NUR 2356 / NUR2356 Multidimensional Care I (MDC 1) Exam 2 (Latest 2026/2027 Update) | Rasmussen University | Complete Study Guide | Verified Questions & Answers | 100% Correct Solutions | Grade A

NUR 2356 / NUR2356 Multidimensional Care I (MDC 1) Exam 2 (Latest 2026/2027 Update) | Rasmussen University | Complete Study Guide | Verified Questions & Answers | 100% Correct Solutions | Grade A Q: A client with a history of chronie aleohol -huse is admitted to tha hochital for alcoho withdrawal. The nurse notes that the client is experiencing confusion, ataxia, anc is most appropriate? Answer hallucinations. The client's serum magnesium level is 1.4 mg/dL. Which nursing action Initiate seizure precautions Q: A client with a history of heart failure is admitted with muscle weakness and low blood pressure. The client's serum potassium level is 2.8 mEq/L. The nurse is preparing to administer intravenous potassium. What is the most appropriate nursing action? Answer Use an infusion pump to administer the potassium intravenously. Q: A client with advanced kidney injury is receiving magnesium sulfate intravenously (IV). The nurse notes that the client has developed hypotension, bradycardia, and decreased deep tendon reflexes. Which action should the nurse take first? Answer a. Administer IV furosemide to enhance magnesium excretion. Stop the magnesium sulfate infusion immediately Q: A client presents with severe vomiting and diarrhea, and laboratory results reveal a serum sodium level of 126 mEq/L. The client is also experiencing muscle cramps, address the client's condition? Answer weakness and muscular twitching. Which intervention should the nurse prioritize Administer IV 0.9% sodium chloride Q: A high school student experiences muscle cramping after running in sports activities attributed to low magnesium levels. The student asks the school nurse how to Increase magnesium in the diet. What foods should the nurse include in the response? Answer Greenleafy vegetables, beans and nuts Q: A surgical nurse is caring for a client who is postoperative on day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The cllent has positive Trousseau and Chostek sign. Which electrolyte Imbalance should the nurse first suspect? Answer Hypocalcemia Q: A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which actions should the nurse take when administering potassium IV? Select all that apply. Answer Follow the facility policy for infusion of potassium. Apply continuous cardiac monitoring. %. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. Q: The nurse is assessing the client for the presence of a Chostek sign. What electrolyte imbalance would a positive Chostek sign indicate? Answer Hypomagnesemia Q: The client was admitted with kidney stones. What electrolyte imbalance should be considered based on this finding? Answer Hypercalcemia Q: A cancer patient is experiencing stomatitis due to chemotherapy what intervention should be applied to alleviate this condition? Answer Recommend saline rinses to relieve pain and prevent infection Q: A cient with prolonged immobilization has a calcium level 13 mg/dL presents with wises and confusion. Which intervention should be prioritized for this physiological effect? Select all that apply Answer Start hydration to lower elevated calcium levels Perform assessment to check mental status changes Administer calcitonin intramuscularly (IM) as prescribed Q: A client admitted with hypoparathyroidism following a radical neck dissection reports irritability, anxiety, and diarrhea. What is the priority nursing intervention? Answer Monitor the client for laryngospasm Q: Apatient with hyperparathyroidism is experiencing symptoms of hypercalcemia. Which care strategy should the nurse apply? Answer Provide IV fluids and administer prescribed diuretics Q: A patient with congestive heart failure (CHF) is taking loop diuretics. Which factor primarily contributes to the electrolyte imbalance in this patient? Answer High potassium loss in urine Q: A patient with diabetic ketoacidosis (DKA) presents with high serum potassium levels. Which factor contributes to this electrolyte imbalance? Answer Potassium shifts from cells to bloodstream Q: A nurse Is assessing a client with chronic renal failure who presents with tall tented T waves on the cardiac electrocardiogram (ECG). Which electrolyte imbalance should the nurse suspect? Answer Hyperkalemia Q: A 52-year-old female with a recent history of prolonged vomiting and nasogastric suction presents with muscle weakness and fatigue. Her electrocardiogram (ECG) reveals flattened T waves and the presence of U waves. The nurse would anticipate the flowing laboratory value to be the cause of the assessment findings Answer Potassium: 2.8mEqL Q: A 70-year-old client with head trauma after a recent fall presents with nausea, vomiting, confusion, and muscle cramps. Laboratory findings indicate