Comprehensive Exam 3 | Verified Answers, Complete Solutions

Comprehensive Exam 3 | Verified Answers, Complete Solutions A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making ex ...

Comprehensive Exam 3 | Verified Answers, Complete Solutions A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement? Assess the client's needs for food, liquids, and rest. During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? Firmly inform the client that acting out anger is not acceptable. A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement? Document a possible Type I latex allergy. In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client? Use of prescribed eye drops since last exam by ophthalmologist. Which action should the nurse implement to assess for JVD in a client with HF? Observe the vertical distention of the veins as the client is gradually elevated to an upright position. The nurse identifies a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding? Failure of the liver to convert ammonia absorbed from the bowel to urea. A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication? Aspiration pneumonia. A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement? Irrigate the NGT with normal saline. A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider? A rigid, boardlike abdomen. A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? Notify HCP A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action? Maintain dry perineal dressings What information in a client's history indicates the highest risk factor for hepatitis C? Intravenous drug abuse A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? Apply a pressure-relieving mattress under the client. A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any symptoms and almost did not come to the clinic. What information should the nurse provide the client? Gonorrhea is often asymptomatic in women because the infection is not visible. A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement? Notify HCP A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? A nasopharyngeal tube. The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to which pathophysiological incident? Umbilical cord compression Which FHR finding should the nurse report to the HCP immediately? Late decelerations A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide? Social smiling begins at approximately 2 months of age The nurse is explaining dietary management to a client with pregestational diabetes during a prenatal visit. Which client statement indicates that the teaching has been effective? Diet and insulin needs will change significantly throughout my pregnancy. The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse identify as the earliest manifestation of a puerperal infection? Temperature of 100.8° F 24 hours after delivery. Which infant is at risk for Rh incompatibility? Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor. An infant who is delivered at 32-weeks gestation arrives in the nursery intubated. After the infant is placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory monitor and pulse oximeter, which indicates an oxygen saturation of 80%. What action should the nurse implement first? Ensure patency of the endotracheal tube. A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress? Arrest of active phase. Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt? Shunt malfunction or infection requires immediate treatment. The nurse is instructing a mother about the care of her child who has pediculosis capitis. Which information should the nurse provide? Use a fine-toothed comb or tweezers to remove nits. The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. Which interventions should the nurse include in the teaching plan? Incorporate favorite foods into the adolescent's diet. The mother of an 8-year-old child with a chronic illness and tracheotomy is rooming-in during this hospitalization. The mother insists on providing all of the child's care and tells the nurse how to care for the child. The nurse should recognize that the mother plays which function when planning this child's care? An expert in care of the child. The parents of a 5-year-old are concerned because their child showed more outward grief when a pet died than when a sibling died from sudden infant death syndrome (SIDS). What response should the nurse provide? The child focuses on another connection because the sibling's death is misunderstood The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? Use a bedside cool-mist vaporizer during naps and night time. The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot stay with the baby except on weekends. Which actions should the nurse-manager implement to address the infant's emotional needs? Assign the same nurse to care for the child each day. The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort? Insert 5 ml of 2% lidocaine lubricant into the urethra. The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? Each pass of the suction catheter should take no longer than five seconds. The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? Weight gain A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? Respiratory acidosis. A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide? This is a common side effect due to the vasodilatory effects of the medication. A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime? Vitamin B12 A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose? Insulin regular (Humulin R). Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider? Receives carvedilol (Coreg) for heart failure (HF). The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment should the nurse implement to determine proper placement of the NGT? Aspirate the tube contents to test the pH. In which order should the nurse implement these actions when withdrawing a solution from an ampule? Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle. When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? The anterosuperior iliac spine and the greater trochanter. The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What action should the nurse implement? Point out the observation immediately to the surgical team. The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with dysphagia. Which action by the UAP requires the nurse's intervention? Divides solid food items into one inch cube pieces The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate? Blurred vision client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect? Decreases inflammation and pain The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris? hydrogen peroxide The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. Which information should the nurse provide? Redness, peeling, and itching may occur at the site of application. The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.) Calcium Potassium Sodium During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when planning care for this client? Maintain an environment that reduces stimulation of the client. A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly debilitated and tells the nurse, Since I haven't been able to go to church, I feel out of touch with God. I pray, but I wonder whether my prayers are heard. Which nursing diagnosis should the nurse include in the client's plan of care? Spiritual distress A mother brings her 4-year-old boy to the clinic because he spends his day in constant motion, talks excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing diagnosis should the nurse formulate? Impaired Social Interaction A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit suicide. What means of suicide should the nurse determine is most lethal if in the client's possession? Loaded gun An 11-year-old boy with oppositional defiant disorder becomes angry and defiant over the rules of the day treatment mental health program. Which response by the nurse is the most effective way to defuse the situation? Tell the child to go to the gym to play basketball (redirect) A female client who is diagnosed with an eating disorder has difficulty translating her pain into words. Which approach should the nurse implement to allow this client greater self-disclosure? Dance therapy Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult? Stimulate memory through associations An adolescent female who lost fifty pounds during the past three months is hospitalized. During the admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails, and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain additional assessment information? Amenorhea (anorexia nervosa) Upon admission, the nurse determines a male client with alcohol withdrawal syndrome is experiencing visual and auditory hallucinations, confusion, dehydration, a swollen tongue, and bruising. Which action should the nurse include in this client's plan of care to ensure physiological stability? Monitor VS When conducting an assessment interview with a new client, which question should the nurse use to elicit the most information? Tell me about you family Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply). Encourage verbal and nonverbal communication Maintain a calm demeanor during all interactions A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles? Rest and increased carbohydrate intake A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset because of the expenses of therapy. What information response should the home health nurse provide as the client's advocate? Explore options with the regional dialysis center about reducing the cost of home dialysis. What is the largest contributing factor for the increase in the need for home care? Clients are more acutely ill when discharged from acute care facilities An older Chinese client refuses to perform the range-of-motion and breathing exercises after a surgical procedure and is hesitant to complete hygienic care and grooming. What cultural factor should the nurse consider that is related to this client's behavior? Reliance on family members to assist with care. Which intervention demonstrates the nurse's accountability in a specific decision-making process? Evaluating a client's outcomes after implementation of care. A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? Allow the client to die with dignity and without life-prolonging techniques. Which individual may legally sign an informed consent? A 16-year-old mother for her newborn Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control? Powerlessness At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for seeking medical care and hospitalization? Orientation phase An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client?