After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should the nurse do first?
Assess the irrigation catheter for patency and drainage.
A 16-year-old girl visits the clinic for the first time. She tells the nurse that she has been exposed to herpes. Initially, with primary genital or Type 2 herpes simplex, the nurse should expect the girl to have:
burning or tingling on vulva, perineum, or vagina.
An elderly client with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities; he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line and I've had it!" Which of the following actions should the nurse take?
Report the comment to the neighbor, the daughter, and the police because there is the potential for a criminal act.
A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
Ask for the prescription to be changed to oral gastric tube.
Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills?
Determining if the client's physical condition is life-threatening
A young school-age child whose mother and aunt have bipolar disorder and whose father has depression is brought to the child psychiatrist’s office by her father. He has custody of the child since the parents divorced. The father says that the child has problems with behavior, attention in school, and sleeping at night. The child says “My brain doesn’t turn off at night.” The psychiatrist diagnoses the child with attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well. What should the office nurse say to the father to reinforce what the psychiatrist said? Select all that apply.
"The psychiatrist diagnosed your child with ADHD because of her attention and behavior problems at school."
The psychiatrist is considering a bipolar diagnosis because of your child's family history of bipolar disorder and her sleep issues."
"ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings."
While caring for a pregnant adolescent, a nurse should develop a care plan that incorporates the adolescent's:
level of emotional maturity.
Which client best fits into the middle-old elderly population?
A 76-year old with hypertension
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?
Airborne and contact precautions
When a nurse is assessing a client for pain, what finding is most significant? The client:
Tells the nurse about experiencing pain.
A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:
assess the client for pain.
A nurse is changing a dressing and providing wound care. Which activity should she perform first?
Wash her hands thoroughly.
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
Encouraging intake of at least 2 L of fluid daily
A mother of a 4-year-old child asks the nurse how to talk with her daughter about strangers. The little girl is very friendly and her mother is concerned that her child could be abducted. The nurse should tell the mother:
to talk with her daughter about what she should do if a stranger talks to her.
The nurse is caring for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first?
Switch the transfusion to normal saline solution.
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
After a laminectomy, the client states, "The physician said that I can do anything I want to." Which of the following client-stated activities indicates the need for further teaching?
Sweeping the front porch.
The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
The nurse identifies the type of presentation shown in the figure as which of the following?
A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?
Receiving a portion of the revenue to improve client services on the unit
A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?
Report back to the nurse immediately if any client has an output less than 240 ml.
A staff nurse on the mental health unit tells the nurse manager that kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway. What is the best reply by the nurse manager?
You sound really frustrated. Let's talk about the meaning of their behavior.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
Security tags in place.
Identification system on mother and infant.
Someone in room able to care for infant.
Bulb syringe within sight.
A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse's best response is which of the following?
A prostate examination can possibly increase the PSA.
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots are which of the following?
The client with glaucoma is scheduled for a hip replacement. Which of the following prescriptions would require clarification before the nurse carries it out?
Administer atropine sulfate.
A nurse is assigned to a client who, after a medication teaching session with her, began receiving amitriptyline (Elavil) to treat depression. One week after starting this drug, the client refuses to take the medication. He says it has caused blurred vision, dry mouth, and constipation, but it hasn't improved his mood. Which nursing diagnosis is appropriate for this client?
Deficient knowledge (treatment regimen) related to inadequate understanding of teaching
When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because:
Status epilepticus may develop.
A client is brought to the mental health center for an evaluation by a police officer because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." Which of the following factors would be most relevant to a decision about this client's disposition?
She seems able to care for herself.