a serum sodium level 118 mEq/L and serum potassium level of 2.5 mEq/L. Which nursing intervention should be prioritized? Select all that apply. Answer Administer 3% sodium chloride intravenously slowly Monitor vital signs closely to assess patiently stability Provide potassium supplements To correct hypokalemia Q: A 80-year-old patient with chronic kidney disease exhibits confusion, and laboratory results show elevated potassium levels. Which intervention should the nurse prioritize? Answer Administer calcium gluconate to stabilize cardiac membranes Q: A patient with a history of hypertension and diabetes is admitted with confusion an hypotension. Laboratory results show a serum sodium level of 122 mEq/L. Which is the most appropriate nursing action? Answer Administer 3% sodium chloride via an infusion pump Q: The nurse assesses a client with peptic ulcer disease (PUD). What che... most ilkely related to a duodenal ulcer? Answer I often notice the pain at night when am trying to sleep. Q: A client with gastrosophageal reflux disease (GERD) is being educated on ways to reduce symptoms. What should the nurse advise the client to avoid? Answer Alcohol intake Q: A client is diagnosed with gastroesophageal reflux disease (GERD) and Barrett esophagus with minor cell changes. Which of the following complications is the client at risk for? Answer Esophageal adenocarcinoma Q: A client with a history of chronic gastritis is being educated on lifestyle modifications to manage their condition. Which statement by the client indicates a need for furthe teaching? Answer I can continue to enjoy my morning coffee as it has no effect on gastritis." Q: A client with a history of NSAID use presents with epigastric pain and hemateme Which nursing action is most appropriate to prioritize for this client's care? Answer Prepare the client for an upper endoscopy A nurse is earing for a patient newly diagnosed with gastric cancer who reports early satiety, unintentional weight loss, and vague epigastric discomfort. The provider discusses treatment options, including surgery. Based on this Information, which nursing intervention best demonstrates clinical reasoning in preparing the patient for a subtotal gastrectomy? Answer a. Educate the patient on signs of dumping syndrome and strategies to minimize symptoms A client with a history of peptic ulcer disease. Which of the following clinical findings would indicate peptic ulcer perforation? Select all that apply Answer Heart rate 129 beats per minute Blood pressure 90/68 Severe, sharp upper abdominal pain Nausea or vomiting The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? I flush my tube with water before and after each of my medications." The nurse is preparing to check for nasogastric tube placement in the client's stomach. What is this nursing action attempting to prevent? Aspiration A client with a duodenal ulcer is prescribed a combination of antibiotics and a proton pump inhibitor. The nurse understands that this regimen is most likely aimed at which outcome? Treat the Helicobacter pylori infection to promote ulcer healing. A client who is being treated for pneumonia reports sudden shortness of breath. Arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mmg, HCO3 24 mmg. Which condition does the ABG reflect? Uncompensated respiratory acidosis A 65-year-old client with gastric suction on low continuous suction ever since being admitted 72 hours ago. Upon reviewing the latest blood work, the nurse notices that the client's serum potassium 2.8 mEq/L, placing the client at risk for what imbalance? Metabolic alkalosis A client with a history of asthma with bronchial spasms to the emergency department with laboratory results indicating a potential acid-base imbalance. The blood gas results are as follows: pH 7.29, PaCO2 68 mmHg, HCO3 29. What is the priority nursing action or this client Administer a bronchondilator as prescribed A client presenting with anxiety has a pH of 7.48 and a PaCO2 of 30 mmHg. What compensatory mechanism would the nurse expect to observe? Increased renal excretion of bicarbonate A client with chronic obstructive pulmonary disease (COPD) is experlencing exacerbation and presents with respiratory acidosis. What is the primary goal of nursing management in this situation? Administering bronchondilator to improve airway patency A client with severe vomiting is seen in the emergency department. Which laboratory findings would the nurse expect to see in the arterial blood gases (ABG)? Increased serum bicarbonate and increased PH A client with chronic kidney disease (CKD) is admitted with symptoms of metabolic acidosis. The nurse notes that the client's serum potassium of 7.0 mEq/L. Which action should the nurse prioritize? Initiate electrocardiogram (ECG) monitoring to detect potential arrhythmias A client with a history of loop diuretic therapy presents with symptoms of metabolic