1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain?
• Serum cholesterol level (not related to th
...
1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain?
• Serum cholesterol level (not related to the acute attack gout)
• Capillary glucose level (not related to the acute attack gout)
• Daily caloric intake (Starvation diet can cause an acute attack of gout)
• Daily calcium intake (not related to the acute attack gout)
2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night he reports a severe, pounding headache, and has observable goose bumps. The nurse should assess for which trigger?
• Loud hallway noise (Not manifestation of autonomic hyperreflexia)
• Fever (Not manifestation of autonomic hyperreflexia)
• Full bladder
• Frequent cough (Not manifestation of autonomic hyperreflexia)
* A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high-level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder.
3. After learning that she as terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this”? Based on this response, the nurse deicides to include Which nursing problem in the client’s plan of care?
• Acute pain (physical pain less than 6 month)
• Spiritual distress (indicates anger toward God for her disease)
• Ineffective coping (not reflect)
• Complicated grieving (not reflect)
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