Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
Comprehensive exam 3
A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client
walking around the unit muttering to himself and gesturing as if he is having auditory
hallucinations. Which action provides the most effective psychotherapeutic management? -
ANS-Reassure the client that he is safe and should rest.
A 38-year-old female client is admitted to the mental health unit after a recent manic episode of
spending large amounts of money on new furniture, making excessive long-distance phone
calls, and not sleeping for three days. During the admission process, the client is wearing a
green bathing suit. What intervention should the nurse implement? - ANS-Assess the client's
needs for food, liquids, and rest.
A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly
debilitated and tells the nurse, Since I haven't been able to go to church, I feel out of touch with
God. I pray, but I wonder whether my prayers are heard. Which nursing diagnosis should the
nurse include in the client's plan of care? - ANS-Spiritual distress
A client is admitted with myasthenia gravi - ANS-Ptosis
A client is comatose upon arrival to the emergency department after falling from a roof. The
client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale
(GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's
airway? - ANS-A nasopharyngeal tube.
A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare
the dose? - ANS-Insulin regular (Humulin R).
A client is receiving an opioid analgesic every 2 hours for intractable pain. Which
pathophysiological consequence should the nurse identify if the client receives the medication at
regular intervals? - ANS-Respiratory acidosis.
A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid
colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The
perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs.
During the early postoperative period, the nurse should give the highest priority to which nursing
action? - ANS-Maintain dry perineal dressings
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of
a perforated ulcer. The healthcare provider's prescriptions include morphine with a
patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric
Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
, Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12
hours after returning to the surgical unit. The nurse determines the client has no bowel sounds,
and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is
the priority action the nurse should implement? - ANS-Notify HCP
A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4
hours, the nurse determines the client has no drainage from the NGT and has absent bowel
sounds. What action should the nurse implement? - ANS-Irrigate the NGT with normal saline.
A client who begins an exercise program asks the nurse about carbohydrate loading. What
concepts should the nurse include in teaching the client ways to increase glycogen store in
muscles? - ANS-Rest and increased carbohydrate intake
A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple
food allergies is scheduled for surgery. Which action should the nurse implement? -
ANS-Document a possible Type I latex allergy.
A client who is taking nitroglycerin for angina is concerned about having headaches after taking
more than one tablet. What information should the nurse provide? - ANS-This is a common side
effect due to the vasodilatory effects of the medication.
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites
and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when
he is turned. Which intervention is most important for the nurse to include in the client's plan of
care? - ANS-Apply a pressure-relieving mattress under the client.
A client with an open reduction and application of an external fixator for open, comminuted
fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not
relieved by analgesics. The client says the toes are numb and tingling, although they appear
pink. What action should the nurse implement? - ANS-Notify HCP
A client with cellulitis is recovering at home after experiencing a severe reaction - ANS-A
malpractice suit based on lack of reasonable and prudent care
A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset
because of the expenses of therapy. What information response should the home health nurse
provide as the client's advocate? - ANS-Explore options with the regional dialysis center about
reducing the cost of home dialysis.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a
side-lying position. The nurse should monitor for the risk of which complication? -
ANS-Aspiration pneumonia.
Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
Comprehensive exam 3
A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client
walking around the unit muttering to himself and gesturing as if he is having auditory
hallucinations. Which action provides the most effective psychotherapeutic management? -
ANS-Reassure the client that he is safe and should rest.
A 38-year-old female client is admitted to the mental health unit after a recent manic episode of
spending large amounts of money on new furniture, making excessive long-distance phone
calls, and not sleeping for three days. During the admission process, the client is wearing a
green bathing suit. What intervention should the nurse implement? - ANS-Assess the client's
needs for food, liquids, and rest.
A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly
debilitated and tells the nurse, Since I haven't been able to go to church, I feel out of touch with
God. I pray, but I wonder whether my prayers are heard. Which nursing diagnosis should the
nurse include in the client's plan of care? - ANS-Spiritual distress
A client is admitted with myasthenia gravi - ANS-Ptosis
A client is comatose upon arrival to the emergency department after falling from a roof. The
client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale
(GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's
airway? - ANS-A nasopharyngeal tube.
A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare
the dose? - ANS-Insulin regular (Humulin R).
A client is receiving an opioid analgesic every 2 hours for intractable pain. Which
pathophysiological consequence should the nurse identify if the client receives the medication at
regular intervals? - ANS-Respiratory acidosis.
A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid
colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The
perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs.
During the early postoperative period, the nurse should give the highest priority to which nursing
action? - ANS-Maintain dry perineal dressings
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of
a perforated ulcer. The healthcare provider's prescriptions include morphine with a
patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric
Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
, Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12
hours after returning to the surgical unit. The nurse determines the client has no bowel sounds,
and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is
the priority action the nurse should implement? - ANS-Notify HCP
A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4
hours, the nurse determines the client has no drainage from the NGT and has absent bowel
sounds. What action should the nurse implement? - ANS-Irrigate the NGT with normal saline.
A client who begins an exercise program asks the nurse about carbohydrate loading. What
concepts should the nurse include in teaching the client ways to increase glycogen store in
muscles? - ANS-Rest and increased carbohydrate intake
A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple
food allergies is scheduled for surgery. Which action should the nurse implement? -
ANS-Document a possible Type I latex allergy.
A client who is taking nitroglycerin for angina is concerned about having headaches after taking
more than one tablet. What information should the nurse provide? - ANS-This is a common side
effect due to the vasodilatory effects of the medication.
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites
and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when
he is turned. Which intervention is most important for the nurse to include in the client's plan of
care? - ANS-Apply a pressure-relieving mattress under the client.
A client with an open reduction and application of an external fixator for open, comminuted
fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not
relieved by analgesics. The client says the toes are numb and tingling, although they appear
pink. What action should the nurse implement? - ANS-Notify HCP
A client with cellulitis is recovering at home after experiencing a severe reaction - ANS-A
malpractice suit based on lack of reasonable and prudent care
A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset
because of the expenses of therapy. What information response should the home health nurse
provide as the client's advocate? - ANS-Explore options with the regional dialysis center about
reducing the cost of home dialysis.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a
side-lying position. The nurse should monitor for the risk of which complication? -
ANS-Aspiration pneumonia.
Comprehensive exam 3.pdf Comprehensive exam 3.pdf Comprehensive exam 3.pdf