alkalosis. The nurse reviews the client's arterial blood gas (ABG) results: pH 7.48, PaCO2 48 mmHg, HCO3 28 mEq/L. Based on these findings, which action should the nurse take to address the client's condition? Consult with the health care provider to evaluate the diuretic therapy. A client presents with acute respiratory acidosis secondary to an overdose of sedatives. The client is lethargic and has a decreased respiratory rate of 8 breaths per minute. Which intervention should the nurse prioritize to address the underlying Administer a reversal agent for the sedative overdose The nurse is caring for a patient with lung cancer who presents with facial swelling, distended neck veins, and shortness of breath. Which condition does the nurse suspect? Superior vena cava syndrome A nurse is assessing a client with suspected hypervolemia. Which of the following assessment findings would the nurse prioritize for immediate intervention? Shortness of breath and crackles in the lungs Which laboratory finding is most consistent with fluid volume excess (hypervolemia)? Decreased blood urea nitrogen (BUN) A physician prescribes furosemide (Lasix) for a client with hypervolemia. What is the most important nursing action before administering the medication? Assess serum potassium level A nurse is teaching a client with chronic heart failure about managing hypervolemia at home. Which client statement indicates a need for further teaching? . "It's okay to drink as much water as I want, since it's healthy." Which of the following conditions is most likely to cause fluid volume excess? Renal failure Based on the client's symptoms, the nurse expects the client's laboratory results will most likely reflect Hypokalemia The nurse would then educate the client to eat foods such as Oranges Bananas From the list of choices Choose 1 Condition that the client is most likely experiencing. Peptic ulcer Action the nurse should take to address that condition. Administer analgesics Administer antiemetic Choose 2 Parameters the nurse should monitor to assess the client's progress Stool for occult blood Monitor hemoglobin level Which 4 findings are MOST urgent? Ph 7.2 PC02 65 mm Hg P02 75 mm Hg Pulse oximeter 87% A nurse is caring for a client with dementia who is experiencing increased agitation and attempting to leave the facility believing they are late for an important meeting Which action should the nurse take to manage the client's behavior? Distract the client with an activity they enjoy and provide reassurance A nurse is caring for a client who has been using cocaine and is experiencing chest pain, tachycardia, and hypertension. Which action should the nurse take to manage the client's acute symptoms? Provide reassurance and a calm environment to reduce anxiety and agitation A nurse is planning care for a client with schizophrenia who has difficulty with abstract thinking Which teaching strategy should the nurse use for this client? Provide concrete examples and clear, direct instructions A nurse is planning care for a chent diagnosed with persistent depressive disorder. The client reports feeling "down" most of the time and strüggles to find enjoyment in activities Which therapeutic activity should the nurse include in the client's care plan? Select all that apply. Join a small support group focused on managing depression Engage in a structured individual hobby that the client previously enjoyed treatent of severe depression wich statementdue the chen indicates that there is understanding of education provided by the nurse related to dietary restrictions? will avoid foods that are high in the amino acid tyramine since they can cause severe side effects. A nurse is caring for a client with dementia who is experiencing increased agitation and attempting to leave the facility believing they are late for an important meeting Which action should the nurse take to manage the client's behavior? Distract the client with an activity they enjoy and provide reassurance During a home visit a nurse notices that a client with early stage dementia has multiple outdated medications in their cabinet. Which action should the nurse take first? Arrange for a medication review with the client's healthcare provider A nurse is developing a care plan for a client undergoing detoxification from benzodiazepines. The client has a history of long term, high-dose benzodiazepine use Which action should the nurse include to prevent complications during detoxification? Prepare to implement a tapering schedule of a long acting benzodiazepine When the client states, "the FBI is recording me through the TV," the nurse's best response is to say I understand this is frightening for you. To support the client's nutritional needs, the nurse off offers food and fluids frequently. The client is taking an antipsychotic, the treatment of choice for schizophrenia, and the nurse instructs the client