NURS MISC NCLEX Exam 2_Study Guide,GRADED A

NURS MISCNCLEX Exam 2_Study Guide NCLEX Exam 2 Cardiac A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Metformin A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? Acute Kidney Injury The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? Continue to monitor A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? Check the client's status and lead placement. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? Status of airway The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? Sinus tachycardia The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? The neurovascular status is normal because of increased blood flow through the leg. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A rise in blood pressure A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? Muffled or distant heart sounds The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." The nurse is providing instructions to a client with a diagnosis of hypertension regarding high- sodium items to be avoided. The nurse instructs the client to avoid consuming which item? Antacids The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? Stop smoking because it causes cutaneous blood vessel spasm The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? Elevate the legs higher than the heart The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? Myocardial infarction The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? Hypotension The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? Listening to lung sounds The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? "This is a normal finding." The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? An attempt to ignore or deny the need to make lifestyle changes A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? An arterial ulcer The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? Maintain activity level as prescribed. A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? "It involves injecting an agent into the vein to damage the vein wall and close it off." A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? "Your health care provider needs to be contacted to report this problem." The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? "I need to adhere to my dietary restrictions." The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? Raspberry juice The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? "Where is the pain located?" The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? "I should use polyunsaturated oils in my diet." A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? "I'm going to have a ham and cheese sandwich and potato chips for lunch. The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? Glucose intolerance The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? "I don't have anyone to help me with doing heavy housework at home." The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? "I will eat enough daily fiber to prevent straining at stool." A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? Ambulates 10 feet (3 meters) farther each day The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? Tells the client that the procedure is painless and takes 30 to 60 minutes A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? Wear loose clothing with a shirt that buttons in front. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places the highest priority on telling the client to report which sensation during the procedure? Chest pain A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? Weigh self on a daily basis. A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? "I probably will feel tired after the test from lying on a hard x-ray table for a few hours." A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? Oxygen saturation monitor Ear The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A red, dull, thick, and immobile tympanic membrane A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? Tinnitus The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? Speak at normal tone and pitch, slowly and clearly. A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? Avoid sudden head movements. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Speak at a normal volume. Endocrine A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? Intravenous infusion of normal saline An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. Comatose state, Deep, rapid breathing, Elevated blood glucose level The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. Shakiness, Palpitations, Lightheadedness A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? Convey empathy, trust, and respect toward the client. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short- acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? IV fluids containing dextrose The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? Polyuria The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? Inadequate fluid volume The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? "I need to stop my insulin." The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? Test the drainage for glucose. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. Initiate an infusion of 3% NaCl Restrict fluids to 800 mL over 24 hours Administer a vasopressin antagonist as prescribed A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? Maintain a patent airway. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? Administer short-duration insulin intravenously. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? "The best time for me to exercise is after breakfast." The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. Polyuria, Headache, Nervousness The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? "I should limit my fluids to 1 liter per day." A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional healthcare team focus on? Select all that apply. Hypotension, Hyperkalemia The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply Tremors, irritability, nervousness The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A heart rate that is 90 beats/minute and irregular The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. Leukocytosis urinary output of 800mL/hr Clear drainage on nasal dripper pad The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? Temperature The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. Feeling cold, Loss of body hair, Persistent lethargy, Puffiness of the face A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Respiratory distress A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. Fever, Nausea, Tremors, Confusion The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high-fiber foods in the diet Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? "Usually these physical changes slowly improve following treatment." The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat hypocalcemic tetany A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? Take a blood glucose test before exercising. The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. A thyroid-releasing inhibitor will be prescribed, Encourage the client to consume a well- balanced diet. A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? The client needs immediate education before discharge A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? "Let me go over the types of insulins with you again." A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? Glucagon A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? Regular insulin via the intravenous (IV) route The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? Positive Trousseau's sign The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? Increased thirst The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? Increased production of glucose The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Severe abdominal pain Eye The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? Eye medications will need to be administered for life. