*****A inurse iis icaring ifor ia iclient iwho ihas iatopic idermatitis iand ia iprescription ifor
itriamcinolone iointment. iThe inurse ishould iassess ithe iclient ito imonitor ifor iwhich iof ithe
ifollowing iadverse ieffects?
Thinning iof ithe iskin
MY i ANSWER
***
**Anur seisa
sesingacl
ie
ntwhohasl
eft
-s
idedhear
tfai
lur
e.Whichoft
he
fol
owi
ngfindi
ngshoul
dthenur
sei
dent
if
yasama ni
fes
tat
ionofle
ft-
si
dedhea
rtf
ail
ure
?
Fr
oth
ysput
um
MY ANSWER
****Anur s
eisc aringforacl
ientwhoisexperi
enc
inga nxi
et
ya swelasnumbne
sandt
ingl
ing
ioft
hel i
psandfin
g e
rs.Thecli
ent'
sABGsa r
e:pH7.48,PCO i30mmHg ,HCO 24mEq/
L, -
2 3
iPaO i85mmHg .Whi
2c hoft
hef olo
winga c
id-
basei
mba la
nceshoul dthenurseident
if
ythathe icl
ienti
se xpe
rie
nci
ng?
Re
spi
rat
orya
lka
los
is
MY ANSWER
****Anur
seisasesi
ngacl
ie
ntwhoha
sCus
hin
g'syndr
ome
.Whi
choft
hef
olo
win
gfindi
ngs
is
houl
dthenurs
eexpe
ct?
Os
teopor
osi
s
MY ANSWER
****Anur
seisi
nspe
cti
ngthes
kinofacl
ie
ntwhoha sba
salc
elc a
rci
noma.Thenur
ses
houl
d
ii
dent
if
ywhic
hofthefolo
wingle
sionc
hara
cte
ris
ti
csonthec
lie
nt'
skin?
Ape
arl
y,wa
xynodul
e
MY ANSWER
****Anursei
sase si
ngac l
ientwhoha shypocal
cemia.Inwhi
chofthefolowin
ga reashoul
d
it
henurset
aponthecl
ient
'
sfacetode t
ecthepr e
senceofChvos
tek'si
gn?(Youwilfindhot
ispot
stose
lec
tinthea
rtworkbelow.Sel
ectonlythehotspotha
tc ore
spondstoyouranswer
.)
Aiscorect
.Thenurs
eshoul
dtapthecl
ie
nt'
schekjus
tinfr
ontoft
heearandbel
owthe
iz
ygomat
ica
rch.Thecl
ie
ntwhohashypoca
lce
miawildis
pla
yaCh v
ost
ek'sign,whi
chi
sa
it
wit
chi
ngofthef
aci
almuscl
e.
,Bisincorec
t.Thenur
seshoul
dappl
yupwa r
dpresur
eathesupr
aor
bit
alr
idg
e,be
lowt
he
ie
yebro
w,toasesfort
enderne
sandinfla
mmat
ionoft
hef
ront
alsi
nus
es.
Ci sincore c
t.Thenurseshouldpalp
atetheja
wandma st
oidmuscl
eofacli
entwhohas
it
empor omandibul
arj
ointd y
sfunct
ion.Thisc
anbecaus
edbymi s
ali
gnedtet
h,art
hrit
is
,or
igr
indingoftheteth.Wi t
hpa lpa
ti
on,thenurs
emightf
elac l
ic
k,pop,orgr
ati
ngsensat
ionwhe
n
it
hec l
ientopensorcl
osesthejaw.
Bot omofFor m
****Anurs einanemer
gencydepar
tmentisasesi
ngacl
ie
ntwhoi
so v
erus
ing
ipr
esc
ribe
ddi ure
ti
csandhasasodi
uml e
velof127mEq/
L.Whic
hofthefol
owing
il
abor
ator
yfindi
ngshouldt
henurseexpec
t?
