Physiological Health Problems 2023 Questions and
Answers with complete solution
A nurse is assigned to care for four clients on the medical-surgical unit. Which
client should the nurse see first on the shift assessment?
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted
to the hospital with a diagnosis of dehydration. For which clinical manifestations
that correlate with this fluid imbalance would the nurse assess the client?
Decreased urine output
Increased respiratory rate
A nurse is reviewing the medical records of the clients to whom she is assigned
on the 7 am-7 pm shift. Which client will the nurse monitor most closely for
excessive fluid volume?
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/h.
A nurse is caring for a client who is being treated for congestive heart failure and
has been assigned a nursing diagnosis of excessive fluid volume. Which
assessment finding causes the nurse to determine that the client's condition has
improved?
Weight loss of 4 lb in 24 hours.
A nurse notes that a client has ST-segment depression on the electrocardiogram
(ECG) monitor. With which of the following serum potassium readings does the
nurse associate this finding?
3.1 mEq/L.
A healthcare provider writes a prescription for the administration of intravenous
(IV) potassium chloride to a client with hypokalemia. What does the nurse plan to
do when preparing and administering this medication?
Ensure that the medication is diluted in an appropriate amount of normal saline solution.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse
interprets this as an expected finding in the client with:
Addison disease.
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical
manifestations of this electrolyte imbalance does the nurse monitor this client?
Hyperactive bowel sounds
Skeletal muscle weakness
A nurse is monitoring a client with hyperparathyroidism for signs of
hypercalcemia. For which of the following clinical manifestations, associated with
this electrolyte imbalance, does the nurse assess the client?
Muscle weakness
Increased urine output
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0
mg/dL. Which assessment findings does the nurse expect to note?
Abdominal distention
Trousseau sign
, A nurse enters a client's room and finds the client unconscious. The nurse
quickly performs an assessment and determines that the client is not breathing.
Which action does the nurse take first?
Beginning chest compressions.
A nurse arrives at the scene of a code and begins to assist with cardiopulmonary
resuscitation (CPR) of an adult. The nurse delivers compressions by pushing
down on the chest to a depth of:
2 inches.
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult
client. Which compression-ventilation ratio is correct?
30:2.
A pediatric nurse finds a hospitalized child unresponsive. A quick assessment
reveals that the child is not breathing and does not have a pulse. The nurse
initiates cardiopulmonary resuscitation (CPR). How many chest compressions
per minute does the nurse deliver?
100.
A nurse attending a recertification course in basic life support (BLS) for
healthcare professionals is practicing BLS on an infant mannequin. Where does
the nurse place the fingers to assess the infant's pulse?
Antecubital fossa of the arm.
A nurse is working in the emergency department. Which of the following clients
should be assessed first?
A client with new-onset atrial fibrillation with a rate of 118 beats/min.
A nurse is having dinner at a restaurant when a man sitting at the next table
collapses and falls to the floor. The nurse yells for help and quickly assesses the
client, noting that the client is not breathing and does not have a pulse. The nurse
initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant
manager rushes to the scene with an automatic external defibrillator (AED). What
should the nurse do next?
Use the AED.
A client with cancer of the larynx is receiving external radiation therapy of the
neck. Which side effect related specifically to the site of irradiation does the
nurse tell the client to expect?
Dysphagia.
The nurse has instructed a client who is about to begin external radiation therapy
in how to maintain optimal skin integrity during therapy. Which statement by the
client indicates a need for further instruction?
I can use over-the-counter cortisone cream on the radiation site if it gets red.
A nurse develops a nursing care plan for a client with a sealed radiation implant.
Which stipulation does the nurse include in the plan?
Visitors must be limited to one half-hour per day.
A female client who has undergone placement of a sealed radiation implant asks
the nurse whether she can take a walk around the nursing unit. How should the
nurse respond to the client's request?
You need to stay in your room for now.
Answers with complete solution
A nurse is assigned to care for four clients on the medical-surgical unit. Which
client should the nurse see first on the shift assessment?
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted
to the hospital with a diagnosis of dehydration. For which clinical manifestations
that correlate with this fluid imbalance would the nurse assess the client?
Decreased urine output
Increased respiratory rate
A nurse is reviewing the medical records of the clients to whom she is assigned
on the 7 am-7 pm shift. Which client will the nurse monitor most closely for
excessive fluid volume?
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/h.
A nurse is caring for a client who is being treated for congestive heart failure and
has been assigned a nursing diagnosis of excessive fluid volume. Which
assessment finding causes the nurse to determine that the client's condition has
improved?
Weight loss of 4 lb in 24 hours.
A nurse notes that a client has ST-segment depression on the electrocardiogram
(ECG) monitor. With which of the following serum potassium readings does the
nurse associate this finding?
3.1 mEq/L.
A healthcare provider writes a prescription for the administration of intravenous
(IV) potassium chloride to a client with hypokalemia. What does the nurse plan to
do when preparing and administering this medication?
Ensure that the medication is diluted in an appropriate amount of normal saline solution.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse
interprets this as an expected finding in the client with:
Addison disease.
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical
manifestations of this electrolyte imbalance does the nurse monitor this client?
Hyperactive bowel sounds
Skeletal muscle weakness
A nurse is monitoring a client with hyperparathyroidism for signs of
hypercalcemia. For which of the following clinical manifestations, associated with
this electrolyte imbalance, does the nurse assess the client?
Muscle weakness
Increased urine output
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0
mg/dL. Which assessment findings does the nurse expect to note?
Abdominal distention
Trousseau sign
, A nurse enters a client's room and finds the client unconscious. The nurse
quickly performs an assessment and determines that the client is not breathing.
Which action does the nurse take first?
Beginning chest compressions.
A nurse arrives at the scene of a code and begins to assist with cardiopulmonary
resuscitation (CPR) of an adult. The nurse delivers compressions by pushing
down on the chest to a depth of:
2 inches.
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult
client. Which compression-ventilation ratio is correct?
30:2.
A pediatric nurse finds a hospitalized child unresponsive. A quick assessment
reveals that the child is not breathing and does not have a pulse. The nurse
initiates cardiopulmonary resuscitation (CPR). How many chest compressions
per minute does the nurse deliver?
100.
A nurse attending a recertification course in basic life support (BLS) for
healthcare professionals is practicing BLS on an infant mannequin. Where does
the nurse place the fingers to assess the infant's pulse?
Antecubital fossa of the arm.
A nurse is working in the emergency department. Which of the following clients
should be assessed first?
A client with new-onset atrial fibrillation with a rate of 118 beats/min.
A nurse is having dinner at a restaurant when a man sitting at the next table
collapses and falls to the floor. The nurse yells for help and quickly assesses the
client, noting that the client is not breathing and does not have a pulse. The nurse
initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant
manager rushes to the scene with an automatic external defibrillator (AED). What
should the nurse do next?
Use the AED.
A client with cancer of the larynx is receiving external radiation therapy of the
neck. Which side effect related specifically to the site of irradiation does the
nurse tell the client to expect?
Dysphagia.
The nurse has instructed a client who is about to begin external radiation therapy
in how to maintain optimal skin integrity during therapy. Which statement by the
client indicates a need for further instruction?
I can use over-the-counter cortisone cream on the radiation site if it gets red.
A nurse develops a nursing care plan for a client with a sealed radiation implant.
Which stipulation does the nurse include in the plan?
Visitors must be limited to one half-hour per day.
A female client who has undergone placement of a sealed radiation implant asks
the nurse whether she can take a walk around the nursing unit. How should the
nurse respond to the client's request?
You need to stay in your room for now.
