Comprehensive exam 3 Questions And Answers

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement? - ANS Assess the client's needs for food, liquids, and rest. During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? - ANS Firmly informs the client that acting out anger is not acceptable. A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement? - ANS Document a possible Type I latex allergy. In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client? - ANS Use of prescribed eye drops since the last exam by an ophthalmologist. Which action should the nurse implement to assess for JVD in a client with HF? - ANS Observes the vertical distention of the veins as the client is gradually elevated to an upright position. The nurse identifies a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding? - ANS Failure of the liver to convert ammonia absorbed from the bowel to urea. A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication? - ANS Aspiration pneumonia. A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement? - ANS Irrigate the NGT with normal saline. A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider? - ANS A rigid, boardlike abdomen. A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? - ANS Notify HCP A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action? - ANS Maintain dry perineal dressings What information in a client's history indicates the highest risk factor for hepatitis C? - ANS Intravenous drug abuse A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? - ANS Apply a pressure-relieving mattress under the client. A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any symptoms and almost did not come to the clinic. What information should the nurse provide the client? - ANS Gonorrhea is often asymptomatic in women because the infection is not visible. A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement? - ANS Notify HCP