Lo
wur
ines
pec
ificgr
avi
ty
MY ANSWER
***Ahomeheal
thnur
sei
sasis
tingacl
ie
ntwit
hplannin
gcar
eforafa
milymemberwhoha
s
iAlz
hei
mer
'sdi
seas
e.Whi
chofthefol
owingi
nst
ruc
tionshoul
dthenurs
einc
lude
?
Re
vie
wthed
ail
ysc
hedul
ewi
tht
hec
li
ente
ver
ymor
nin
g.
***Anur
seisc
ari
ngf
orac l
ie
ntwhohasde
vel
ope
da c
uter
espi
rat
orydi
str
ess yndr
ome(ARDS)
.
iWhic
hofthef
olowi
ngfindi
ngshoul
dthenur
sei
dent
ifya
sama ni
fest
at
ionofthisyndr
ome
?
Re
fra
ctor
yhypo
xemi
a
MY ANSWER
***Anemerge
ncyroomnur sei
sasesin
gac l
ie
ntwhoha
sas
thmaanddiffic
ult
ybreat
hing.
iWh i
choft
hefolo
wi n
gfindi
ngshoul
dindi
cat
etot
henur
set
hathecl
ie
nti sexpe
rie
ncingst
at
u
s ias
thmat
ic
us?
Us
eofa
cesor
ymus
cle
s
MY ANSWER
, ****Anur
sei st
eac
hingacli
entwhoha sanewpres
cri
pti
onf
orphenyt
oint
otrea
ta
is
eizur
edi
sorder
.Whichofthefolowi
nga d
vers
eefe
ctshoul
dthenurs
eins
truc
the
ic
li
entoreporti
mme di
at
elytothepro
vider
?
Ski
nra
sh
MY ANSWE
***Anurs
eismonit
ori
ngac l
ie
ntfolowingalumba rl
amine
ctomy.Thec
li
enthasadrain
ia
ndindweli
nguri
nar
yc a
thet
er.Thenurs
eshoul
di dent
if
ywhi c
hofthef
olowin
gfindi
ngs
iasa
nindi
cat
ionofacompli
cat
ionofthesur
gery?
Cl
eardr
aina
geont
hedr
esi
ngs
MY ANSWER
***Anurs
eisase
singacl
ie
ntwhohasright
-s
idedhear
tfa
il
ure.Whichoft
hef
olo
win
gfind
ing
s
is
houl
dthenur
sei
dent
if
yasamani
fe
stat
ionofright
-s
ide
dheartfa
il
ure
?
I
ncr
eas
eda
bdomi
MY ANSWER
nalgi
rt
h
***Anurs
ei sc
ari
ngforacl
ientwhor ece
ntl
yasumedtheroleofcar
egi
verf
orthei
r
iagi
ngpar
entswhoha
v echr
onicilneses.Thenur
seshoul
dident
ifyt
hatwhichoft
h
e ifol
owingst
ate
mentsbythecl
ientindi
cat
esacept
anceoftherol
echange
?
"
Icha
nge
dthefloorpl
anofourhomet
oacommoda
temyf
athe
r'
swhel
cha
ir.
"
****Anursei
sc ar
ingforacli
entwhoisrece
ivi
ngvancomy
cininter
mite
ntIVbol usther
apyf
or
imethi
cil
in-
resi
st
antStaphyl
ococc
usaureus(MRSA).Whic
hoft hefol
owingfindi
ngsisan
ii
ndica
ti
ontothenursethathecl
ienti
sexperi
enc
inganadv
erseefe
ctoft
heme dic
a t
ion?
Thec
li
enti
sbe
comi
ngflus
hed.
MY ANSWER
***Anurs
eiscari
ngf
oramal
ecl
ientwhoha sane
wpres
cri
pti
onforc
ycl
ospor
inef
olowinga
iki
dne
ytrans
pla
nt.Whi
choft
hef
ol o
wingfindin
gshoul
dthenurs
eide
nti
fyasanadv
ers
ee fe
ct
ioft
hist
hera
py?
