QUESTIONS AND ANSWERS (SOLVE) 100%
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1 of 51
Term
The registered nurse (RN) is caring for an older
client who has been bedridden for two weeks. Which
assessment findings indicate to the RN that the
client is developing a complication related to
immobility?
Decreased pedal pulses.
Edema in upper
extremities. Loss of
appetite for food.
Stiffness in right ankle joint.
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, Reduced pain and minimized bruising
Rationale
Cold applications produce a topical anesthetic effect to reduce pain
as well as constricts blood vessels to minimize bruising.
Hematemesis.
Gastric pain on an empty stomach.
Intolerance of spicy foods.
Rationale
Manifestations of PUD include hematemesis, gastric pain, and
spicy food intolerance.
Attention to details.
Rationale
When conducting the MMSE and having the client count backwards
by 7s; this evaluates their ability to do simple calculations and is
specific to the client's attention to detail and staying focus and not
getting distracted by external
stimuli.
Stiffness in right ankle joint.
Rationale
Stiffness in joints is an early sign of contractures and
muscle atrophy related to inactivity and immobility
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2 of 51
Term
,The registered nurse (RN) is caring for a client with
acute
pancreatitis and assesses the admission laboratory
results. What laboratory value should the RN anticipate
being elevated with this diagnosis?
Triglycerides
. Amylase.
Creatinine.
Uric acid.
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Polydipsia.
Rationale
A characteristic finding of DI is excretion of large quantities of
urine (5 to 20L/day), and most clients compensate for fluid loss
by drinking large
amounts of water (polydipsia). DI can occur when there has been
damage or
injury to the pituitary gland or hypothalamus as a result of head
trauma, tumor or an illness such as meningitis. This damage
interrupts the ADH production, storage and release causing the
excessive urination and thirst.
Dystonia.
Rationale
Dystonia can be a sudden adverse reaction to this psychotropic
medication
which should be discontinued to resolve dystonia, and the
healthcare provider notified immediately.
Amylase.
Rationale
, An elevated amylase level is associated with acute
pancreatitis.