Exam 1: Adult Health

The emergency department nurse is triaging clients.  Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

The nurse is caring for a client with a history of headaches.  The client has talked to the nurse, smiled at guests, and maintained stable vital signs.  The nurse notes the following changes in the client's status.  Which assessment finding is criticalto report to the health care provider (HCP)?

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

After receiving report, which client should the nurse assess first?

The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD).  The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with pathways that just allow passage from one room to another.  What is the priority nursing action?

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation.  Pulse oximetry is 84% on room air.  The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe.  Which prescription should the nurse question?

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling.  The health care provider diagnoses a lateral ankle sprain.  Which interventions does the nurse include in the discharge instructions?  Select all that apply.

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss.  The nurse's response is based on an understanding of which of the following?

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma.  Which clinical finding warrants immediate intervention?

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease.  Which statement by the client indicates a need for further teaching?

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP).  The nurse will need to notify the HCP about which client?

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease.  Which strategies should the nurse include?  Select all that apply.

A client with suspected moderate to large pericardial effusion is admitted for monitoring.  The nurse performs a head-to-toe assessment.  Which of these findings indicate likely cardiac tamponade and require immediate intervention?  Select all that apply.

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur.  Which client information is most important to report to the primary health care provider (PHCP)?

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis.  Blood pressure is 80/60 mm Hg.  Which prescribed intervention should the nurse implement first?

A client had a percutaneous nephrolithotripsy 3 hours ago to remove left renal calculi.  Since then, the indwelling urethral catheter has drained 125 mL of urine and the nephrostomy tube has drained 0 mL.  The client now reports left flank pain radiating to the left groin along with severe nausea.  What is the appropriate nursing intervention?

A client on a medical-surgical unit is receiving heparin therapy.  Platelet levels decreased from 230,000/mm³ (230 × 10⁹/L) 2 days ago to 80,000/mm³ (80 × 10⁹/L) today.  Which nursing actions are appropriate?  Select all that apply.

A client is admitted to the intensive care unit with suspected pheochromocytoma.  The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min.  The client is sweating profusely and reports a severe headache.  Which prescription should the nurse implement first?

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved.  Which of the following instructions should the nurse include to prevent the reoccurrence of DVT?  Select all that apply.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal.  The client is concerned about swelling in her arm on the affected side.  Which instructions should the nurse discuss with the client?  Select all that apply.