A client with delusions tells the nurse

An older client is admitted to the cardiac step down unit following coronary artery bypass surgery surgery. which postoperative nursing intervention is most beneficial to prevent respiratory complication. A) assist to a chair the day after the surgery when condition is stable b)provide ice or oral liquids when the client passes flatus c)note areas of atelectasis on the daily chest x-rays d) promote full diaphragmatic excursion by massaging the back
A client with delusions tells the nurse, ”You aren’t doing your job. Go get those people over there and shoot them before they get me. Which statement is the nurse best response a)what would you like to see me do to protect you b)You seem quite frightened right now c)There is no one who will hurt you d)you are in safe place. No one can get to you here.
when the parent of a 6 years old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father. this is your fault! It never would have happened if we had sought treatment sooner! a)assure the parents that a terminal diagnosis was inevitable b)explain to the parents that anger is a common response to grief c)tell the parents that blaming each other will not change the situation d)refer the parents to the chaplain to provide grief counseling
The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first a) complete CBC in AM b)straight catheterization if unable to void c)cefazolin 1 gram IVPB q6 hours d) advance from clear liquids as tolerated
The nurse is assessing a 4 year old child with eczema. the child skin is dry and scaly and the mother reports that the child frequently scratches the lessons on the skin to the point of causing bleeding. Which guideline is indicated of care of this child. a) apply baby lotion to the skin twice daily b)allow the child to wear only 100% cotton clothing c)keep the nails trimmed short d)bathe the child daily with bath oil
The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse. Select all that apply a) Thirst and frequent requests for bathroom breaks b)sunburn with blisters on the face, arms, and hands c) shaking that changes the child handwriting legibility d) bruises on both knees after the weekend. E) refuses to complete written homework assignments
An older client who lives with a granddaughter was brought to the clinic for an appointment and the granddaughter remain in the examination room with the client. When interviewing the client, who is normally alert and oriented, the nurse observes slow responses to questions, little eye contact and slurred speech. Which action should the nurse take next a) ask the client if an assisted living facility has been considered. B) interview the client privately without the family member present. C)complete a neurological and musculoskeletal assessment d) request social services to make a home visit
An older client preparing to transition from a rehabilitation facility to home is receiving discharge instructions from the nurse. which action should the nurse take while providing the discharge instructions a) turn on the overhead lights while giving instructions b) stand behind the client to avoid intimidation c) use background music to promote relaxation d) provide handout written at a 12^th grade reading level
which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis a)electrolytes and hemoglobin b)blood and urine cultures c) glucose and calcium levels d) renal and liver functions tests
The healthcare provider prescribes finasteride 5mg by mouth daily with benign prostatic hyperplasia. In evaluating the effectiveness of this drug, the nurse should assess for which outcome a) increases sperm count b) decreased post-voiding dribbling c) enhanced libido d) relief from urinary tract infection
When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse. select all that apply a) sloughing tissues around wound edges b)loss of sensation to the left lower extremity c) change in the quality of the peripheral pulses d)weeping serosanguineous fluid from wounds e)complaint of increased pain and pressure.
which conditions are most likely to respond to treatment with antihistamines? Select all that apply a) bronchitis b) otitis media c)contact dermatitis d)allergic rhinitis e) myocarditis
An client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. chest tubes were inserted in the emergency dept prior to his transfer to the intensive care unit. The nurse observes that the suction control chamber is bubbling at the -10cm H2O mark with fluctuation in the water seal and over the past hour 75ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement a) add sterile water to the suction control chamber b)give blood from the collection chamber as autotransfusion c)increase wall suction to eliminate fluctuation in water seal d) manipulate blood in tubing to drain into the chamber
with chronic renal insufficiency is preparing for discharge from the hospital. which information is most important for the nurse to include in this client discharge teaching a) need for maintaining good oral hygiene b)instruction regarding a restricted protein diet c) use of topical applications to manage pruritis d)strategies to promote independent self-care.
