should the nurse advise a 68-year-old client experiencing tremors?
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What change would best indicate improvement in a client receiving chemotherapy for breast cancer?
What change would best indicate improvement in a client receiving chemotherapy for breast cancer?
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What symptoms reported by the client with benign prostatic hyperplasia (BPH) indicate medications are not working?
What symptoms reported by the client with benign prostatic hyperplasia (BPH) indicate medications are not working?
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Which client complaint concerning systemic scleroderma should be of most concern to the homecare nurse?
Which client complaint concerning systemic scleroderma should be of most concern to the homecare nurse?
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Which measures can caregivers take to reduce the risk of falls in their elderly parent?
Which measures can caregivers take to reduce the risk of falls in their elderly parent?
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What is the highest priority goal for a client after total hip replacement?
What is the highest priority goal for a client after total hip replacement?
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What is the best indicator of the effectiveness of an escharotomy after a circumferential burn?
What is the best indicator of the effectiveness of an escharotomy after a circumferential burn?
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For a major burn, which evaluation of fluid resuscitation is most effective in the first 24 hours?
For a major burn, which evaluation of fluid resuscitation is most effective in the first 24 hours?
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What provides the most accurate information regarding diet for a client with advanced cirrhosis?
What provides the most accurate information regarding diet for a client with advanced cirrhosis?
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Which signs and symptoms validate the nurse's suspicions of a cholinergic crisis in a myasthenia gravis client?
Which signs and symptoms validate the nurse's suspicions of a cholinergic crisis in a myasthenia gravis client?
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What is the most significant assessment finding in a client with acute coronary syndrome?
What is the most significant assessment finding in a client with acute coronary syndrome?
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What intervention should the nurse implement for a graft site within the first 24 hours?
What intervention should the nurse implement for a graft site within the first 24 hours?
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What interventions should be included for clients to prevent and treat fungal infections of the feet?
What interventions should be included for clients to prevent and treat fungal infections of the feet?
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Which assessment finding is most indicative of fluid volume overload?
Which assessment finding is most indicative of fluid volume overload?
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What therapeutic statement should the nurse make to an elderly client afraid of falling when first ambulating post-hip replacement?
What therapeutic statement should the nurse make to an elderly client afraid of falling when first ambulating post-hip replacement?
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What should the nurse do first for a client showing decreased consciousness and vital sign changes post-CABG?
What should the nurse do first for a client showing decreased consciousness and vital sign changes post-CABG?
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Which laboratory results provide evidence of diabetes insipidus?
Which laboratory results provide evidence of diabetes insipidus?
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What action should the nurse take if constant bubbling is noted in the water seal chamber of a chest tube two days post-insertion?
What action should the nurse take if constant bubbling is noted in the water seal chamber of a chest tube two days post-insertion?
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Which findings should be expected in elderly clients regarding nutrition?
Which findings should be expected in elderly clients regarding nutrition?
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What should the nurse do first for a client with acute myeloid leukemia experiencing pain from mucositis?
What should the nurse do first for a client with acute myeloid leukemia experiencing pain from mucositis?
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What is the nurse's priority action upon finding an unfamiliar client standing in a puddle of liquid?
What is the nurse's priority action upon finding an unfamiliar client standing in a puddle of liquid?
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Which observation indicates a serious complication for a client with a closed head injury?
Which observation indicates a serious complication for a client with a closed head injury?
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Which statements from teenage girls indicate effective teaching on breast self-awareness?
Which statements from teenage girls indicate effective teaching on breast self-awareness?
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Which meal option should the client diagnosed with gout select?
Which meal option should the client diagnosed with gout select?
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What score should be assigned to a client assessed using the Braden Scale?
What score should be assigned to a client assessed using the Braden Scale?
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What acid-base imbalance do the lab values indicate to a nurse for a newly admitted client?
What acid-base imbalance do the lab values indicate to a nurse for a newly admitted client?
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Study Notes
NCLEX Practice Questions - Adult Health Study Notes
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Primary Hyperaldosteronism and Spironolactone
- Potential side effects include erectile dysfunction, gastrointestinal upset, and gynecomastia.
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Peripheral Vascular Disease (PVD) Teaching
- Foot and leg care recommendations: Wear soft cotton socks, avoid hot whirlpools, and clear pathways in the house.
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Guillain-Barre Syndrome Findings
- Expected assessments include areflexia, dysphagia, and orthostatic hypotension.
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Burn Care
- Wrap each digit individually when dressing a hand burn to prevent webbing.
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Edrophonium (Tensilon) Test
- Client should understand that repetitive movements will be tested after the medication is administered.
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Emergency Assessment after Burns
- Immediate priority assessment is airway integrity for clients with burns.
