PNLE 3 - CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIALPulse is increased from 87 to 95, with an occasional skipped beat.ALTERATIONSThe client is
... [Show More] oriented when aroused from sleep, and goes backto sleep immediately.1. Nurse Michelle should know that the drainage is normal 4 daysThe client refuses dinner because of anorexia.after a sigmoid colostomy when the stool is:11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which ofGreen liquidthe following symptoms may appear first?Solid formedAltered mental status and dehydrationLoose, bloodyFever and chillsSemiformedHemoptysis and Dyspnea
2. Where would nurse Kristine place the call light for a male clientPleuritic chest pain and coughwith a right-sided brain attack and left homonymous hemianopsia?12. A male client has active tuberculosis (TB). Which of the followingOn the client's right sidesymptoms will be exhibit?On the client's left sideChest and lower back painDirectly in front of the clientChills, fever, night sweats, and hemoptysisWhere the client likeFever of more than 104°F (40°C) and nausea
3. A male client is admitted to the emergency department followingHeadache and photophobia
an accident. What are the first nursing actions of the nurse?13. Mark, a 7-year-old client is brought to the emergencyCheck respiration, circulation, neurological response.department. He's tachypneic and afebrile and has a respiratory rateAlign the spine, check pupils, and check for hemorrhage.of 36 breaths/minute and has a nonproductive cough. He recentlyCheck respirations, stabilize spine, and check circulation.had a cold. Form this history; the client may have which of theAssess level of consciousness and circulation.following conditions?4. In evaluating the effect of nitroglycerin, Nurse Arthur should knowAcute asthmathat it reduces preload and relieves angina by:Bronchial pneumoniaIncreasing contractility and slowing heart rate.Chronic obstructive pulmonary disease (COPD)Increasing AV conduction and heart rate.Emphysema
Decreasing contractility and oxygen consumption.14. Marichu was given morphine sulfate for pain. She is sleeping andDecreasing venous return through vasodilation.her respiratory rate is 4 breaths/minute. If action isn't taken quickly,5. Nurse Patricia finds a female client who is post-myocardialshe might have which of the following reactions?infarction (MI) slumped on the side rails of the bed and unresponsiveAsthma attackto shaking or shouting. Which is the nurse next action?Respiratory arrestCall for help and note the time.SeizureClear the airwayWake up on his ownGive two sharp thumps to the precordium, and check the pulse.15. A 77-year-old male client is admitted for elective knee surgery.Administer two quick blows.Physical examination reveals shallow respirations but no sign of6. Nurse Monett is caring for a client recovering from gastro-respiratory distress. Which of the following is a normal physiologicintestinal bleeding. The nurse should:change related to aging?Plan care so the client can receive 8 hours of uninterruptedIncreased elastic recoil of the lungssleep each night.Increased number of functional capillaries in the alveoliMonitor vital signs every 2 hours.Decreased residual volumeMake sure that the client takes food and medications atDecreased vital capacityprescribed intervals.16. Nurse John is caring for a male client receiving lidocaine I.V.Provide milk every 2 to 3 hours.Which factor is the most relevant to administration of this7. A male client was on warfarin (Coumadin) before admission, andmedication?has been receiving heparin I.V. for 2 days. The partial thromboplastinDecrease in arterial oxygen saturation (SaO2) when measured withtime (PTT) is 68 seconds. What should Nurse Carla do?a pulse oximeter.Stop the I.V. infusion of heparin and notify the physician.Increase in systemic blood pressure.Continue treatment as ordered.Presence of premature ventricular contractions (PVCs) on aExpect the warfarin to increase the PTT.cardiac monitor.Increase the dosage, because the level is lower than normal.Increase in intracranial pressure (ICP).8. A client undergone ileostomy, when should the drainage appliance17. Nurse Ron is caring for a male client taking an anticoagulant. Thebe applied to the stoma?nurse should teach the client to:24 hours later, when edema has subsided.Report incidents of diarrhea.In the operating room.Avoid foods high in vitamin KAfter the ileostomy begin to function.Use a straight razor when shaving.When the client is able to begin self-care procedures.Take aspirin to pain relief.
9. A client undergone spinal anesthetic, it will be important that the18. Nurse Lhynnette is preparing a site for the insertion of an I.V.nurse immediately position the client in:catheter. The nurse should treat excess hair at the site by:On the side, to prevent obstruction of airway by tongue.Leaving the hair intactFlat on back.Shaving the areaOn the back, with knees flexed 15 degrees.Clipping the hair in the areaFlat on the stomach, with the head turned to the side.Removing the hair with a depilatory.
10.While monitoring a male client several hours after a motor19. Nurse Michelle is caring for an elderly female with osteoporosis.vehicle accident, which assessment data suggest increasingWhen teaching the client, the nurse should include informationintracranial pressure?about which major complication:Blood pressure is decreased from 160/90 to 110/70.Bone fracture
Loss of estrogen29. The nurse is caring for Kenneth experiencing an acute asthmaNegative calcium balanceattack. The client stops wheezing and breath sounds aren't audible.Dowager's humpThe reason for this change is that:
20. Nurse Len is teaching a group of women to perform BSE. TheThe attack is over.nurse should explain that the purpose of performing theThe airways are so swollen that no air cannot get through.examination is to discover:The swelling has decreased.Cancerous lumpsCrackles have replaced wheezes.Areas of thickness or fullness30. Mike with epilepsy is having a seizure. During the active seizureChanges from previous examinations.phase, the nurse should:Fibrocystic massesPlace the client on his back remove dangerous objects, and insert
21. When caring for a female client who is being treated fora bite block.hyperthyroidism, it is important to:Place the client on his side, remove dangerous objects, and insertProvide extra blankets and clothing to keep the client warm.a bite block.Monitor the client for signs of restlessness, sweating, andPlace the client o his back, remove dangerous objects, and holdexcessive weight loss during thyroid replacement therapy.down his arms.Balance the client's periods of activity and rest.Place the client on his side, remove dangerous objects, and protectEncourage the client to be active to prevent constipation.his head.
22. Nurse Kris is teaching a client with history of atherosclerosis. To31. After insertion of a cheat tube for a pneumothorax, a clientdecrease the risk of atherosclerosis, the nurse should encourage thebecomes hypotensive with neck vein distention, tracheal shift,client to:absent breath sounds, and diaphoresis. Nurse Amanda suspects aAvoid focusing on his weight.tension pneumothorax has occurred. What cause of tensionIncrease his activity level.pneumothorax should the nurse check for?Follow a regular diet.Infection of the lung.Continue leading a high-stress lifestyle.Kinked or obstructed chest tube
23. Nurse Greta is working on a surgical floor. Nurse Greta mustExcessive water in the water-seal chamberlogroll a client following a:Excessive chest tube drainageLaminectomy32. Nurse Maureen is talking to a male client, the client beginsThoracotomychoking on his lunch. He's coughing forcefully. The nurse should:HemorrhoidectomyStand him up and perform the abdominal thrust maneuver fromCystectomy.behind. [Show Less]