Exam 1: Adult Health

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy.  Which of the following instructions should the nurse include to prevent dumping syndrome?  Select all that apply.

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs.  Where would the nurse observe an air leak?

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome.  Which measures will the nurse include in the teaching plan?  Select all that apply.

The nurse reinforces teaching about self-management strategies for a client with urge incontinence.  Which of the following statements indicate that teaching has been effective?  Select all that apply.

A nurse cares for a client with impairment of cranial nerve VIII.  What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living?

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine.  The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days.  Which question is most important for the nurse to ask next?

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus.  Which result is of greatest concern and prompts the nurse to notify the health care provider?

A client with a C3 spinal cord injury has a headache and nausea.  The client's blood pressure is 170/100 mm Hg.  How should the nurse respond initially?

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices.  The nurse documents the presence of which communication deficit?

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis.  Which instruction will the nurse include in the discharge teaching plan?

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier.  Which laboratory report requires priority follow-up?

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first.  Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?

The nurse is caring for a client in the acute phase of meningococcal meningitis.  Which nursing actions should be included in the client's plan of care?  Select all that apply.

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest.  The client reports itching and pain around the rash.  What is the priority question for the nurse to ask the client?

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall.  Which assessment findings would the nurse most likely expect?  Select all that apply.

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis.  Which symptoms reported by the client would be most consistent with this condition?  Select all that apply.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes?

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis.  Which of the following clinical manifestations should the nurse expect?  Select all that apply.

The nurse is caring for a client with acute pericarditis.  Which clinical finding would require immediate intervention by the nurse?

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk.  On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg.  An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg.  Which action does the nurse anticipate taking next?