to report any muscle stiffness or tremors The nurse is educating a client and family regarding the antipsychotic medications The client needs further teaching when they name which as an extrapyramidal symptom caused by antipsychotic drugs? Polydipsia A client is prescribed 0.5 mg of alprazolam PO every 6 hours PRN for anxiety. The medication available is alprazolam 0.25 mg/tablet How many tablets should the nurse administer per dose? 2tab A nurse is assessing a client with suspected delirium. Which symptom is most indicative of delirium rather than dementia? Fluctuating levels of consciousness throughout the day. Nurse is assessing a client with a history of major depressive sorder who reports a recent worsening of depressive symptoms. le client has formulated a plan for suicide by overdose and has cess to the necessary medications. Implement suicide precautions and ensure constant observation of the client A nurse is assessing a client who has been using sedati prolonged period. The client is showing signs of withdra symptoms should the nurse expect to observe? Elevated blood pressure and temperature A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client is restless, approaches the nurse, and states, "I'm going to take a walk outside. I'll be back in about 10 minutes " Which is the most appropriate nursing action? Designate a staff member to accompany the client on the walk. A nurse is caring for a client who has been diagnosed with major depressive disorder and has recently started taking sertraline. The client mentions feeling more energetic but still feels hopeless. Which nursing action is most appropriate to ensure the client's safety? Monitor the client closely for signs of increased suicidal ideation or plans A client with bipolar disorder in the manic phase is making grandiose plans for starting multiple businesses When staff attempt to discuss the feasibility of these plans, the client becomes increasingly agitated. Which action should the nurse take? Redirect the client to a less stimulating activity that requires concentration A nurse is evaluating the outcomes of a psychosocial intervention program for clients with schizophrenia. Which client statement best reflects an improvement in negative symptoms? I've started volunteering at the local food bank and enjoy it." The nurse is evaluating several clients with a diagnosis oT schizophrenia Which client will be assessed as having the worst potential outcomes? I've started volunteering at the local food bank and enjoy it." The nurse is evaluating several clients with a diagnosis oT schizophrenia Which client will be assessed as having the worst potential outcomes? an adolescent client with alogia, anhedonia, and a flat or blunted affect The nurse is performing a medication reconciliation for a client at a high risk for suicide. Which antidepressant drug identified by the nurse will be best in the treatment of this client and reduces the risk of lethal overdose? Sertraline A nurse is caring for a client with a diagnosis of catatonia Which assessment findings would the nurse expect to observe in this client? Select all that apply. The client demonstrates waxy flexibility, maintaining a fixed posture for extended periods. • Motor activity is either excessively purposeless or shows complete immobility A nurse is conducting a lethality assessment on a client who has expressed suicidal ideation. The client has a detailed plan to overdose on medication and has access to the means to carry out the plan What is the nurse's immediate priority? Arrange for one-to-one supervision of the client A nurse is developing a plan of care for a client with schizophrenia who has significant self care deficits Which intervention is most appropriate for the nurse to include? • Encourage the client to establish a daily routine that includes self-care tasks The nurse is educating a client taking clozapine. Which statement made by the client indicates that the education is effective? "I should call the health care provider if I develop a sore throat and fever A client who is recovering from substance abuse is reluctant to discuss their past drug use. Which approach should the nurse take to facilitate an accurate psychosocial assessment? Assure the client that the information will remain confidential and explain its importance in their recovery A nurse is caring for a client with a history of alcohol abuse who is being treated for pancreatitis. The client is scheduled for a cholecystectomy and expresses concern about the risk of experiencing withdrawal symptoms while hospitalized. Which assessment should the nurse prioritize to monitor for early signs of alcohol withdrawal? Monitor for coarse hand tremors and changes in vital signs client with a history of bi"polar I disorder is being discharged from the hospital. The nurse is providing education on medication compliance. The client's spouse