Which clinical manifestation should a nurse expect to find in newly diagnosed intrinsic cancer?
Hoarseness
A female client is recovering from breast
... [Show More] cancer surgery that included axillary node dissection. The nurse realizes that this client is at risk for developing:
Lymphedema
A client asks the nurse, "what does it matter what grade the tumor I had in my stomach?" The best response by the nurse is:
"It explains how aggressive the tumor is."
Post-resuscitation goals include which of the following? (Select all that apply)
*Maintain airway *Maintain blood pressure *Control dysrhythmias
When caring for an AIDS patient what nursing intervention would be appropriate for protecting the patient's skin surfaces?
Keep bed linens free of wrinkles
Mr. B., age 78 with a history of bladder cancer, is admitted post-op to the oncology floor after a urethra diversion and cystectomy. At 3a.m., the RN sees the following EKG:
The patient is easy to arouse, alert and oriented despite an accelerated heart rate. BP=112/68. The nurse calls the rapid response team. The MD orders 10 mg IV of metroprolol push and it slows the heart rate down. After few minutes Mr. B develops right arm weakness, facial droop and aphasia. A stroke code is called. Mr. B goes to CT. The MD reports that the CT is negative and that Mr.B has an acute blockage of the left middle-cerebral artery.
Patient is sent to interventional radiology for IA thrombolysis and clot extraction.
The clot is removed, and the follow-up angiography shows reperfusion to the ischemic area.
What about the CT shows indication for IA thrombolytic? There is an occlusion in the middle cerebral artery
The insertion site used for the clot extraction is: femoral artery
If the patient is transferred to the ICU. The immediate nursing assessment is: neurological status
The main complication of IA thrombolytic therapy that the nurse needs to monitor for is: intracranial hemorrhage (ICH)
What rhythm is this patient in? atrial fibrillation
A 55-year-old woman presents to your office for a physical examination. Her medical history is significant for migraine with aura. She is taking multivitamins and hormone replacement therapy. The patient reports that she is a social drinker and has a 20 pack-year smoking history. Her body mass index is 30 kg/m2. Which of the following variables is not a risk factor for stroke in this patient?
Social drinking
A client is burned circumferentially over right arm, trunk and the perineum. Using the rule of 9"s what is the burned?
28
The nurse assesses a patient’s GCS score to be 3. What is the best interpretation by the nurse? Does not open eyes, no motor response, and no verbal response
The nurse is reviewing with a certified nursing assistant (CNA) the care for a patient diagnosed with AIDS and has developed PCP. Which of the following precautions would the nurse review with the CNA?
Standard precautions
The client states, "My husband is the person you should talk with if I am not able to make decisions about my care." The nurse realizes the spouse has been identified as:
The health care surrogate
You are staffing the medical area for a 5 K marathon in your city. The ambient temperature is 81 degrees F and the relative humidity is 46%. One of the runners, a 32-year-old man, crosses the finish line, walks over to the medical area, and asks for your help. He is sweating profusely and says he just needs to sit down and rest. He complains of some slight cramping in his legs. He says he drank water along the course. He indicates that he has no past medical problem and is not taking any medication. He has participated in marathons before. He appears to be of average height and weight and says he runs about 10 miles a day. You take his vital signs and find a temperature of 98.8 F, respirations of 20 per minute, and a B/P of 118/60 mm hg. The monitor shows the rhythm below:
the interpretation of EKG above is: Sinus Tachycardia
Your initial treatment of the man would be to: offer him water or a sports drink
The nurse hears the cardiac monitor and notes that the patient has a cardiac pattern of EKG waves of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should:
start basic cardiopulmonary resuscitations (CPR).
A patient has chosen to receive palliative care after his lung cancer metastasized to his bones and liver. Which of the following is most appropriate during palliative cancer care?
The use of chemotherapy to reduce pain
A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with ALS approximately 1 year ago. Which of the following client findings should the nurse anticipate? (Select all that apply)
*Muscle weakness *Muscle atrophy *Ineffective cough
Endotracheal suctioning: should be performed as dictated by patient assessment.
A 49-year-old patient is diagnosed with ovarian cancer. What is a characteristic of malignant cells that differentiates them from normal body cells?
Cancerous cells grow in an uncontrollable fashion.
Select all the factors that may predispose the patient to respiratory acidosis.
*Central nervous system depression *Overdose of sedatives
A client with multiple sclerosis will take oral prednisone at home. Which discharge instruction is most important for the nurse to include?
"Do not stop taking the medication suddenly."
Mr. M is a 32 year old man brought to the emergency department by paramedics after a fall from the second story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal x-rays are obtained, the physicians determine that he has a vertebral compression injury at the C4-C5 level. After Mr.M undergoes endotracheal intubation and is placed on mechanical ventilation, his oxygen saturation increases to 96% and respiratory decreases to 18 breaths/min ( 10
ventilator breaths per minute). On auscultations, he has breathe sounds present in all lung lobes bilaterally.Mr. M has a nursing diagnosis of Impaired Physical Mobility. Which nursing actions should you delegate to the nursing student on the unit? SELECT ALL THAT APPLY
*Providing pin site care using hydrogen peroxide and normal saline.
*Administering IV ranitidine (Zantac) 50 mg. in 50 ml normal saline to prevent gastric ulcers.
A client on chemotherapy is having hematological effects including decreased RBC, WBC, and platelets. Which should the nurse emphasize as an important action for the patient care attendant:
Frequent monitoring of temperature
Which of the following statements concerning ALS is true?
ALS resulted from the degenerative and demyelination of both upper and lower neurons in the anterior horn of the spinal cord, brainstem, and cerebral cortex. [Show Less]