PNLE 3 – CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS

PNLE 3 – CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS 1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is: Green liquid Solid formed Loose, bloody Semiformed 2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? On the client’s right side On the client’s left side Directly in front of the client Where the client like 3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? Check respiration, circulation, neurological response. Align the spine, check pupils, and check for hemorrhage. Check respirations, stabilize spine, and check circulation. Assess level of consciousness and circulation. 4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by: Increasing contractility and slowing heart rate. Increasing AV conduction and heart rate. Decreasing contractility and oxygen consumption. Decreasing venous return through vasodilation. 5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? Call for help and note the time. Clear the airway Give two sharp thumps to the precordium, and check the pulse. Administer two quick blows. 6. Nurse Monett is caring for a client recovering from gastro- intestinal bleeding. The nurse should: Plan care so the client can receive 8 hours of uninterrupted sleep each night. Monitor vital signs every 2 hours. Make sure that the client takes food and medications at prescribed intervals. Provide milk every 2 to 3 hours. 7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? Stop the I.V. infusion of heparin and notify the physician. Continue treatment as ordered. Expect the warfarin to increase the PTT. Increase the dosage, because the level is lower than normal. 8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? 24 hours later, when edema has subsided. In the operating room. After the ileostomy begin to function. When the client is able to begin self-care procedures. 9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in: On the side, to prevent obstruction of airway by tongue. Flat on back. On the back, with knees flexed 15 degrees. Flat on the stomach, with the head turned to the side. 10.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? Blood pressure is decreased from 160/90 to 110/70. Pulse is increased from 87 to 95, with an occasional skipped beat. The client is oriented when aroused from sleep, and goes back to sleep immediately. The client refuses dinner because of anorexia. 11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? Altered mental status and dehydration Fever and chills Hemoptysis and Dyspnea Pleuritic chest pain and cough 12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit? Chest and lower back pain Chills, fever, night sweats, and hemoptysis Fever of more than 104°F (40°C) and nausea Headache and photophobia 13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions? Acute asthma Bronchial pneumonia Chronic obstructive pulmonary disease (COPD) Emphysema 14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions? Asthma attack Respiratory arrest Seizure Wake up on his own 15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? Increased elastic recoil of the lungs Increased number of functional capillaries in the alveoli Decreased residual volume Decreased vital capacity 16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication? Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter. Increase in systemic blood pressure. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Increase in intracranial pressure (ICP). 17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: Report incidents of diarrhea. Avoid foods high in vitamin K Use a straight razor when shaving. Take aspirin to pain relief. 18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by: Leaving the hair intact Shaving the area Clipping the hair in the area Removing the hair with a depilatory. 19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: Bone fracture