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Numbness after Flu Illness
- Priority action is to notify the primary healthcare provider due to potential complications.
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Facial Pain Diagnosis
- Excruciating, paroxysmal facial pain after cold exposure suggests trigeminal neuralgia.
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Laboratory Results and Urgent Issues
- Critical renal changes require immediate notification to the healthcare provider.
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Postoperative Complications - Leg Pain
- In a patient post-femoral artery bypass, notify the healthcare provider if leg pain and coolness occur.
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Lymphedema Teaching Post-Mastectomy
- Recommendations include using a thimble for sewing, wearing heavy oven mitts, long sleeves to prevent insect bites, and using an electric razor.
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Iron Deficiency Anemia Education
- Emphasize iron-rich foods, report any symptoms like glossitis, and educate on ferrous sulfate supplements.
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Tremors in Elderly Clients
- Report tremors to the primary health care provider due to potential underlying issues.
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Cancer Treatment Management
- Weight gain after chemotherapy indicates improvement in the client's condition.
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Impact of Benign Prostatic Hyperplasia Medications
- Symptoms indicating treatment failure include bladder pain, urinary frequency, and terminal dribbling.
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Scleroderma Concerns
- Difficulty swallowing is a significant concern for clients with scleroderma.
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Fall Prevention in Elderly
- Key strategies include ensuring adequate lighting, using contrasting colors for stairs, and installing grab bars.
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Post-Total Hip Replacement Care
- Highest priority goal is to prevent respiratory complications.
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Escharotomy Evaluation
- Prompt capillary refill under 2 seconds after blanching indicates effectiveness of the procedure.
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Burn Fluid Resuscitation Monitoring
- Effective resuscitation is indicated by urine output of 860 mL within 24 hours.
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Dietary Limitations in Cirrhosis
- Protein intake must be restricted due to elevated ammonia levels in cirrhosis patients.
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Cholinergic Crisis Signs
- Validation of crisis includes symptoms such as diarrhea, increased urination, and nausea or vomiting.
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Acute Coronary Syndrome Monitoring
- Ventricular fibrillation is the most significant finding during continuous cardiac monitoring.
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Management of Grafted Sites
- Position the arm to prevent pressure on the graft site within the first 24 hours post-surgery.
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Fungal Infection Prevention for Feet
- Wash feet daily, apply terbinafine cream, wear breathable shoes, and use shower sandals in public places.
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Fluid Volume Overload Indicators
- Pitting edema in lower extremities is indicative of fluid volume overload.
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Therapeutic Communication for Elderly
- Encourage discussions about fears or worries regarding ambulation to promote a supportive environment.
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Post-Surgery Complications Following CABG
- Administer 100% oxygen immediately for decreased level of consciousness and vital signs indicating shock.
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Diabetes Insipidus Indicators
- Urine specific gravity of 1.004 and elevated serum sodium levels are indicative of diabetes insipidus.
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Chest Tube Observations
- Constant bubbling in the water seal chamber after chest tube insertion necessitates notifying the healthcare provider.
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Elderly Nutrition Assessments
- Dental problems, decreased appetite, and varying caloric needs are common in elderly clients.
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Acute Myeloid Leukemia Pain Management
- Administer pain medication first for clients experiencing pain from mucositis.
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Priority Actions for New Clients in Long-Term Care
- Ensure the safety of clients by addressing any spills immediately.
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Serious Complications in Head Injuries
- Report a petechial rash with a temperature increase as it may indicate a serious condition.
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Effective Breast Self-Awareness Teaching
- Statements regarding monthly self-exams and recognizing warning signs indicate effective education.
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Systemic Lupus Erythematosus Flare-Up Signs
- Abdominal discomfort, alopecia, and butterfly rash are common indicators of SLE flares.
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Dietary Selection for Gout
- Choose options such as vegetable soup, whole wheat toast, and skim milk to manage gout.
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Portosystemic Encephalopathy Neurological Deterioration
- Elevated ammonia levels (80 mcg/dl) are likely responsible for neurological symptoms.
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Prednisolone Monitoring in Nephrotic Syndrome
- A weight gain of 2 lbs in 24 hours is a priority concern and should be addressed immediately.
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Alzheimer's Disease Care Planning
- Focus on assessing self-care abilities, breaking tasks into manageable steps, and providing companionship through communication.### Card Assessments and Interventions
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Prioritize assessment findings post-total hip replacement, focusing on a temperature of 101.8°F (38.7°C) due to potential infection risk.
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For a patient with diverticulosis, correct dietary selections include avocados, acorn squash, lima beans, and raspberries, indicating understanding of prescribed dietary modifications.
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In suspected pancreatitis, additional concerns include Cullen's Sign and tachycardia in a patient with severe abdominal pain and a history of alcoholism.
