COMPREHENSIVE EXAM 3
Aui38-year-
olduifemaleuiclientuiisuiadmitteduitouitheuimentaluihealthuiunituiafteruiauirecentuimanicuiepiso
deuiofuispendinguilargeuiamountsuiofuimoneyuionuinewuifurniture,uimakinguiexcessiveuilong-
distanceuiphoneuicalls,uianduinotuisleepinguiforuithreeuidays.uiDuringuitheuiadmissionuiproc
ess,uitheuiclientuiisuiwearinguiauigreenuibathinguisuit.uiWhatuiinterventionuishoulduitheuinurs
euiimplement?ui-uians--Assessuitheuiclient'suineedsuiforuifood,uiliquids,uianduirest.
Duringuiauigroupuitherapyuisession,uiauiclientuiwithuihypomaniauithreatensuitouistrikeuianoth
eruiclient.uiWhatuiinterventionuiisuibestuiforuitheuinurseuitouiimplement?ui-uians--
Firmlyuiinformuitheuiclientuithatuiactinguioutuiangeruiisuinotuiacceptable.
Auiclientuiwhouiisuiauilaboratoryuitechnicianuianduihasuiauihistoryuiofuiallergicuirhinitis,uiasth
ma,uianduimultipleuifooduiallergiesuiisuischeduleduiforuisurgery.uiWhichuiactionuishoulduitheu
inurseuiimplement?ui-uians--DocumentuiauipossibleuiTypeuiIuilatexuiallergy.
Inuireviewinguitheuimedicaluirecord,uitheuinurseuinotesuithatuiauiclient'suilastuieyeuiexaminati
onuirevealeduianuiIOPuiofui28uimmHg.uiWhatuiinformationuishoulduitheuinurseuiaskuitheuiclie
nt?ui-uians--Useuiofuiprescribeduieyeuidropsuisinceuilastuiexamuibyuiophthalmologist.
WhichuiactionuishoulduitheuinurseuiimplementuitouiassessuiforuiJVDuiinuiauiclientuiwithuiHF?
ui-uians--
Observeuitheuiverticaluidistentionuiofuitheuiveinsuiasuitheuiclientuiisuigraduallyuielevateduitoui
anuiuprightuiposition.
Theuinurseuiidentifiesuiauiclient'suilaboratoryuiresultsuianduiidentifiesuianuielevateduiserumui
ammoniauilevel.uiWhichuipathophysiologicaluiprocessuicontributesuitouithisuifinding?ui-
uians--Failureuiofuitheuiliveruitouiconvertuiammoniauiabsorbeduifromuitheuiboweluitouiurea.
AuiclientuiwithuiGERDuiisuiunconsciousuianduiunresponsiveuitouistimuli.uiTheuinurseuiplaces
uitheuiclientuiinuiauiside-
lyinguiposition.uiTheuinurseuishoulduimonitoruiforuitheuiriskuiofuiwhichuicomplication?ui-
uians--Aspirationuipneumonia.
AuiclientuireturnsuitouitheuiunituiafteruiabdominaluiNissenuifundoplicationuiforuitreatmentuiofui
GERD.uiAfterui4uihours,uitheuinurseuideterminesuitheuiclientuihasuinouidrainageuifromuitheui
NGTuianduihasuiabsentuiboweluisounds.uiWhatuiactionuishoulduitheuinurseuiimplement?ui-
uians--IrrigateuitheuiNGTuiwithuinormaluisaline.
, Auimaleuiclientuiwhouiisuiadmitteduiwithuiauibleedinguipepticuiulceruidevelopsuisudden,uiseve
reuiupperuiabdominaluipain.uiTheuiclientuibecomesuidiaphoreticuianduidrawsuihisuikneesuiov
eruihisuiabdomen.uiWhichuifindinguishoulduitheuinurseuireportuitouitheuihealthcareuiprovider
?ui-uians--Auirigid,uiboardlikeuiabdomen.