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? A sense of a curtain falling across the field of vision The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Blurred vision The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over, Take acetaminophen for minor eye discomfort, Place an eye shield on the surgical eye at bedtime, contact the surgeon if a decrease in visual acuity occurs Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Note the time of day the test was done A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Instruct the client that he or she may need glasses when driving A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? Cardiovascular disease A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? Client report of tunnel vision The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? "The hearing aid should not be worn if an ear infection is present." The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. Position the client with the affected side down after the irrigation, Warm the irrigating solution to a temperature that is close to body temperature, Position the client to turn the head so that the ear to be irrigated is facing upward, Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? Speak in a normal tone and face the client when speaking. A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? Instillation of mineral oil The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? "It's a sensorineural hearing loss that occurs with the aging process." The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? Avoid air travel. The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? A myringotomy The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? Safety measures The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? Monitor for signs of facial nerve injury The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? Tinnitus The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? Ambulation four times daily Gastrointestinal The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? Notify the health care provider (HCP). A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. Gray-blue color at the flank, Abdominal guarding and tenderness, Left upper quadrant pain with radiation to the back The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. Fever, Complaints of indigestion, Pain in the upper right quadrant after a fatty meal A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? Increase intake of fluids, including juices. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assess 8 ment finding? Malaise A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. Administer stool softeners as prescribed., Encourage a high-fiber diet to promote bowel movements without straining., Apply cold packs to the anal-rectal area over the dressing until the packing is removed. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. Coffee, Chocolate, Peppermint, Fried chicken A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? Assessing for the return of the gag reflex The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? "I'm glad I don't have to lie still for this procedure.” The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? "I ate shellfish about 2 weeks ago at a local restaurant.” The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. Nuts, Liver, Lentils The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? Document the findings. Expected drainage will range from 500 to 1000 mL/day. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A rigid, boardlike abdomen The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? Irrigating the nasogastric tube The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? Limit the fluids taken with meals. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. Maintain NPO (nothing by mouth) status, Encourage coughing and deep breathing., Give hydromorphone intravenously as prescribed for pain. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? "I should increase the fiber in my diet.” The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Ask the client to extend the arms.-Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? Pasta with sauce The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? Pain relieved by food intake A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? Purple discoloration of the stoma A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? This is a normal, expected event. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Fluid and electrolyte imbalance The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? "I need to limit my intake of dietary fiber.” The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? Sweating and pallor A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? Assessment of vital signs The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? Inability to pass flatus The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? Dark red drainage A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? "I can go back to work right away.” -Rest is especially important until laboratory studies show that liver function has returned to normal. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? Leukocytosis with a shift to the left After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? Waves of loud gurgles auscultated in all 4 quadrants -Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? Pernicious anemia A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? "I eat at least 3 large meals each day.” The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? Check the suction device to make sure it is working. The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? Decreased hemoglobin A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? Applesauce and a graham cracker The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. Jaundice, Clay-colored stools, Elevated bilirubin levels, Dark or tea-colored urine The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? "I need to decrease fiber in my diet." Hematological A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? Red tongue that is smooth and sore The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? "I need to avoid situations that may lead to an infection." The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. Pallor, Fever, Joint swelling, Abdominal pain The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? Initiate an intravenous (IV) line for the administration of fluids. The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? Shortness of breath with activity The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? "I need to increase my fluid intake." A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? Disseminated intravascular coagulopathy (DIC) The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. Transfusions, splenectomy, corticosteroids, immunosuppressive agents The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? Decreased production of erythropoietin is causing anemia. When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? Dietary intake of iron The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. I may continue to use an electric shaver, I will not blow my nose if I get a cold, I should use a soft-bristled toothbrush. Immune 1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? "I should take hot baths because they are relaxing." 2. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? "I have an autoimmune disease that causes blistering in the epidermis." 3. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? Protecting the client from infection 4. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? Ask the client if he ever sustained a bee sting in the past. 5. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? Hairdressers 6. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. -Use nonlatex gloves. -Use medications from glass ampules. -Keep a latex-safe supply cart available in the client's area. -Avoid the use of medication vials that have rubber stoppers. 7. A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? "Have you been camping in the last month?" 8. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? Administer corticosteroids as prescribed for inflammation. 9. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. -Tell the client to avoid any woody, grassy areas that may contain ticks. -Instruct the client to immediately start to take the antibiotics that are prescribed. -Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 10. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? Positive punch biopsy of the cutaneous lesions 11. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. -Record site, date, and time of the test. -Give the client a list of potential allergens if identified. 12. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? Bananas 13. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? Ensure that the client uses an electric razor for shaving. 14. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? Fever, hypertension, and graft tenderness 15. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? Complete blood cell (CBC) count 16. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? Amylase 17. A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? CD4+ cell count 18. A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? Infection caused by leukopenic effects of the medication 19. A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? Skin rash 20. Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? Cardiac conduction deficits 21. The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? Complaints of joint pain 22. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? Tell the client to return to the clinic in 4 to 6 weeks. 23. A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? A 14 to 21 day course of doxycycline 24. The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? Facial rash 25. A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? A Western blot will be done to confirm these findings. 26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? Cough 27. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? The client has disseminated histoplasmosis infection. 28. The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. -Keep liquids at the bedside. -Place a towel over the pillowcase. -Make sure the pillow has a plastic cover. -Keep a change of bed linens nearby in case they are needed. 29. A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? Remove dairy products and red meat from the meal. 30. The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? The use of latex condoms Integumentary A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? "Take a shower immediately, lathering and rinsing several times.” A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A skin infection of the dermis and underlying hypodermis The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Thinner and decrease in number of reddish papules, Scarce amount of silvery-white scaly patches on the arms The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? Positive culture results -a viral culture of the lesion provides the definitive diagnosis A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. Lesion is highly metastatic Lesion is a nevus that has changes in color. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A pearly papule with a central crater and a waxy border Location in the bald spot atop The head that is exposed to outdoor sunlight A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A white color to the skin, which is insensitive to touch -Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Partial-thickness skin loss of the dermis An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 36% The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Return of distal pulses- The escharotomy releases the tourniquet-like compression around the arm The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Elevated hematocrit levels- the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Urine output The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Immobilization of the affected leg The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun Examine your body monthly for any lesions that may be suspicious. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Multiple straight or wavy threadlike lines underneath the skin The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? "Apply a warm, damp washcloth if discomfort occurs.” The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. Reposition every 2 hours., Use a bed cradle as indicated. Apply protective pads to heels and elbows Provide perineal care every 8 hours and after incontinence. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? Gastric lavage The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? A client who tans in an indoor tanning bed The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? "The local anesthetic may cause a stinging sensation.” The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? "I will return tomorrow to have the sutures removed.” The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? Tell the client that the procedure is painless. The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? Keep the test sites dry. The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? Apply emollients to the skin after bathing. The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? It is caused by a tick bite. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? "This skin infection involves the deep dermis and subcutaneous fat.” The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? Applying warm compresses to the affected area The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? Clustered skin vesicles The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. "I need to clean the site as prescribed to prevent infection.” "I need to expect some swelling and tenderness in the affected area.” The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? Apply an emollient lotion to the skin to enhance softening. Musculoskeletal The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A sedentary 65-year-old woman who smokes cigarettes The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? I need to report a fever or swelling to my health care provider The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? Stay with the victim and encourage him or her to remain still. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Thick, yellow drainage from the pin sites The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? Presence of a "hot spot" on the cast A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? Impaired tissue perfusion The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? Elevated on pillows continuously for 24 to 48 hours A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? I need to avoid getting the cast wet A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? Injury to the brachial plexus nerves The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. I should not use someone else's crutches I need to remove any scatter rugs at home I need to have spare crutches and tips available The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? Clear mentation The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? Numbness and tingling in the fingers A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? Separation of the wound edges The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? Rewrap the residual limb with an elastic compression bandage A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? Bending or lifting The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? Temperature of 101.6°F (38.7°C) orally The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? Uric acid level of 9.0 mg/dL (0.54 mmol/L) A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? Check the weights to ensure that they are off of the floor The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? Place a clock and calendar in the client's room The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? Signs of skin breakdown The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? The need for sensory stimulation The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? All caregi