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A burn victim's area that is pale but has good capillary refill necessitates keeping the room warm to promote blood flow.
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Indicators of a tension pneumothorax include tracheal deviation and dyspnea.
Nutritional Education and Dietary Considerations
- Post-gastric bypass symptoms like dizziness can be alleviated by reducing carbohydrate intake, eating small meals, and sitting semi-recumbent during meals.
- Signs of diabetic ketoacidosis in a patient may include dry mucous membranes, fruity breath, and glycosuria.
- In educating adults about essential foods for vitamin B12 intake, emphasize calf liver, feta cheese, shrimp, and tuna.
Patient Education and Risk Assessments
- Palliative care focuses on symptom management and improving quality of life, not solely on curative measures.
- For a postmenopausal client, combined low doses of estrogen and progestin may be recommended for hormonal therapy, especially when a uterus is present.
- Assessing for home safety should include ensuring fire safety measures are in place, such as fire extinguishers on each level and testing smoke alarms monthly.
Health Risks and Monitoring
- Recognize the increased risk of aspiration pneumonia in stroke survivors with a history of GERD, characterized by lethargy and facial droop.
- Educate about heart health by emphasizing daily weight checks and the elimination of alcohol in patients with liver issues after discharge.
- Monitor for potential complications post-ERCP, especially if the patient reports significant abdominal pain.
Special Considerations for Conditions
- For clients with conditions like multiple sclerosis, expect symptoms such as fatigue, ptosis, blurry vision, and electrical sensations while bending the neck.
- Individuals diagnosed with idiopathic thrombocytopenic purpura (ITP) are likely to experience bleeding gums, ecchymosis, and petechiae.
- In cases of hypomagnesemia following chronic alcoholism, prioritize the identification of the electrolyte imbalance affecting the patient.
Client Management in Critical Situations
- After intubation of a client, assess bilateral breath sounds as a priority action before securing the endotracheal tube or obtaining an x-ray.
- In evaluating a client recovering from a stroke and presenting with homonymous hemianopia, place their meal on the unaffected side for ease of access.
- During a nursing assessment of a client with suspected tuberculosis, prompt identification of symptoms should occur alongside isolation procedures.
Understanding Dietary Restrictions
- Educate clients with celiac disease that they can’t consume wheat products, emphasizing a strict gluten-free diet while dispelling misconceptions about other foods.
- In coaching a client recovering from a thyroidectomy, ensure the avoidance of nuts such as roasted almonds due to potential complications in recovery.
- Guide clients on clear liquid diets by identifying acceptable options like white grape juice, gelatin, and broth, while correcting misunderstandings about pudding and other non-clear items.### Pain Management and Interventions
- Abdominal pain with rigidity indicates potential severe conditions; interventions include NG tube suction, side-lying position, and PCA pump for hydromorphone.
- Frequent small feedings are not prioritized for acute pain management.
Post-Lumbar Puncture Care
- Severe headaches post-lumbar puncture should be managed by placing the client in a supine position to alleviate pressure.
Client Care with Skull Fracture
- UAP actions should be monitored; assisting with turn, cough, and deep breathing is inappropriate for clients with skull fractures due to risk of increased intracranial pressure.
Medications in Heart Failure Management
- Switching from hydralazine to metoprolol addresses reflex tachycardia, reducing chest pain episodes in clients with congestive heart failure.
Pancreatitis Indicators
- Clients with severe abdominal pain and a history of alcoholism presenting with umbilical bruising, fever with tachycardia, and back-radiating pain may indicate pancreatitis.
Urinary Tract Infection Prevention
- Effective prevention strategies include timely urination, hydration, dietary acidity enhancement, and proper hygiene practices.
Understanding Upper GI Series
- Knowledge of upper GI series includes consuming contrast material for x-ray imaging, essential for accurate diagnosis.
Chronic Renal Failure Management
- Nursing care for clients with chronic renal failure involves skin care with emollients, wearing cotton gloves at night, cutting fingernails, and oral hygiene.
Early Signs of Alzheimer's Disease
- Key early warning signs include mild disorientation and difficulties with words and numbers, essential for caregivers to recognize.
Cancer Risk Screening Indicators
- Symptoms suggesting a need for further investigation include leukoplakia, prolonged hoarseness, hematuria, and persistent abdominal bloating.
Acute Post-Operative Care
- In cases of acute chest pain and shortness of breath, raising the head of the bed is a critical first intervention to improve respiratory function.
Influenza Risk Factors
- High-risk groups for influenza complications include individuals over 65, those with diabetes, renal disease, and residents of nursing homes.
Smokeless Tobacco Education
- Education for teens on smokeless tobacco should emphasize regular oral inspections, reporting of lesions, and cessation strategies, as it poses health risks.
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