1) A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative
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Vital signs
Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.
2) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse should plan for which priority intervention?
Providing assisted ventilation and obtaining the necessary equipment
The highest priority with epiglottitis is to have assisted ventilation available because the highest risk with this child is complete airway obstruction. Therefore, interventions related to airway are the priority.
Physiological interventions continue to have the highest priority, with assessment of breath and heart sounds and then obtaining pulse oximetry being priorities. Once the airway is stabilized, the temperature, weight, and a chest x-ray can be obtained. The last priority is asking about precipitating events, which is done once physiological needs are met.
3) The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken by the nurse before leaving the room?
Instituting safety measures
Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to prevent injury as a result of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are useful but not essential to the client's safety in this situation.
4) An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client?
Risk for self-harm
Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close observation is usually initiated to protect the client from impulsive behavior. If any of the other options exist, they are of lesser priority.
5) The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
Client pain level
The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.
6) A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment?
"Do you have any family problems?"
In the African American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. The psychosocial assessment would be of lowest priority during the initial admission assessment. Additionally, because cardiovascular, renal, and gastrointestinal assessments are physiological, they are the priority assessments.
7) The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority?
Risk for infection
The client with immunodeficiency has inadequate or no immune bodies and is at risk for infection. The priority concern would be risk for infection. The question presents no data indicating that the client is experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective isolation, but these are not the priority problems for this client. Infection can be life-threatening and is the priority. [Show Less]