108 EXAM 3
A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client
asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse
explains neuropathic pain in terms that are accessible to the client. The nurse should describe
what pathophysiologic process? - ANS-The abnormal reorganization of the nervous system
A client comes into the emergency department (ED) by ambulance after slipping on a small
carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented;
his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is
anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the
nurse's most likely explanation for the low urine output? - ANS-The man is having a sympathetic
reaction, which has stimulated the renin-angiotensin-aldosterone system that results in
diminished urine output.
A client is receiving care on the oncology unit for breast cancer that has metastasized to her
lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should
consider what characteristic of cancer pain? - ANS-Cancer pain can be acute or chronic and it
typically requires comparatively high doses of pain medications.
A client is responding poorly to interventions aimed at treating shock and appears to be
transitioning to the irreversible stage of shock. What action should the intensive care nurse
include during this phase of the client's care? - ANS-Communicate clearly and frequently with
the client's family.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg,
HCO3 = 24 mm Hg. What does the ABG reflect? - ANS-Respiratory acidosis
A client with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake
and her tumor location rules out the use of enteral feeding. What intervention will best meet this
client's nutritional needs? - ANS-Parenteral nutrition given via a peripherally inserted central
catheter
A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for
high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of
care? - ANS-Limit the time that visitors spend at the client's bedside.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in
clients who are being treated for shock. What intervention should be specified in the client's plan
of care while the client is ventilated? - ANS-Performing frequent oral care
, A gerontologic nurse practitioner provides primary care for older adults who are living with
various forms of cardiovascular disease. This nurse is well aware that heart disease is the
leading cause of death in the aged. What is an age-related physiologic change that contributes
to this trend? - ANS-Heart muscle and arteries lose their elasticity.
A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a
client with increased intracranial pressure. This solution will increase the number of dissolved
particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries
and increase the blood volume. This process is best described as which of the following? -
ANS-Osmosis and osmolality
A nurse is caring for an older adult client who has become increasingly frail and unsteady on her
feet. During the assessment, the client indicates that she has fallen three times in the month,
though she has not yet suffered an injury. The nurse should take action in the knowledge that
this client is at a high risk for what health problem? - ANS-A hip fracture
A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states,
"A client in kidney disease partially loses the ability to regulate changes in pH." What is the
cause of this partial inability? - ANS-The kidneys regenerate and reabsorb bicarbonate to
maintain a stable pH.
A school nurse is providing health promotion teaching to a group of high school seniors. The
nurse should prioritize prevention of what risk factor for traumatic brain injury? - ANS-Substance
Abuse
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be
having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage
nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What
interventions should the nurse prioritize? - ANS-Establishing a patent airway and beginning
cardiopulmonary resuscitation
An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip
arthroplasty. The client is oriented to name only. The client's family is very upset because,
before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed
with postoperative delirium. What should the nurse explain to the client's family? - ANS-Delirium
of this type is treatable and her cognition will return to previous levels.
An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse
that she is generally enjoying good health, but that she has been having occasional episodes of
constipation over the past 6 months. What intervention should the nurse first suggest? -
ANS-Increase daily intake of water.
An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer that
can no longer be treated in a community setting. During assessment, the nurse finds that the
A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client
asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse
explains neuropathic pain in terms that are accessible to the client. The nurse should describe
what pathophysiologic process? - ANS-The abnormal reorganization of the nervous system
A client comes into the emergency department (ED) by ambulance after slipping on a small
carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented;
his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is
anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the
nurse's most likely explanation for the low urine output? - ANS-The man is having a sympathetic
reaction, which has stimulated the renin-angiotensin-aldosterone system that results in
diminished urine output.
A client is receiving care on the oncology unit for breast cancer that has metastasized to her
lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should
consider what characteristic of cancer pain? - ANS-Cancer pain can be acute or chronic and it
typically requires comparatively high doses of pain medications.
A client is responding poorly to interventions aimed at treating shock and appears to be
transitioning to the irreversible stage of shock. What action should the intensive care nurse
include during this phase of the client's care? - ANS-Communicate clearly and frequently with
the client's family.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg,
HCO3 = 24 mm Hg. What does the ABG reflect? - ANS-Respiratory acidosis
A client with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake
and her tumor location rules out the use of enteral feeding. What intervention will best meet this
client's nutritional needs? - ANS-Parenteral nutrition given via a peripherally inserted central
catheter
A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for
high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of
care? - ANS-Limit the time that visitors spend at the client's bedside.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in
clients who are being treated for shock. What intervention should be specified in the client's plan
of care while the client is ventilated? - ANS-Performing frequent oral care
, A gerontologic nurse practitioner provides primary care for older adults who are living with
various forms of cardiovascular disease. This nurse is well aware that heart disease is the
leading cause of death in the aged. What is an age-related physiologic change that contributes
to this trend? - ANS-Heart muscle and arteries lose their elasticity.
A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a
client with increased intracranial pressure. This solution will increase the number of dissolved
particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries
and increase the blood volume. This process is best described as which of the following? -
ANS-Osmosis and osmolality
A nurse is caring for an older adult client who has become increasingly frail and unsteady on her
feet. During the assessment, the client indicates that she has fallen three times in the month,
though she has not yet suffered an injury. The nurse should take action in the knowledge that
this client is at a high risk for what health problem? - ANS-A hip fracture
A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states,
"A client in kidney disease partially loses the ability to regulate changes in pH." What is the
cause of this partial inability? - ANS-The kidneys regenerate and reabsorb bicarbonate to
maintain a stable pH.
A school nurse is providing health promotion teaching to a group of high school seniors. The
nurse should prioritize prevention of what risk factor for traumatic brain injury? - ANS-Substance
Abuse
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be
having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage
nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What
interventions should the nurse prioritize? - ANS-Establishing a patent airway and beginning
cardiopulmonary resuscitation
An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip
arthroplasty. The client is oriented to name only. The client's family is very upset because,
before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed
with postoperative delirium. What should the nurse explain to the client's family? - ANS-Delirium
of this type is treatable and her cognition will return to previous levels.
An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse
that she is generally enjoying good health, but that she has been having occasional episodes of
constipation over the past 6 months. What intervention should the nurse first suggest? -
ANS-Increase daily intake of water.
An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer that
can no longer be treated in a community setting. During assessment, the nurse finds that the
