Wood25

1. Hematological Disorders: Determining Priority Client A. Acute vs. chronic, urgent vs. nonurgent, stable vs. unstable -A client who has an acute problem takes priority over a client who has a chronic problem. -A client who has an urgent need takes priority over a client who has a nonurgent need. -A client who has unstable findings take priority over a client who has stable findings. B. Sickle Cell Anemia- Vaso-occlusive crisis (painful episode) -Acute (related to dehydration and decrease...

The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? A) The client spends more time by himself B) The client doesn't engage in delusional thinking C) The client doesn't harm himself or others D) The client demonstrates ability to meet his own self-care needs The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather,...

1. A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline? a. Wafarin b. Fluoxetine c. Calcium carbonate d. Acetaminophen 2. A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client? ...

Mental Status • Mental status is a person’s emotional and cognitive functioning o Optimal functioning aims toward simultaneous life satisfaction in work, caring relationships, and within the self o Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally Question The nurse understands that all of the following are components of the mental status assessment except? 1. Known illness or health problem 2. Current medic...

A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should...

1. What are the phases of the cycle of violence that can occur between domestic partners and what may take place during each of these phases? -Tension-building phase: The abuser has minor episodes of anger and can be verbally abusive and responsible for some minor physical violence. The vulnerable person is tense during this stage and tends to accept the blame for what is happening. -Acute battering phase: The tension becomes too much to bear, and serious abuse takes place. The vulnerable pers...

1) A nurse is contributing the plan of care for a client admitted with a paranoid personality disorder. What are important recommendations to make during this time? • When contributing to the plan of care, safety is priority. Some clients with PD are at risk for violence or self-injury. • Clients with personality disorder often have the comorbidity of substance abuse and/or a history of violent and nonviolent crimes. • The nurse should set limits, be consistent, and firm, yet supportiv...

1.A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? 1. Heart rate 90/min 2. Absent bowel sounds → normal findings after major bowel surgery; takes several days to return to normal. 3. Hgb 8.2 g/dl 4. Gastric pH of 3.0 Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. 2. A nurse is caring for a client who has diabetes insipidus. Which of t...

1. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instruction should the nurse include in the teaching? a. Apply an ice pack directly to the affected area b. Immobilize the affected extremity with a splint c. Place tourniquet above and below the affected area d. Elevate the affected extremity 2. A nurse in an Emergency Department is caring for a client who sustain...

1) A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a. “You should continue this medication if you develop muscle rigidity”. b. “You will experience weight loss while taking this medication.” c. “You will notice your symptoms improve within 24 hours of taking this medication.” d. “You should increase your consumption of complex carbohydrates.” 2) A nurse ...

1) Inflammaandwardry Bowel Disease: Dietary Recommendations (583) • low fiber • download protein • decreased calories Ulcerative Colitis and Crohn’s Disease • Eat foods high in protein and calories, and low in fiber • Identify foods that trigger clinical manifestations • Joined caffeine and alcohol, take multivitamin w/ iron • Eat small frequent meals • Dietary supplements high in protein and low in fiber • Moniandwardr and electrolyte imbalance especially potassium...

1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is ...

1. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instruction should the nurse include in the teaching? a. Apply an ice pack directly to the affected area b. Immobilize the affected extremity with a splint c. Place tourniquet above and below the affected area d. Elevate the affected extremity 2. A nurse in an Emergency Department is caring for a client who sustain...

1. A Nurse is contributing to the plan care of a care to promote a restful night’s sleep for a client who has Alzheimer’s disease. Which of the following interventions should the nurse include in the plan? Encourage stimulating activities after dinner Encourage a late afternoon nap Offer a small snack at bedtime Offer hot chocolate at bedtime 2. A nurse if reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by t...

1. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take? Administer oxytocin to the client via intravenous infusion. Apply oxygen at 2 L/min via nasal cannula. Prepare for insertion of an intrauterine pressure catheter. Assist the client into the knee-chest position. 2. A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals....

1. A nurse is assessing a newborn following forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopumonary dysplasia 2. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching? “The medication could cause me to experien...

1. Which nursing diagnosis has the highest priority for a postpartum client who has developed disseminated intravascular coagulopathy (DIC) A. Anticipating Grieving B. High risk for infection C. Risk for deficient fluid volume D. Spiritual Distress 2. A newly delivered 9lb 4 ounce baby boy exhibits of respiratory distress. The nurse obtains a blood sample to assess the infant for which of the following? A. Hypoglycemia B. Pneumonia C. Sepsis D. Hyperbilirubinemia 3. The nurse explain...

1) A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? a) apply mineral oil to the nipples between feedings b) keep the nipples covered between breastfeeding sessions c) change the newborn’s position on the nipples with each feeding d) increase the length of time between feedings 2) A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated ka...

1.A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain i. Mastitis - painful or tender localized hard mass and reddened area, usually on one breast. (Pg. 143) b. Persistent abdominal striae i. Stretch marks - expected finding c. Lochia alba i. Lasts approx day 11 up to 4-8 weeks post-birth d. WBC count 12,000/mm3 2. A nur...

Intrapersonal communication is the communication within an individual. It is each person’s “self-talk,” the internal discussion when thinking but not outwardly verbalizing thoughts. Interpersonal communication is communication between two people. This form of communication is the most common in nursing and requires an exchange of information with another individual. Public communication is communication within groups of people. Transpersonal communication is communication that addresses s...