Auiclientuireturnsuitouitheuipostoperativeuiunituiafteruiauigastroduodenostomyui(BillrothuiI)uifo
ruitreatmentuiofuiauiperforateduiulcer.uiTheuihealthcareuiprovider'suiprescriptionsuiincludeui
morphineuiwithuiauipatient-
controlleduianalgesiaui(PCA),uinasogastricuitubeui(NGT)uitouilowuiintermittentuinasogastricu
isuction,uianduiIVuifluidsuianduiantibiotics.uiTheuiclientuicomplainsuiofuiincreasinguiabdomin
aluipainui12uihoursuiafteruireturninguitouitheuisurgicaluiunit.uiTheuinurseuideterminesuitheuicli
entuihasuinouiboweluisounds,uiandui200uimluiofuibrightuireduinasogastricuidrainageuiisuiinuith
euisuctionuicanisteruiinuitheuipastuihour.uiWhatuiisuitheuipriorityuiactionuitheuinurseuishoulduii
mplement?ui-uians--NotifyuiHCP
Auiclientuireturnsuifromuisurgeryuiafteruiundergoinguianuiabdominal-
perinealuiresectionuiwithuiauisigmoiduicolostomy.uiTheuicolostomyuiisuidresseduiwithuipetrol
eumuijellyuigauzeuianduidryuigauzeuidressings.uiTheuiperinealuiincisionuiisuipartiallyuiclosed
uiwithuitwouidrainsuiattacheduitouiJackson-
Prattuisuctionuibulbs.uiDuringuitheuiearlyuipostoperativeuiperiod,uitheuinurseuishoulduigiveuit
heuihighestuipriorityuitouiwhichuinursinguiaction?ui-uians--Maintainuidryuiperinealuidressings
Whatuiinformationuiinuiauiclient'suihistoryuiindicatesuitheuihighestuiriskuifactoruiforuihepatitisui
C?ui-uians--Intravenousuidruguiabuse
Auiclientuiwithuiadvanceduicirrhosisuianduihepaticuiencephalopathyuiisuimanifestinguimounti
nguiascitesuiandui4+uipittinguiedemauiofuitheuifeetuianduilegs.uiTheuinurseuiidentifiesuifluiduil
eakinguifromuihisuiskinuiwhenuiheuiisuiturned.uiWhichuiinterventionuiisuimostuiimportantuiforui
theuinurseuitouiincludeuiinuitheuiclient'suiplanuiofuicare?ui-uians--Applyuiauipressure-
relievinguimattressuiunderuitheuiclient.
Auifemaleuiclientuiarrivesuiatuitheuiclinicuibecauseuiheruiboyfrienduireceiveduitheuiresultsuiofu
iauiGramuistainuismearuithatuirevealeduitheuipresenceuiofuiNeisseriauigonorrhoeae.uiTheuicli
entuitellsuitheuinurseuithatuisheuihasuinotuihaduianyuisymptomsuianduialmostuididuinotuicome
uitouitheuiclinic.uiWhatuiinformationuishoulduitheuinurseuiprovideuitheuiclient?ui-uians--
Gonorrheauiisuioftenuiasymptomaticuiinuiwomenuibecauseuitheuiinfectionuiisuinotuivisible.
Auiclientuiwithuianuiopenuireductionuianduiapplicationuiofuianuiexternaluifixatoruiforuiopen,uico
mminuteduifracturesuiofuitheuitibiauianduifibulauibeginsuitouicomplainuiofuisevereuipainuiinuith
euiaffecteduileg,uiwhichuiisuinotuirelieveduibyuianalgesics.uiTheuiclientuisaysuitheuitoesuiareui
numbuianduitingling,uialthoughuitheyuiappearuipink.uiWhatuiactionuishoulduitheuinurseuiimpl
ement?ui-uians--NotifyuiHCP
Auiclientuiisuicomatoseuiuponuiarrivaluitouitheuiemergencyuidepartmentuiafteruifallinguifromui
auiroof.uiTheuiclientuiflexesuiwithuipainfuluistimuli,uianduitheuinurseuideterminesuitheuiclient's
Aui38-year-
olduifemaleuiclientuiisuiadmitteduitouitheuimentaluihealthuiunituiafteruiauirecentuimanicuiepiso
deuiofuispendinguilargeuiamountsuiofuimoneyuionuinewuifurniture,uimakinguiexcessiveuilong-
distanceuiphoneuicalls,uianduinotuisleepinguiforuithreeuidays.uiDuringuitheuiadmissionuiproc
ess,uitheuiclientuiisuiwearinguiauigreenuibathinguisuit.uiWhatuiinterventionuishoulduitheuinurs
euiimplement?ui-uians--Assessuitheuiclient'suineedsuiforuifood,uiliquids,uianduirest.
