Exam 1: Adult Health

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L).  Which assessment finding does the nurse anticipate?

A client with blunt head injury is admitted for observation, including hourly neurologic checks.  At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen.  At 02:00 AM, the client appears to be sleeping.  Which action should the nurse take?

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool.  Which of the following assessment findings are likely contributing to the client's delirium?  Select all that apply.

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture.  Which statements made by the client would be the priority to assess further?

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions.  What is the nurse's immediate action?

The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease.  Which client statement indicates appropriate understanding?  Select all that apply.

A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks.  Assessing for which finding is most important?

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome.  Which instruction is appropriate to include in the teaching plan?

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII).  Which direction should the nurse give the client to test this cranial nerve?

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety.  Current symptoms include occasional confusion and wandering.  Which of the following responses by the caregiver show correct understanding?  Select all that apply.

Which of these instructions is appropriate teaching for a 60-year-old woman?  Select all that apply.

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow.  What actions should the nurse perform initially?  Select all that apply.

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home.  Which of the following actions by the nurse are appropriate?  Select all that apply.

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured diverticulum who is scheduled for surgery in the early morning.  Which laboratory value is most important for the nurse to report to the health care provider?

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately?

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized.  The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission.  Which foods would be the best for this client?

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness.  Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?

A nurse cares for a client after cardiac catheterization.  During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client's leg.  What should the nurse do first?

The nurse prepares a community education program about health promotion strategies for postmenopausal women.  Which of the following teaching points are appropriate to include?  Select all that apply.