A nurse is caring for a client who has a new diagnosis of type 2 diabetes Mellitus and
reports difficulty following the diet and remembering to take the
... [Show More] prescribed medication.
Which of the following actions should the nurse take to promote client compliance?
(Select all that apply)
A. Recommend a referral to the dietitian to assist with meal planning
B. Contact the clients support system.
C. Collect data regarding age related cognitive awareness
D. encourage the use of daily medication dispenser,
E. review provided educational materials for home use - ANS-A, B, D, E.
A nurse is assisting with the evaluation of the level of wellness for clients using the
illness-wellness continuum tool. The nurse should identify which of the following clients
as being at the center of the continuum?
A. A college student who has influenza
B. An older adult who has a new diagnosis of type 2 diabetes mellitus
C. A new mother who has a urinary tract infection
D. A young male client who has a long history of well controlled rheumatoid arthritis -
ANS-D. young male client who has a long history of well controlled rheumatoid arthritis
A nurse is assisting with the evaluation of clients at a health fair for modifiable variables
affecting health and wellness. The nurse should identify which of the following variables
as modifiable? (Select all that apply)
A. Smoking on social occasions
B. BMI of 28
C. Alopecia
D. Trisomy 21
E. History of reflux - ANS-A, B, E. Smoking on social occasions, BMI of 28, history of
reflux
A nurse is caring for a client who was just informed of a new diagnosis of breast cancer.
Which of the following statements by the client reflects a lack of understanding of an
illness perspective?
A. "I have no family history of breast cancer
B. I need a second opinion. There is no lump.
C. I am glad we live in the city near several large hospitals.
D. I will schedule surgery next week, over the holidays. - ANS-B. "I need a second
opinion. There is no lump."
ABCDE - ANS-Airway, breathing, circulation, disability, exposure
Hypoxia - ANS-lack of oxygen, brain injury or death occurs in 3-5 min
If a client is not breathing or is breathing inadequately - ANS-manual ventilation should
be performed by a bag valve mask with supplemental oxygen or mouth-to-mask
ventilation until bag valve mask can be obtained
Shock is... - ANS-The body's response to inadequate tissue perfusion and oxygenation.
Increased heart rate, hypotension, results in tissue ischemia and necrosis
AVPU mnemonic - ANS-A-alert V- responsive to voice, P- responsive to pain, Uunresponsive
Glasgow Coma Scale - ANS-eyes, verbal, motor
Max- 15 pts, 3= totally unresponsive
Victims are at risk for... - ANS-Hypothermia (35c 95F or less)
Hypothermia leads to - ANS-Coma, hypoxemia, acidosis
Heat stroke - ANS-Temp 104 (40 c) no sweat, tachycardia... give oxygen, ensure largegauge iv catheter, maybe indwelling catheter, cold wet towels etc
Frost bite: - ANS-Superficial, partial thickness, or full thickness (3 and 4 degree) put in
bath, administer tetanus toxoid IM vaccine
Poisoning... - ANS-Exposure to toxic agent. Medical emergency. Rapid management
therapy .antivenin for snakes.
Reverse heroin/ other opiate toxicity with.. - ANS-Naloxone
SBAR stands for - ANS-Situation, Background, Assessment, Recommendation
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
A. Client who has a pressure injury and blood glucose is 300 mg/dL
B. Client who develops an irregular heart beat and decreased loss of consciousness.
C. Client who reports a sore throat after an endoscopy.
D. Client who reports increased pain from kidney stone. - ANS-B. Irregular heart beat,
loss of consciousness
A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomiting.
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
E. Administer a cathartic - ANS-B, C, E... [Show Less]