Duringuiauigroupuitherapyuisession,uiauiclientuiwithuihypomaniauithreatensuitouistrikeuianoth
eruiclient.uiWhatuiinterventionuiisuibestuiforuitheuinurseuitouiimplement?ui-uians--
Firmlyuiinformuitheuiclientuithatuiactinguioutuiangeruiisuinotuiacceptable.
Auiclientuiwhouiisuiauilaboratoryuitechnicianuianduihasuiauihistoryuiofuiallergicuirhinitis,uiasth
ma,uianduimultipleuifooduiallergiesuiisuischeduleduiforuisurgery.uiWhichuiactionuishoulduitheu
inurseuiimplement?ui-uians--DocumentuiauipossibleuiTypeuiIuilatexuiallergy.
Inuireviewinguitheuimedicaluirecord,uitheuinurseuinotesuithatuiauiclient'suilastuieyeuiexaminati
onuirevealeduianuiIOPuiofui28uimmHg.uiWhatuiinformationuishoulduitheuinurseuiaskuitheuiclie
nt?ui-uians--Useuiofuiprescribeduieyeuidropsuisinceuilastuiexamuibyuiophthalmologist.
WhichuiactionuishoulduitheuinurseuiimplementuitouiassessuiforuiJVDuiinuiauiclientuiwithuiHF?
ui-uians--
Observeuitheuiverticaluidistentionuiofuitheuiveinsuiasuitheuiclientuiisuigraduallyuielevateduitoui
anuiuprightuiposition.
Theuinurseuiidentifiesuiauiclient'suilaboratoryuiresultsuianduiidentifiesuianuielevateduiserumui
ammoniauilevel.uiWhichuipathophysiologicaluiprocessuicontributesuitouithisuifinding?ui-
uians--Failureuiofuitheuiliveruitouiconvertuiammoniauiabsorbeduifromuitheuiboweluitouiurea.
AuiclientuiwithuiGERDuiisuiunconsciousuianduiunresponsiveuitouistimuli.uiTheuinurseuiplaces
uitheuiclientuiinuiauiside-
lyinguiposition.uiTheuinurseuishoulduimonitoruiforuitheuiriskuiofuiwhichuicomplication?ui-
uians--Aspirationuipneumonia.
AuiclientuireturnsuitouitheuiunituiafteruiabdominaluiNissenuifundoplicationuiforuitreatmentuiofui
GERD.uiAfterui4uihours,uitheuinurseuideterminesuitheuiclientuihasuinouidrainageuifromuitheui
NGTuianduihasuiabsentuiboweluisounds.uiWhatuiactionuishoulduitheuinurseuiimplement?ui-
uians--IrrigateuitheuiNGTuiwithuinormaluisaline.
, Auimaleuiclientuiwhouiisuiadmitteduiwithuiauibleedinguipepticuiulceruidevelopsuisudden,uiseve
reuiupperuiabdominaluipain.uiTheuiclientuibecomesuidiaphoreticuianduidrawsuihisuikneesuiov
eruihisuiabdomen.uiWhichuifindinguishoulduitheuinurseuireportuitouitheuihealthcareuiprovider
?ui-uians--Auirigid,uiboardlikeuiabdomen.