BUN24MGDL
itriamcinolone iointment. iThe inurse ishould iassess ithe iclient ito imonitor ifor iwhich iof ithe
ifollowing iadverse ieffects?
Thinning iof ithe iskin
MY i ANSWER
***
**Anur seisa
sesingacl
ie
ntwhohasl
eft
-s
idedhear
tfai
lur
e.Whichoft
he
fol
owi
ngfindi
ngshoul
dthenur
sei
dent
if
yasama ni
fes
tat
ionofle
ft-
si
dedhea
rtf
ail
ure
?
Fr
oth
ysput
um
MY ANSWER
****Anur s
eisc aringforacl
ientwhoisexperi
enc
inga nxi
et
ya swelasnumbne
sandt
ingl
ing
ioft
hel i
psandfin
g e
rs.Thecli
ent'
sABGsa r
e:pH7.48,PCO i30mmHg ,HCO 24mEq/
L, -
2 3
iPaO i85mmHg .Whi
2c hoft
hef olo
winga c
id-
basei
mba la
nceshoul dthenurseident
if
ythathe icl
ienti
se xpe
rie
nci
ng?
Re
spi
rat
orya
lka
los
is
MY ANSWER
****Anur
seisasesi
ngacl
ie
ntwhoha
sCus
hin
g'syndr
ome
.Whi
choft
hef
olo
win
gfindi
ngs
is
houl
dthenurs
eexpe
ct?
Os
teopor
osi
s
MY ANSWER
****Anur
seisi
nspe
cti
ngthes
kinofacl
ie
ntwhoha sba
salc
elc a
rci
noma.Thenur
ses
houl
d
ii
dent
if
ywhic
hofthefolo
wingle
sionc
hara
cte
ris
ti
csonthec
lie
nt'
skin?
Ape
arl
y,wa
xynodul
e
MY ANSWER
****Anursei
sase si
ngac l
ientwhoha shypocal
cemia.Inwhi
chofthefolowin
ga reashoul
d
it
henurset
aponthecl
ient
'
sfacetode t
ecthepr e
senceofChvos
tek'si
gn?(Youwilfindhot
ispot
stose
lec
tinthea
rtworkbelow.Sel
ectonlythehotspotha
tc ore
spondstoyouranswer
.)
Aiscorect
.Thenurs
eshoul
dtapthecl
ie
nt'
schekjus
tinfr
ontoft
heearandbel
owthe
iz
ygomat
ica
rch.Thecl
ie
ntwhohashypoca
lce
miawildis
pla
yaCh v
ost
ek'sign,whi
chi
sa
it
wit
chi
ngofthef
aci
almuscl
e.
,Bisincorec
t.Thenur
seshoul
dappl
yupwa r
dpresur
eathesupr
aor
bit
alr
idg
e,be
lowt
he
ie
yebro
w,toasesfort
enderne
sandinfla
mmat
ionoft
hef
ront
alsi
nus
es.
Ci sincore c
t.Thenurseshouldpalp
atetheja
wandma st
oidmuscl
eofacli
entwhohas
it
empor omandibul
arj
ointd y
sfunct
ion.Thisc
anbecaus
edbymi s
ali
gnedtet
h,art
hrit
is
,or
igr
indingoftheteth.Wi t
hpa lpa
ti
on,thenurs
emightf
elac l
ic
k,pop,orgr
ati
ngsensat
ionwhe
n
it
hec l
ientopensorcl
osesthejaw.
Bot omofFor m
****Anurs einanemer
gencydepar
tmentisasesi
ngacl
ie
ntwhoi
so v
erus
ing
ipr
esc
ribe
ddi ure
ti
csandhasasodi
uml e
velof127mEq/
L.Whic
hofthefol
owing
il
abor
ator
yfindi
ngshouldt
henurseexpec
t?
