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1. A nurse and a provider Office is assisting with the care of a client who has a
new diagnosis of type two diabetes mellitus. The client is at risk for developing
_____ during to _____.: -delayed wound healing
-glucose levels
2. A nurse is assisting in the care of a client who is one day postoperative
following a total thyroidectomy. The client is the greatest risk for developing
_____ as evidenced by _____.: -hypocalcemia
-muscle spasms
3. A nurse in the emergency department is assisting in the care of a client. The
nurse should suspect the client is experiencing _____ as evidenced by the client's
_____.: -serotonin syndrome
-altered mental status
4. A nurse is caring for a client in an outpatient setting. The client is exhibiting
manifestations of _____ as evidenced by the client's drop _____.: -Heart failure
-BNP level
5. A nurse is assisting with the care of an adolescent client in the emergency
department. For each finding click to specify if the finding is consistent with
bacterial meningitis or encephalitis. Each finding may support more than one
disease process.: -Bacterial Meningitis: fever, photophobia, pain, mental status, and rash
-Encephalitis: fever, pain, and mental status
6. A nurse is assisting in the care of a client who is postoperative following an
appendectomy. Which of the following client findings should the nurse report
to the charge nurse?: -pain
-nausea
-heart rate
-oxygen saturation
7. A nurse is assisting with the care of a client who is pregnant in the acute
care setting. The nurse should first address the client's _____, followed by the
_____.: -Respirations
-LOC
8. A nurse in an urgent care setting is assisting with the care of a client. For
each finding click to specify if the finding requires follow-up or does not require
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follow up.: -Requires follow-up: BP, Heart rate, HbA1c, and BMI
-Does not require follow-up: Sodium and BUN
9. A nurse is assisting with the admission of an older adult client. Which of the
following actions should the nurse take first?: complete a fall risk assessment on the client
10. A nurse is reinforcing teaching about puberty with a group of prepubescent
female clients. Which of the following information should the nurse include in
the teaching?: you will likely gain weight before you start to get taller
11. A nurse is assisting with planning palliative care for a client who has stage IV
cancer and is in the active stage of dying. Which of the following interventions
should the nurse include in the plan of care?: administer atropine to reduce the clients respiratory
secretions
12. A nurse is collecting a urine specimen for a female client who has diabetes
insipidus. Which of the following findings should the nurse expect?: Urine specific
gravity of 1.002
13. A nurse is contributing to the plan of care for a client who has viral meningi-
tis. Which of the following interventions should the nurse include?: Place the client
in a private room.
14. A nurse is assisting with the care of a client who is postoperative following
coronary artery bypass surgery (CABG). The client is at greatest risk for devel-
oping _____ as evidenced by _____.: -dysrhythmia
-Laboratory reports and muscle cramps
15. A nurse is assisting with the care of a client who is 24 hours postoperative
following a cesarean birth. The client is a risk for developing _____ as evidenced
by _____.: -seizures
-severe features of preeclampsia
16. A nurse is assisting with the care of a client. Complete the diagram by drag-
ging from the choices below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address the condition, and 2
parameters the nurse should monitor to assess the client's progress.: Action 1:?
Action 2:?
Potential Condition: Somatic symptom disorder
Parameter to Monitor 1: Secondary gains from their illness
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Parameter to Monitor 2: Physical manifestations
Upon recognizing and analyzing the client's assessment findings, such as joint pain and physical inactivity, the nurse's
priority hypothesis is that the client is most likely experiencing somatic symptom disorder. It is essential to generate
solutions and take actions by monitoring for both the presence of secondary gains from their illness and the client's
physical manifestations. Somatic symptom disorders are characterized by the presence of many physical manifestations
like dizziness, nausea, back pain, joint pain, etc. The nurse should evaluate and monitor the client's vital signs and pain
level.
17. A nurse is assisting in the care of a client who is one hour postpartum. Select
the 6 actions the nurse should take.: -Firmly massage the uterine fundus
-Administer methylergonovine
-Weigh the perineal pads
-Provide emotional support
-Insert indwelling urinary catheter
-administer oxygen at 12 L/min via non rebreather face mask
18. A nurse is assisting in the care of a client who experienced a spinal cord injury
(SCI). Complete the diagram by dragging from the choices below, to specify
what condition the client is most likely experiencing, 2 actions the nurse should
take to address that condition, and 2 parameters the nurse should monitor to
assess the client's progress.: -Autonomic dysreflexia
-blood pressure
-noxious stimuli
-administer nifedipine or a nitrate
Upon collecting data, the nurse should recognize the client cues of high blood pressure, headache, face and neck warm
to the touch, and constipation. The nurse should recognize that the client is likely experiencing autonomic dysreflexia,
and that it is important to generate solutions and take actions that will decrease the client's blood pressure and noxious
stimuli. Therefore, the nurse should prepare to administer nifedipine or a nitrate to decrease the client's blood pressure
and check for bladder distention, which may be contributing to visceral stimuli. The nurse should monitor the client's
blood pressure every 10 to 15 min and monitor vision for changes caused by autonomic dysreflexia, such as blurred
vision.