A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this
... [Show More] diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness - ✔✔ Elevated Temperature
Rationale: The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.
A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?
A. "I know this must be difficult, but your mother will calm down soon."
B. "Lets discuss some strategies you can use when this happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is ready to die?" - ✔✔ " Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce anxiety and enhance decision making. This response creates a safe environment, fosters trust and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia - ✔✔ Lethargy
rationale: Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in level of consciousness, such as restlessness, irritability, and disorientation. Lethargy is the first sign of increased ICP.
A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?
A. facial edema
b. urinary frequency
c. acid indigestion
d. breast leakage - ✔✔ Facial edema
rationale: facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.
A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion. - ✔✔ Stop the infusion
Rationale: This prevents further damage to vessel and minimizes any additional harm to the client
A nurse is reinforcing teaching with a caregiver who has aphasia. The nurse should include which of the following communication strategies in the teaching?
A. Cue the client by providing picture cards that portray common needs.
B. Increase the volume of the voice when speaking to a client.
C. Encourage the client to limit hand gestures when communicating.
D. Vary the use of phrases and terminology in discussions. - ✔✔ Cue the client by providing picture cards that portray common needs.
Rationale: Using picture cards enhances communication. The nurse should include this communication strategy in the teaching.
A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?
A. Administer epinephrine (Adrenaline)
B. Elevate the lower extremities
C. Determine respiratory status
D. Apply oxygen via non-rebreather mask. - ✔✔ Determine respiratory status
Rationale: The client is experiencing angioedema indicating a possible anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.
A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting - ✔✔ Excessive vomiting
rationale: Metabolic alkalosis is a potential complication of excessive vomiting because of loss of acid from the body.
A nurse is caring for neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). because of administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?
A. Tachycardia
B. Sternal retractions
C. Hypoglycemia
D. Hypothermia - ✔✔ hypoglycemia [Show Less]