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NURS21000HESIMed-SurgExamQuestionsand
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Whichassessmentismostimportantforthenursetoperformonaclient
whoishospitalizedforGuillain-Barresyndromethatisrapidly
progressing?
•Respiratoryeffort.
•Unsteadygait.
•Intensityofpain.
•Abilitytoeat.
Guillain-Barresyndromecausesparalysisorweaknessthattypicallystarts
atthefeetandprogressesupwards.Astheconditionprogresses,thenurse
mustensurethattheclientisabletobreatheeffectively.
Heuther,UnderstandingPathophysiology,6thed.p.412
Amaleclientcomesintotheclinicwithahistoryofpeniledischarge
withpainful,burningurination.Whichactionshouldthenurse
implement?
•Collectacultureofthepeniledischarge.
•Palpatetheinguinallymphnodesgently.
•Observeforscrotalswellingandredness. NURSNGNHESIMed-SurgExamQuestionsand
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NURS21000HESIMed-SurgExamQuestionsand
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•Expressthedischargetodeterminecolor. NURSNGNHESIMed-SurgExamQuestionsand
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NURS21000HESIMed-SurgExamQuestionsand
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Peniledischargewithpainfulurinationiscommonlyassociatedwith
gonorrhea.Thenurseshouldcollectacultureofthepeniledischargeto
determinethecauseofthesesymptoms.Thecausemustbedeterminedor
confirmedthroughculturetoidentifytheorganismandensureeffective
treatment.
JarvisPhysicalExaminationandHealthAssessment,
6thedition3
Aclientwithhistoryofatrialfibrillationisadmittedtothetelemetryunit
withsudden
onsetofshortnessofbreath.Thenurseobservesanewirregularheart
rhythmandshouldperformwhichassessmentatthistime?
•Checkforapulsedeficit.
•Palpatetheapicalimpulse.
•Inspectjugularveinpulse.
•Examineforacarotidbruit.
Aclientwithapasthistoryofatrialfibrillationmayreturntothat
rhythm.Anysignsofatrialfibrillation,suchassuddenonsetshortness
ofbreath,requiresfurtherinvestigation.Thenurseshouldassessthis
clientforapulsedeficitbecausethisconditionoccurswithatrial
fibrillation. NURSNGNHESIMed-SurgExamQuestionsand
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NURS21000HESIMed-SurgExamQuestionsand
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Jarvis.(2016);PhysicalExaminationandHealthAssessment,(Chap19)
7thed.,p.481
4.
Whichclientshouldbefurtherassessedforanectopicpregnancy?
•A24-year-oldwithshoulderandlowerabdominalquadrantpain.
•A33-year-oldwithintermittentlowerabdominalcramping.
•A20-year-oldwithfeverandrightlowerabdominalcolic.
•A40-year-oldwithjaundiceandrightlowerabdominalpain.
A24-year-oldwithsuddenonsetoflowerabdominalquadrantpain
shouldbeassessedforanectopicpregnancy.Thepaincanalsobe
referredtotheshoulderandmaybeassociatedwithvaginalbleeding.
HealthAssessmentforNursingPractice,Wilsonand
Giddens.p.2695.
Whichdietaryassessmentfindingismostimportantforthenurseto
addresswhen
caringforaclientwithdiabeticnephropathy?
•Drinksasixpackofbeereveryday.
•Enjoysahamburgeronceamonth.
•Eatsfortifiedbreakfastcerealdaily.
•Consumesbeansandriceeveryday.