When documenting assessment data, which statement should the nurse record in the
narrative
nursing notes?
A. Slight tenderness in the left upper quadrant.
B. Most all permanent teeth are present.
C. Hair is within normal limits.
D. S1 murmur auscultated in supine position.
D. S1 murmur auscultated in supine position.
RATIONALE:
Documentation of subjective and objective data obtained from the physical
assessment should be
communicated using precise, descriptive, clear, and accurate information,
such as auscultated
, heart sounds while the client is in a specified position (C). (A, B, and D) are
nonspecific.
Which instruction should the nurse include in the discharge teaching for a client who is
taking an antipsychotic medication?
A. Increase daily intake of raw fruits and vegetables.
B. Follow a low carbohydrate diet.
C. Report increased urine output to the healthcare provider immediately.
D. Take a multivitamin daily
A. Increase daily intake of raw fruits and vegetables.
RATIONALE:
A common side effect of antipsychotic medications is constipation, and
increasing high-fiber
foods in the diet (A) can help to alleviate this problem. (B and C) have no
particular effect on
possible side effects from taking antipsychotic medications. While some
antipsychotic
medications cause urinary retention, which should be reported to the
healthcare provider, urine
output increase (D) is likely to occur if additional fluids are consumed to
overcome a dry mouth,
which is a common side effect of antipsychotic medications
An older client who has been bedridden for a month is admitted with a pressure ulcer on
the
left trochanter area. The nurse determines that the ulcer extends into the subcutaneous
tissue. At
which stage should the nurse document this finding?
A. Stage 3.
,B. Stage 1.
C. Stage 2.
D. Stage 4
A. Stage 3
RATIONALE:
Pressure ulcers develop over skin surfaces usually covering bony prominences
and are caused by
external pressure that impedes blood flow, causing ischemia of the skin and
underlying tissue.
The stage of the pressure area is determined by the depth of tissue damage,
and this client's
lesion should be documented as a Stage 3 (C) because it is a full thickness
tissue loss with visible
subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a non-
blanchable pressure
point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister
or shallow open
ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed
bone, tendon or
muscle, slough or eschar, and often includes undermining and tunneling.
The nurse is caring for critically ill clients. Which client should be monitored for the
development of neurogenic shock? A client with
A. congestive heart failure.
B. diabetes insipidus.
C. spinal cord injury.
D. gastrointestinal hemorrhage.
, C. spinal cord injury.
RATIONALE:
Spinal cord injuries (C) place the client at high risk for the development of
neurogenic
distributive shock. The development to watch for in (A) is cardiogenic shock, in
(B) is
hemorrhagic shock, and in (D) is hypovolemic shock.
A client who is one week postoperative after an aortic valve replacement suddenly
develops severe pain in the left leg. On assessment, the nurse determines that the client's
leg is pale and
cool, and no pulses are palpable in the left leg. After notifying the healthcare provider,
which action should the nurse take?
A. Keep the client in bed in the supine position.
B. Apply firm pressure to the femoral artery.
C. Encourage the client to exercise the leg.
D. Elevate the legs and medicate for pain.
A. Keep the client in bed in the supine position.
RATIONALE:
A common postoperative complication after valve replacement is arterial
occlusion from a clot,
which requires anticoagulant therapy to prevent further enlargement of the
thrombus and reduce
the risk of embolization. Recently formed thrombi can also be effectively
treated with an
intraarterial infusion of a thrombolytic agent, followed by bed rest (C) and
periodic angiography
to monitor the dissolution of the clot. (A, B, and D) are contraindicated due to
the risk of
vascular occlusion and embolization.
narrative
nursing notes?
A. Slight tenderness in the left upper quadrant.
B. Most all permanent teeth are present.
C. Hair is within normal limits.
D. S1 murmur auscultated in supine position.
D. S1 murmur auscultated in supine position.
RATIONALE:
Documentation of subjective and objective data obtained from the physical
assessment should be
communicated using precise, descriptive, clear, and accurate information,
such as auscultated
, heart sounds while the client is in a specified position (C). (A, B, and D) are
nonspecific.
Which instruction should the nurse include in the discharge teaching for a client who is
taking an antipsychotic medication?
A. Increase daily intake of raw fruits and vegetables.
B. Follow a low carbohydrate diet.
C. Report increased urine output to the healthcare provider immediately.
D. Take a multivitamin daily
A. Increase daily intake of raw fruits and vegetables.
RATIONALE:
A common side effect of antipsychotic medications is constipation, and
increasing high-fiber
foods in the diet (A) can help to alleviate this problem. (B and C) have no
particular effect on
possible side effects from taking antipsychotic medications. While some
antipsychotic
medications cause urinary retention, which should be reported to the
healthcare provider, urine
output increase (D) is likely to occur if additional fluids are consumed to
overcome a dry mouth,
which is a common side effect of antipsychotic medications
An older client who has been bedridden for a month is admitted with a pressure ulcer on
the
left trochanter area. The nurse determines that the ulcer extends into the subcutaneous
tissue. At
which stage should the nurse document this finding?
A. Stage 3.
,B. Stage 1.
C. Stage 2.
D. Stage 4
A. Stage 3
RATIONALE:
Pressure ulcers develop over skin surfaces usually covering bony prominences
and are caused by
external pressure that impedes blood flow, causing ischemia of the skin and
underlying tissue.
The stage of the pressure area is determined by the depth of tissue damage,
and this client's
lesion should be documented as a Stage 3 (C) because it is a full thickness
tissue loss with visible
subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a non-
blanchable pressure
point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister
or shallow open
ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed
bone, tendon or
muscle, slough or eschar, and often includes undermining and tunneling.
The nurse is caring for critically ill clients. Which client should be monitored for the
development of neurogenic shock? A client with
A. congestive heart failure.
B. diabetes insipidus.
C. spinal cord injury.
D. gastrointestinal hemorrhage.
, C. spinal cord injury.
RATIONALE:
Spinal cord injuries (C) place the client at high risk for the development of
neurogenic
distributive shock. The development to watch for in (A) is cardiogenic shock, in
(B) is
hemorrhagic shock, and in (D) is hypovolemic shock.
A client who is one week postoperative after an aortic valve replacement suddenly
develops severe pain in the left leg. On assessment, the nurse determines that the client's
leg is pale and
cool, and no pulses are palpable in the left leg. After notifying the healthcare provider,
which action should the nurse take?
A. Keep the client in bed in the supine position.
B. Apply firm pressure to the femoral artery.
C. Encourage the client to exercise the leg.
D. Elevate the legs and medicate for pain.
A. Keep the client in bed in the supine position.
RATIONALE:
A common postoperative complication after valve replacement is arterial
occlusion from a clot,
which requires anticoagulant therapy to prevent further enlargement of the
thrombus and reduce
the risk of embolization. Recently formed thrombi can also be effectively
treated with an
intraarterial infusion of a thrombolytic agent, followed by bed rest (C) and
periodic angiography
to monitor the dissolution of the clot. (A, B, and D) are contraindicated due to
the risk of
vascular occlusion and embolization.