expresses concern about recognizing early signs of a manic episode. Which response by the nurse is most appropriate? You should monitor for any changes in sleep patterns or increased irritability in y A client diagnosed with bipolar disorder is experiencing hypomania and is reporting increased productivity at work However, the client's coworker has shared concerns that the client is becoming more impulsive and taking on numerous projects. Which approach should the nurse take when discussing this situation with the client? Discuss with the client the importance of maintaining balance and the potential consequences of overwhelming themselves with tasks A client with a history of opioid abuse is admitted for treatment after a relapse. The client is motivated to achieve a substance-free lifestyle and has a strong support system. Based on the nurse's understanding of factors associated with successful recovery, which plan should the nurse prioritize in the client's care? Focus on building the client's motivation and strengthening their support system. A client is providing discharge education to a client taking lithium at home for the treatment of bipolar disorder Which client statements) indicate the education is effective? Select all that apply. It is not necessary to alter my usual dietary salt intake." It will weigh myself weekly at the same time of day" "Hydration is important with at least 2 L of decaffeinated fluid daily." "If I get sick with the flu, I will notify my health care provider." A client with schizophrenia becomes violent on the unit. What is the first nursing action? Call for staff assistance to ensure safety of staff and the other clients. A nurse is conducting an abbreviated cognitive examination for a client suspected of having early stage dementia Which tasks should the nurse include to assess the client's cognitive abilities? Select all that apply. Assess the clients orientation to person, place, and time Instruct the client to name common objects in the room → Test the client's ability to follow multistep commands. A nurse is caring for a client with delirium caused by a urinary tract infection. Which interventions should the nurse implement to manage the client's delirium effectively? Select all that apply. Treat the underlying medical cause of delirium to resolve symptoms. Ensure the room is well-lit and is without glare or shadows. Administer haloperidol to reduce agitation and psychotic symptoms if necessary. Ensure adequate nutritional and fluid intake to support the client's recovery A client diagnosed with bipolar disorder is experiencing hypomania and is reporting increased productivity at work However, the client's coworker has shared concerns that the client is becoming more impulsive and taking on numerous projects Which approach should the nurse take when discussing this situation with the client? Discuss with the client the importance of maintaining balance and the potential consequences of overwhelming the A client with schizophrenia reports feeling hopeless about the future Which nursing intervention is most appropriate to address the client's emotional needs? Encourage the client to identify small positive actions they can take daily A client with dementia becomes agitated when they cannot find their glasses Which action should the nurse take to help the client cope with this situation? Assist the clientin looking for the glasses and provide reassurance A client with schizophrenia is showing signs of tardive dyskinesia, including lip-smacking and involuntary movements of the arms. Which action should the nurse take to address the assessment findings? Arrange for the client to undergo an Abnormal Involuntary Movement Scale (AIMS) assessm A nurse is assessing a client with persistent depressive disorder who reports increased feelings of sadness and hopelessness. Which question is most important for the nurse to ask to evaluate the client's risk for suicide? Have you thought about ways you might hurt yourself?" The nurse is assessing a client weaning from a selective serotonin reuptake inhibitor (SSRI) to a monoamine oxidase inhibitor (MAOl) The client's heart rate is 104, temperature 102°F (38 9°C), BP 98/58 mm Hg, and they have profuse diaphoresis. Which condition does the nurse suspect is occurring? Serotonin syndrome A client with bipolar disorder has been taking lithium, and today the client's serum lithium level is 2.0 mEq/L (reference range: 0.5-1.5 mEqL) What effects would the nurse expect to see? Nausea, diarrhea, and confusion A nurse is caring for a client with major depressive disorder who reports feeling overwhelmed by daily responsibilities. The client has difficulty making decisions and prioritizing tasks Which nursing intervention is most appropriate to assist the client in improving daily functioning? Assist the client in creating a structured daily schedule with manageable tasks