The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. which assessment test result should the nurse report to the healthcare provider. A)plumb line test indicates fetal position curvature b)Ortolani maneuver causing a click at the hip joint c)moro test precipitating a startle response
A 17 year old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with the flu-like symptoms for the past 24 hours. Which intervention should the nurse implement? A)place a mask on the clients face b)assess the client temperature c)determine the client blood pressure d) obtain a client x-ray per protocol.
An older client is admitted in respiratory distress secondary to heart failure, coronary artery disease, hypertension and atrial fibrillation. Which nursing problems should the nurse include in this client plan of care. Select all that apply. A) decreased cardiac output b) altered peripheral tissue perfusion c) fatigue d)fluid volume deficit e)fluid volume excess
An older adult patient is receiving a second unit of blood when the nurse enters the room and finds the patient sitting up in bed. The patient is dyspneic and seems confused. Lung auscultation reveals crackles in the bases of both lungs. Vital signs measurement reveals a rapid, bounding pulse and elevated blood pressure. After discontinuing the transfusion, which intervention should the nurse implement? A) Keep the IV access line intact for diuretics administration b) Send the blood bag and blood tubing to the blood bank c) Monitor for hives and purities d) Obtain urine specimen
The nurse is caring for a client who is entering the second stage of labor. which action should the nurse implement first a) prepare the client for spinal anesthesia b) convey to the client that birth is imminent c) prepare the coach to accompany the client to delivery. D)empty the client bladder using a straight catheter.
A family member accompanies client with schizophrenia to the mental health unit. The family member describes to the nurse the client experiencing a prolonged psychotic episode that lasted for three days. Which action should the nurse implement first a) review the list of medications taken at home b)assess if warning signs were observed c) verify nutrition and hydration status d) explore possible triggers to the episode
A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion and is diagnosed with acute infective endocarditis. During the admission, the nurse observes multiple areas of petechiae on the client skin. Which intervention should the nurse include in the client plan of care. Select all that apply a) report changes in pre-existing murmurs b)initiate contact transmission precaution c)maintain record of fluid intake and output d)schedule rest periods between activities e)monitor cardiac rhythm via telemetry.
A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care a)concentrate on and ventilate emotions when distressed b)focus on small achievable tasks not taxing problems c)analyze past hurts and resentment to identify the source d) relax and reduce the amount of effort to solve the problem.
A client with chronic obstruction pulmonary disease is experiencing worsening dyspnea and low oxygen levels. vitals sign are temperature 99.6F, heart rate 98beats/min, respirations 28 breath/min, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement a)prepare client for endotracheal intubation b) apply a non-rebreather mask at 100% oxygen c)place the client in a forward leaning position d)obtain a sputum sample for culture and sensitivity
An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the clients living will. Which actions should the nurse take a) Alert the nursing staff of the clients do not resuscitate status b) place a certified copy of the living will in the client record c)notify the healthcare provider of the client wishes d) facilitate a family meeting with the palliative team
A client arrives at the clinic experiencing shortness of breath with a possible right spontaneous pneumothorax. which lung sounds should the nurse expect to auscultate a) High-pitched harsh crowing sound or stridor heard during inspiration b) high pitched wheezing with a musical quality on inspiration and expiration c) adventitious popping sounds or crackles that occur on inspiration or expiration d) diminish to absent breath sounds from the apex to the base of right lung fields.
A client with a history of alcohol addictions says, my body feels fine when I abstain from alcohol consumption but i miss my late-night glasses of wine. Which concept should the nurse discuss with the client a) withdrawal b) craving c) denial d) tolerance
A nurse determines that more than 25% of the student at a middle school are overweight. The nurse presents the information at a parent teacher meeting. what action is most important for the nurse to include in the meeting a) have several teachers talk about health risks associated with obesity b)provide information on ways to increase activity for the family c) determine the parents degree of concern about their children weight d)distribute a shopping list of suggested healthy snacks items

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