Lo
wur
ines
pec
ificgr
avi
ty
MY ANSWER
***Ahomeheal
thnur
sei
sasis
tingacl
ie
ntwit
hplannin
gcar
eforafa
milymemberwhoha
s
iAlz
hei
mer
'sdi
seas
e.Whi
chofthefol
owingi
nst
ruc
tionshoul
dthenurs
einc
lude
?
Re
vie
wthed
ail
ysc
hedul
ewi
tht
hec
li
ente
ver
ymor
nin
g.
***Anur
seisc
ari
ngf
orac l
ie
ntwhohasde
vel
ope
da c
uter
espi
rat
orydi
str
ess yndr
ome(ARDS)
.
iWhic
hofthef
olowi
ngfindi
ngshoul
dthenur
sei
dent
ifya
sama ni
fest
at
ionofthisyndr
ome
?
Re
fra
ctor
yhypo
xemi
a
MY ANSWER
***Anemerge
ncyroomnur sei
sasesin
gac l
ie
ntwhoha
sas
thmaanddiffic
ult
ybreat
hing.
iWh i
choft
hefolo
wi n
gfindi
ngshoul
dindi
cat
etot
henur
set
hathecl
ie
nti sexpe
rie
ncingst
at
u
s ias
thmat
ic
us?
Us
eofa
cesor
ymus
cle
s
MY ANSWER
, ****Anur
sei st
eac
hingacli
entwhoha sanewpres
cri
pti
onf
orphenyt
oint
otrea
ta
is
eizur
edi
sorder
.Whichofthefolowi
nga d
vers
eefe
ctshoul
dthenurs
eins
truc
the
ic
li
entoreporti
mme di
at
elytothepro
vider
?
Ski
nra
sh
MY ANSWE
***Anurs
eismonit
ori
ngac l
ie
ntfolowingalumba rl
amine
ctomy.Thec
li
enthasadrain
ia
ndindweli
nguri
nar
yc a
thet
er.Thenurs
eshoul
di dent
if
ywhi c
hofthef
olowin
gfindi
ngs
iasa
nindi
cat
ionofacompli
cat
ionofthesur
gery?
Cl
eardr
aina
geont
hedr
esi
ngs
MY ANSWER
***Anurs
eisase
singacl
ie
ntwhohasright
-s
idedhear
tfa
il
ure.Whichoft
hef
olo
win
gfind
ing
s
is
houl
dthenur
sei
dent
if
yasamani
fe
stat
ionofright
-s
ide
dheartfa
il
ure
?
I
ncr
eas
eda
bdomi
MY ANSWER
nalgi
rt
h
***Anurs
ei sc
ari
ngforacl
ientwhor ece
ntl
yasumedtheroleofcar
egi
verf
orthei
r
iagi
ngpar
entswhoha
v echr
onicilneses.Thenur
seshoul
dident
ifyt
hatwhichoft
h
e ifol
owingst
ate
mentsbythecl
ientindi
cat
esacept
anceoftherol
echange
?
"
Icha
nge
dthefloorpl
anofourhomet
oacommoda
temyf
athe
r'
swhel
cha
ir.
"
****Anursei
sc ar
ingforacli
entwhoisrece
ivi
ngvancomy
cininter
mite
ntIVbol usther
apyf
or
imethi
cil
in-
resi
st
antStaphyl
ococc
usaureus(MRSA).Whic
hoft hefol
owingfindi
ngsisan
ii
ndica
ti
ontothenursethathecl
ienti
sexperi
enc
inganadv
erseefe
ctoft
heme dic
a t
ion?
Thec
li
enti
sbe
comi
ngflus
hed.
MY ANSWER
***Anurs
eiscari
ngf
oramal
ecl
ientwhoha sane
wpres
cri
pti
onforc
ycl
ospor
inef
olowinga
iki
dne
ytrans
pla
nt.Whi
choft
hef
ol o
wingfindin
gshoul
dthenurs
eide
nti
fyasanadv
ers
ee fe
ct
ioft
hist
hera
py?
BUN24MGDL
