Exam 1: Adult Health

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic.  Which priority interventions should the nurse perform?  Select all that apply.

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer.  The client is receiving patient-controlled analgesia (PCA) with morphine.  Which nursing diagnoses (NDs) are appropriate to include in the client's care plan?  Select all that apply.

A nurse is screening clients at a community health event.  Which of the following client statements should the nurse recognize as a warning sign of cancer?  Select all that apply.

The nurse is caring for a 76-year-old client newly admitted with pneumonia and Clostridium difficile infection.  Which of the following would be priority to report to the health care provider?

A nurse is caring for a client admitted to the intensive care unit for toxic epidermal necrolysis.  Which interventions should be included in this client's care plan?  Select all that apply.

The nurse is assessing a client an hour after a left lung lobectomy.  The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale.  Pulse oximetry is 92% on 4 L oxygen via nasal cannula.  The chest tube is set to continuous water seal suction at -20 cm H₂O.  The collection chamber has accumulated 320 mL of frank red drainage in the last hour.  What is the priority nursing action?

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer?  Select all that apply.

The emergency nurse plans care for a female victim of sexual assault.  Which of the following interventions should the nurse include in the care plan?  Select all that apply.

A client with polycythemia vera comes to the clinic for a monthly treatment.  The nurse knows that treatment for this condition will consist of which of the following?

The nurse is caring for a client with cardiomyopathy and coronary artery disease.  The client is reporting increasing chest pain and has bilateral lung crackles on auscultation.  The health care provider has written several new prescriptions.  Which new prescription should the nurse clarify?  Select all that apply.

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis.  Which client statements indicate a correct understanding of teaching?  Select all that apply.

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia.  Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)?  Select all that apply.

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction.  The RN intervenes when the GN performs which action?

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders.  Which of the following parent statements indicates an appropriate understanding of care for sunburn?  Select all that apply.

A client is 48 hours post abdominal aneurysm repair.  Which assessment by the nurse is cause for greatest concern?

The nurse teaches proper foot care to a client with diabetes mellitus.  Which statement by the client indicates that further teaching is needed?

An 80-year-old client has been hospitalized with pneumonia and malnutrition.  Physical assessment findings include weakness and decreased muscle mass.  Which finding best indicates that the client is responding to treatment?

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital.  What information should the nurse plan to include related to the prevention of dumping syndrome?

The nurse in the outpatient clinic is reviewing phone messages.  Which client should the nurse call back first?

The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT).  Which action by the client would require an immediate intervention by the nurse?