Rn adult medical surgical nursing 2023 with complete solution questions and answers

A nurse caring for a client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medications. Which promotes client compliance -The nurse provides resources to strengthen coping ability by asking the dietician to assist the client with meal planning. This will improve client compliance A nurse in a health care clinic is evaluating the level of wellness for clients using the illness-wellness continuum tool. The nurse should identify which of the following clients as being at the center of the continuum? A young male client who has a long history of well-controlled rheumatoid arthritis - measured at the center of the continuum which is the normal state of health A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable smoking on special occasions -Bmi of 28 - history of reflux A nurse is caring for a client who was just informed of a new diagnosis of breast cancer. The nurse evaluates the clients response. Which of the following statements by the client reflects a lack of understanding of an illness perspective "I need a second opinion there is no lump" -the patient denial reflects a lack of understanding of the illness perspective and can influence the clients acceptance of the diagnosis Common causes of pulseless electrical activity 5 H (hypovolemia, hypoxia, hydrogen ion accumulation resulting acidosis, hyper or hypokalemia, hypothermia) 5 Ts (toxins, tamponade, tension pneumothorax, thrombosis coronary or pulmonary) A nurse on a medical surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A client who reports right calf pain and shortness of breath. - The nurse should identify that the client is at risk for respiratory arrest due to a possible embolism. The nurse should call the rapid response team because manifestations can indicate the beginning of a rapid decline in the clients condition A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take -Activated charcoal absorbs toxic substances and the charcoal does not pass into the bloodstream - A gastric lavage with aspiration removes the toxic substance when instilled fluid is suctioned from the gastrointestinal tract - Infuse IV fluids help dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys. A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly, which actions should the nurse take? -Remove wet clothing - Apply warm blankets - infuse warm IV fluids A nurse in the emergency department is assessing a client who is unresponsive. The clients partner states, "he was pulling weeds in the yard and slumped to the ground," Which of the following techniques should the nurse use to open the clients airway The nurse should open the client's airway by using a head-tilt, chin-lift because the client is unresponsive without suspicion of trauma A nurse is reviewing the common emergency management protocol for clients who have asystole.. Which of the following actions should the nurse plan to take during this cardiac emergency? Administer IV epinephrine - during asystole increases heart rate, improves cardiac output, and promotes bronchodilation What are the five levels of ED triage system Resuscitation: the client needs immediate treatment to prevent death Emergent: the client requires time-sensitive treatment for a problem that has the potential to become a life or limb-threatening situation Urgent: the client requires treatment but the situation is not life-threatening Less urgent: The client is able to wait for a period of time without immediate treatment Nonurgent: the client requires a simple evaluation and minor management of care. What is the criteria for each of the five levels of triage -Resuscitation: a client who is experiencing cardiac arrest, stroke, pulmonary emboli, or drug overdose. - Emergent: a client who has sustained a traumatic amputation, head or neck injury, snake or spider bite - Urgent: a client who has a kidney stone, gallbladder colic or fracture - Less urgent: a client who has a bladder infection, laceration, or infected toe. - Non-urgent: a client who has a rash, minor cut or backache A nurse is caring for a client who is post procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? -Assist the patient to a supine position (the nurse should assist the client in a supine position which can relieve a headache following a lumbar puncture - The nurse should administer an opioid medication for the client's report of headache pain - The nurse should encourage an increased fluid intake to maintain a positive fluid balance which can relieve a headache following the lumbar puncture A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A nurse should monitor a client who has a ventriculostomy for infection which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition which can result in meningitis A nurse is assessing a client for changes in the level of consciousness using the Glascow Coma scale. The client opens his eye when spoken to, speaks coherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document E3+V4+M4=11 E3 represents opening eyes secondary to voice stimulation. V4 represents verbal conversation that is incoherent and disoriented. M4 represents motor response as a general withdrawal to pain A nurse developing a plan for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider -The nurse should report the clients statement of possible pregnancy because the contrast media can place the fetus at risk - The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography - The nurse should report a clients report of allergy to shrimp which is a shellfish to the provider due to a potential allergic reaction to the contrast media - The nurse should report the clients intake of food to the provider since the client should remain NPO for 4 to 6 hours prior to the procedure A nurse is providing education to a client who is to undergo an electroencephalogram the next day. Which of the following information should the nurse include in the teaching The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity What are the interventions (pre, intra, post) for an MRI machine magnetic resonance imaging -Pre: remove all jewelry, determine if the patient is claustrophobic, question the client concerning implants containing metal, question clients allergies - Intra: stabilize the patients head -Post: monitor for allergic reaction to the contrast media used during the MRI A nurse is caring for a client who is experiencing mild acute pain after spraining ankle. Which of the following analgesics should the nurse expect to administer Ketorolac is an NSAID useful for anti-inflammatory effects in managing minor pain following a sprain A nurse at a clinic is talking with a client who has cancer and takes extended- release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? Breakthrough pain is an acute exacerbation of pain beyond the level the client typically experiences. A nurse is caring for a client who is receiving morphine via a patient controlled analgesia infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device " I should tell the nurse if the pain doesn't stop after I use this device" - The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the clients pain management plan A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include/ The nurse should identify that pain is a subjective experience, and the client is the best source of information about it. A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics -Respiratory depression which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesics - Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesics - Nausea and vomiting are common adverse effects of opioid analgesia Acute pain protective, temporary, usually self limiting, resolves with tissue healing Tachycardia, hypertension, anxiety, diaphoresis, muscle tension Grimacing, moaning, flinching, guarding Chronic pain not protective, ongoing or recurs frequently, lasts longer than 3 months, persists beyond tissue healing, can be chronic cancer pain or chronic non cancer pain No change in vital signs, depression, fatigue, decreased level of functioning, disability Nociceptive pain arises from damage to or inflammation of tissue other than that f the peripheral and central nervous systems is usually throbbing, aching, localized pain typically responds to opioid and non opiod medications Neuropathic pain arises from abnormal or damaged pain nerves (phantom limb pain, pain below the level of a spinal cord injury, diabetic neuropathy, usually intense, shooting, burning, or pins and needles. -Physiologically responses to adjacent medications (antidepressants, antispasmodic agents, skeletal muscle relaxants A nurse is assessing a client who reports severe headache and a stiff neck. The nurse assessment reveals positive Kernigs and Brydzinski signs. Which of the following actions should the nurse perform first? Implement droplet precautions - Meningitis is suspected A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? -The nurse should place the client in supine position when assessing for Brudzinskis sign - The nurse should place her hands behind the clients neck when assessing for Brudzinskis sign in order to flex the clients neck - The nurse should bend the client head toward the chest when assessing for Brudzinskis sign A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? -