ATI Final Medsurge - mental health nursing PDF

Preview

Summary

mental health nursing...

Description

Final ATI MEDSURGE

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? Prepare for replacement of the missing clotting factor A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? Omega-3 fatty acids A nurse is reviewing a client's repeat lab results 4 hrs after administering fresh frozen plasma (FFP). Which of the following lab results should the nurse review? Prothrombin time A nurse is assessing a client who has right sided heart failure. Which of the following findings should the nurse expect? Dependent edema A nurse is administering a unit of packed RBCs to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first? Stop the infusion of blood The nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hrs? Ventricular dysrhythmias A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type is B positive. Which of the following actions should the nurse take? Remove the unit of plasma immediately and start an IV infusion of normal saline solution. A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client’s vital signs are BP 160/98, HR 102/min, R 22/min, SpO2 95%. Which of the following actions should the nurse take? Administer antihypertensive medication for the elevated BP A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? Lower back discomfort

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select All That Apply) Jugular vein distention Moist crackles Increased heart rate A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? Auscultate blood pressure for pulsus paradoxus A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? HTN is a common adverse effect of epoetin alfa A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? Dry, pale skin with minimal body hair A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect? Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? Weight gain 1kg (2.2lbs) in 1 day A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? Dyspnea with hiccups A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? Coarse crackles A nurse is reviewing lab values for an adult client who has sickle cell anemia and history of receiving blood transfusions. For which of the following complication should the nurse monitor? Iron toxicity (hemosiderosis) A nurse is providing teaching about lifestyle changes to a client who had myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

Before taking my medication, I will count my radial pulse rate. A nurse is monitoring a client who has heart failure related to mitral stenosis. The client report shortness of breath upon exertion. Which of the following conditions should the nurse expect? Increased pulmonary congestion A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? Chest pain lasting longer than 15 min. A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? Position the client supine with his legs elevated when in bed A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. What laboratory result should the nurse anticipate as the cause of this ECG change? Potassium 2.8 mEq/L A nurse is planning care for a client who is having percutaneous transluminal coronary angioplasty with stent placement. Which of the following actions should the nurse anticipate in the post procedure plan of care? Monitor for bleeding A nurse is assessing for a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? Petechiae and ecchymosis A nurse on the telemetry unit is caring for a client who has irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? Atrial rate of 300/min with QRS complex of 80/min A nurse is planning for a client who has pernicious anemia. Which of the following intervention should the nurse include in the plan? Initiate weekly injections of vitamin B12 A nurse is caring for a client who has hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? 0.9 sodium chloride A nurse is preparing a transfuse 250mL of packed red blood cells to a client over 4 hr. Available is blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? 10 gtt/mL

A nurse is preparing to transfuse a unit of packed RBC to a client who has anemia, what action should the nurse take first? Witness the informed consent The nurse is caring for a client who has a lesion on the back of his right hand. The client asked the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? Melanomas The nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? Leukopenia A nurse is assessing the skin of a patient who has frostbite. The patient has small blisters that contain blood and the skin of the affected areas does not blanch. The nurse should classify this injury as which of the following? Third degree frostbite The nurse is assessing a patient who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the patient sacral area. The nurse should document that the patient pressure ulcer at which the following stages? Stage II pressure ulcer A nurse in the provider’s office is assessing a client´s skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings which of the following skin lesions? Papules A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client’s questions about the dressing, the nurse explains that it is obtained from which of the following sources? Pig skin A nurse in a provider’s office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? Acyclovir A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? Shift your weight in the wheelchair every 15 minutes

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma? Light skin A nurse is providing discharge instructions to client who is postoperative following a surgical excision of a basal cell carcinoma. Which the following findings should the nurse include as an indication of a potential malignancy of a mole? Ulceration The nurse is assessing a client who has a lesion on the skin. Which of the following findings is a clinical manifestation of the malignant melanoma? Irregularly shaped lesions w/ blue tones A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? Sodium 132 mEq/L The nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider? Temperature of 39.1°C (102.4° F) A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? Surgical excision A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? Immobilize the limb at the level of the heart. A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicated an understanding of the teaching? I will be on a special shower table. A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? Surgical incision A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? Vitamin C

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? May I go with my family to the visitor's lounge? A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? Avoid exposure to the midday sun. A nurse is monitoring a client with Graves' disease for the development of thyroid storm. The nurse should report which of the following to the provider? Hypertension A nurse is teaching a client with Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching? Turkey and cheese sandwich. A nurse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the disease. Which of the following statements by the client indicates an understanding of the teaching? My cells are resistant to the effects of insulin. A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? Bronze pigmentation of skin A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (Select all that apply.) Tachycardia and hypertension Laryngeal stridor and a hoarseness Positive Trousseau's sign A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. The nurse should understand that which of the following laboratory values is consistent with diabetic ketoacidosis? Bicarbonate level of 12 mEq/L A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect? Hyponatremia A nurse is providing teaching to a client who has type 1 diabetes mellitus about exercise. Which of the following statements should the nurse include in the teaching? Wear a medical alert identification tag when you exercise

A nurse is assessing a client with Graves' disease. Which of the following findings should the nurse expect the client to display? Difficulty sleeping A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? Check the client´s urine specific gravity A nurse is planning care for a client who is experiencing the Somogyi effect and takes intermittent-acting insulin. Which of the following actions should the nurse include in the plan? Monitor the client´s nighttime blood glucose levels A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings should indicate to the nurse that the client has hyperglycemia? Increased urination A nurse is caring for a client who is postoperative following a parathyroidectomy to treat hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a therapeutic effect of the procedure? Calcium A nurse is preparing a 24-hour urine specimen for a client who is suspected to have pheochromocytoma. Which of the following laboratory tests from the 24-hour urine specimen should the nurse use to determine the client´s condition? Vanillylmandelic acid (VMA) A nurse is checking laboratory values to determine if a client who has diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination? Glycosylated hemoglobin levels A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? Shakiness A nurse is caring for a client who is postoperative following a bilateral adrenalectomy. The nurse should expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic effects? Compensate for decrease in cortisol levels A nurse is assessing a client who has manifestations of acromegaly. Which of the following findings should the nurse expect? Increased head size

A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following clients should the nurse include in the screening? Men and women who are obese A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? Polyuria A nurse is providing teaching to a client who has tuberculosis and a prescription for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the provider? Decreased visual acuity A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? Respiratory alkalosis A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS discharge teaching with a client who has AIDS. Which of the following statements should the nurse include in the teaching? You should take antiretroviral medications on a routine schedule A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client´s plan of care? Encourage increased fluid intake A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? "I will use lemon and glycerin swabs after meals A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? Ask the client about first aid performed at the scene. A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? Offer the client a bedpan every 2 hr. A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.) Take allopurinol as prescribed.

Exercise several times a week. Limit intake of foods high in purine. A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? Involuntary muscle spasms A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? Clear fluid coming from the nares A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? Infuse the heparin using an electronic IV pump. A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? Characteristics of the cough and sputum A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? Apply lateral pressure to the client's nose for 10 min. A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? I need to lie still in bed during my brachytherapy treatment A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? An irregular border A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Check the client's pain level. A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? Elevated LDL levels A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? My diet will have to change to a soft diet after surgery

A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? You should take this medication on an empty stomach. A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Apply pressure to the puncta after instilling the medication. A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? I will need to take methotrexate even if I'm in remission A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following...