Nursing: Medical-Surgical Review

Nursing: Medical-Surgical Review Which method elicits the most accurate information during a physical assessment of an older adult? A. use reliable assessment tools for older adults B. Review the past medical record for medications C. Ask the client to recount one's health history D. Obtain the client's information from a caregiver Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. A and B are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a written record may not be available or currently accurate. A client who has just tested positive for HIV does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? A. teach the client about the medications that are available for treatment B. discuss retesting to verify the results, which will ensure continuing contact C. identify the need to test others who have had risky contact with the client D. inform the client how to protect sexual and needle-sharing partners encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about A, B, and C, retesting encourages the client to maintain medical follow-up and management. The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC). what is the most significant desired outcome for this client? A. free from injury of drug side effects B. maintenance of intact perineal skin c. adequate oxygenation D. return to pre-illness weight MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long management problem. Client outcomes for adequate oxygenation are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition. A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? A. assist the client to ambulate in the hall B. obtain a prescription for a laxative C. administer the prescribed morphine sulfate D. withhold all oral fluid and food Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and distention minimized by implementing early and frequent ambulation. Based on the client's status, laxatives or withholding dietary progression are not indicated at this time. although pain management should be implemented, another analgesic prescription may be needed because morphine reduces intestinal motility and contributes to the client's gas pains. A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? A. keep the head of the bed elevated 30 degrees B. turn off the television and darken the room c. encourage fluids to 3000 mL per day D. change the client's position every two hours to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. Turning off the television and darkening the room minimize fluorescent lights, flickering television lights, and distracting sound. The other are ineffective in managing the client's symptoms. a client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? A. check vital signs every 15 minutes for 2 hours B. allow the client nothing by mouth until the gag reflex returns C. encourage fluid intake to promote elimination of the contrast media D. keep the client on bed rest for 8 hours the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. The others are not indicated after bronchoscopy The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? A. observe the client for coughing colored sputum after drinking a small amount of colored water B. ask the client to try to speak C. auscultate for pulmonary crackles after the client drinks a small amount of clear water D. assess for respiratory distress to evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then be observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water. What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. vesicular breath sounds decrease B. wheezing becomes louder C. bronchodilators stimulate coughing D. cough remains unproductive In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive. vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields. A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. limit the client's intake of oral fluids B. teach the client about prevention of crises C. evaluate the effectiveness of narcotic analgesics D. encourage the client to ambulate as tolerated Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled. The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. What action should the nurse implement? A. provide oral hygiene every 2 hours B. check for fever every 4 hours C. encourage fluids to 3000 mL/day D. check stools for occult blood Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds. A client is admitted for complaints of chest pain and aching for the past 4 days. the results for serum creatine kinase-MB (CK-MB) and troponin are obtained. What rationale should the nurse use to evaluate the laboratory findings? A. serum myoglobin levels are needed to confirm myocardial damage B. myocardial damage that occurred several days earlier is best validated by serum troponin levels C. the most reliable indicator of myocardial necrosis is serum CK-MB D. serum cardiac markers are inconclusive in determining myocardial injury after waiting several days Serum CK-MB and troponin are the two most important serum cardiac markers for confirming myocardial infarction. CK-MB begins to rise in the first 3 to 12 hours after the myocardial infarction, peaks in 24 hours, and returns to normal in 2 to 3 days. the troponin level rises as quickly but remains elevated for 2 weeks. Three weeks after discharge fro an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states "I guess we will never have sex again after this." Which response is best for the nurse to provide? A. sexual activity can be resumed whenever you and you wife feel like it because the sexual response is more emotional rather than physical B. you should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities D. sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife ..................