Auiclientuireturnsuitouitheuipostoperativeuiunituiafteruiauigastroduodenostomyui(BillrothuiI)uifo
ruitreatmentuiofuiauiperforateduiulcer.uiTheuihealthcareuiprovider'suiprescriptionsuiincludeui
morphineuiwithuiauipatient-
controlleduianalgesiaui(PCA),uinasogastricuitubeui(NGT)uitouilowuiintermittentuinasogastricu
isuction,uianduiIVuifluidsuianduiantibiotics.uiTheuiclientuicomplainsuiofuiincreasinguiabdomin
aluipainui12uihoursuiafteruireturninguitouitheuisurgicaluiunit.uiTheuinurseuideterminesuitheuicli
entuihasuinouiboweluisounds,uiandui200uimluiofuibrightuireduinasogastricuidrainageuiisuiinuith
euisuctionuicanisteruiinuitheuipastuihour.uiWhatuiisuitheuipriorityuiactionuitheuinurseuishoulduii
mplement?ui-uians--NotifyuiHCP
Auiclientuireturnsuifromuisurgeryuiafteruiundergoinguianuiabdominal-
perinealuiresectionuiwithuiauisigmoiduicolostomy.uiTheuicolostomyuiisuidresseduiwithuipetrol
eumuijellyuigauzeuianduidryuigauzeuidressings.uiTheuiperinealuiincisionuiisuipartiallyuiclosed
uiwithuitwouidrainsuiattacheduitouiJackson-
Prattuisuctionuibulbs.uiDuringuitheuiearlyuipostoperativeuiperiod,uitheuinurseuishoulduigiveuit
heuihighestuipriorityuitouiwhichuinursinguiaction?ui-uians--Maintainuidryuiperinealuidressings
Whatuiinformationuiinuiauiclient'suihistoryuiindicatesuitheuihighestuiriskuifactoruiforuihepatitisui
C?ui-uians--Intravenousuidruguiabuse
Auiclientuiwithuiadvanceduicirrhosisuianduihepaticuiencephalopathyuiisuimanifestinguimounti
nguiascitesuiandui4+uipittinguiedemauiofuitheuifeetuianduilegs.uiTheuinurseuiidentifiesuifluiduil
eakinguifromuihisuiskinuiwhenuiheuiisuiturned.uiWhichuiinterventionuiisuimostuiimportantuiforui
theuinurseuitouiincludeuiinuitheuiclient'suiplanuiofuicare?ui-uians--Applyuiauipressure-
relievinguimattressuiunderuitheuiclient.
Auifemaleuiclientuiarrivesuiatuitheuiclinicuibecauseuiheruiboyfrienduireceiveduitheuiresultsuiofu
iauiGramuistainuismearuithatuirevealeduitheuipresenceuiofuiNeisseriauigonorrhoeae.uiTheuicli
entuitellsuitheuinurseuithatuisheuihasuinotuihaduianyuisymptomsuianduialmostuididuinotuicome
uitouitheuiclinic.uiWhatuiinformationuishoulduitheuinurseuiprovideuitheuiclient?ui-uians--
Gonorrheauiisuioftenuiasymptomaticuiinuiwomenuibecauseuitheuiinfectionuiisuinotuivisible.
Auiclientuiwithuianuiopenuireductionuianduiapplicationuiofuianuiexternaluifixatoruiforuiopen,uico
mminuteduifracturesuiofuitheuitibiauianduifibulauibeginsuitouicomplainuiofuisevereuipainuiinuith
euiaffecteduileg,uiwhichuiisuinotuirelieveduibyuianalgesics.uiTheuiclientuisaysuitheuitoesuiareui
numbuianduitingling,uialthoughuitheyuiappearuipink.uiWhatuiactionuishoulduitheuinurseuiimpl
ement?ui-uians--NotifyuiHCP
Auiclientuiisuicomatoseuiuponuiarrivaluitouitheuiemergencyuidepartmentuiafteruifallinguifromui
auiroof.uiTheuiclientuiflexesuiwithuipainfuluistimuli,uianduitheuinurseuideterminesuitheuiclient's
