Physiological Adaptation

The nurse is caring for a 50-year-old male patient with hyperthyroidism. Which assessment does the nurse anticipate?

A nurse in a long-term care facility is caring for a 78-year-old man with dementia. Which of the following are the main signs and symptoms of Alzheimer’s dementia?

A 51-year-old man complains of mild headache and dizziness when standing up from bed. Which of the following medications was recently started?

The nurse is caring for a 50-year-old man who has undergone below-the-knee amputation of his right leg 4 hours ago. The patient complains of pain, numbness and tingling of the right leg and foot. Which of the following types of pain is most likely attributed to the patient’s complaints?

A 75-year-old woman appears in the emergency room with a wrist fracture sustained during a minor fall. Which of the following conditions is most likely related to the patient’s condition?

Which test is most helpful to diagnose kidney failure?

A 26-year-old woman is concerned about a lack of menstrual period over the last 8 weeks. Which hormone do you expect will be assessed?

An 18-year-old man arrives at the emergency department with suspected diabetic ketoacidosis. Which of the following is the characteristic breathing for this patient?

Which of the following is not indicative that a patient may be in diabetic ketoacidosis?

Which of the following symptoms would the nurse expect could be associated with an acute subdural hemorrhage in the right occipital lobe?

The nurse is assessing a patient with hypoparathyroidism. Which assessment finding does the nurse expect to see in this patient?

The nurse is taking care of a patient who recently received an allogenic stem-cell transplant for acute lymphoblastic leukemia (ALL). The patient abruptly complains of right upper quadrant abdominal pain. Upon assessment, the nurse notes abdominal swelling and yellowing of the sclera and skin. The nurse anticipates the provider will prescribe which treatment?

A teenager with type 1 diabetes mellitus presents to the emergency department with worsening illness, vomiting, and fatigue. Upon assessment, the nurse notes a sweet, fruity odor on the patient’s breath and suspects diabetic ketoacidosis (DKA). Which additional symptom(s) would confirm the diagnosis of diabetic ketoacidosis? Select all that apply.

A client with an intracranial hemorrhage has a sudden increase of 25 mmHg intracranial pressure. The nurse also notes an elevated temperature, increased blood pressure, fixed and dilated right pupil, loss of consciousness, and irregular pulse and respirations. Which condition does the nurse suspect is causing these signs and symptoms?

The nurse is providing discharge teaching for a client who had abdominal surgery and is being discharged with a Jackson-Pratt (JP) drain. Which statements does the nurse include in the teaching? Select all that apply.

An 82-year-old client with a history of hypertension becomes acutely confused and complains of a severe headache. The nurse is concerned the client is having a stroke. Which action does the nurse take first?

The patient presents to the emergency department with pain and deformity in her wrist after falling on her outstretched arm. The provider diagnoses the patient with a Colles fracture. How does the nurse interpret this information?

Which term denotes the heart’s dominant pacemaker?

The 24-year-old female patient presents to the emergency department with hematemesis. She rarely drinks alcohol and has no known medical conditions. She is afebrile and her laboratory tests are normal, though she has signs of dehydration. The physician diagnoses the patient with Mallory-Weiss Syndrome. The nurse assesses the patient for which conditions?

Chronic peptic ulcers are associated with the presence of which bacterium?

The patient presents to the clinic with rectal bleeding. Which diagnosis is most likely?

Which assessment would prompt the nurse to document gynecomastia?

Which patient in the emergency department does the nurse assess first?

The patient tells the nurse, “I’ve had two children. I do not want to have any more. What can I do?” While you will discuss various options, which treatment best suits the patient’s needs based on the current information?

The nurse finds a 70-year-old client admitted with heart failure, unresponsive with agonal gasping respirations. Which action does the nurse take first?

A 35-year-old client with a three-day history of vomiting is admitted with dehydration. The provider prescribes 1 liter of normal saline solution to infuse over 4 hours. As the nurse prepares to insert an intravenous (IV) catheter, she’s unable to palpate the vein at the intended insertion site. How does the nurse proceed?

Which finding in a client receiving a continuous magnesium sulfate infusion for preeclampsia indicates toxicity?

The nurse is teaching a client with new-onset type 1 diabetes mellitus about his care. Which statement by the client indicates that teaching was effective?

The patient presents to the emergency department complaining of severe headache and muscle and joint pain that started two days ago. Vital signs are significant for a heart rate of 112 bpm and temperature of 103°F. Upon assessment, the nurse notes a maculopapular rash on the patient’s wrists. Which question is most helpful in determining the cause of this patient’s symptoms?

The patient has been diagnosed with Rocky Mountain spotted fever (RMSF). The nurse is aware this patient’s symptoms are caused by which microorganism?

The nurse has been called to help with a 24-year-old G1P0 female with a viable intrauterine pregnancy at 42-weeks’ estimated gestational age. Patient is not in active labor, following an arrest of descent at the end of the first stage of labor. There was meconium detected in the amniotic fluid after PROM, and the fetus has had multiple episodes of bradycardia and late decelerations. Patient has a history of cocaine abuse. Which of the following statements is most correct regarding the management of this neonate when it is delivered?

The labor and delivery nurse is assigned to a 25-year-old G2P1 female with a viable intrauterine pregnancy at 40-weeks estimated gestational age. After the patient had PROM, dark green fluid was noted, which was not malodorous. Which of the following terms does the nurse use to document this finding?

The nurse is called to assist a 32-year-old G1P0 female who is in active labor with a viable intrauterine pregnancy at 30-weeks estimated gestational age. The patient delivers a neonate who requires intubation due to secondary apnea. The nurse auscultates to assess for endotracheal tube placement and notes breath sounds are louder on the right than the left. Which of the following is the next best step in management?

A patient with congestive heart failure (CHF) complains of worsening cough with frothy secretions. The nurse notes the patient is sitting in the tripod position and appears to be air hungry. A chest x-ray is ordered. Which of the following x-ray findings most likely explains the patient’s acute symptoms?

The patient is under general anesthesia for a surgical procedure. Because an inhaled anesthetic is being administered, the nurse should be vigilant for which of the following early signs of malignant hyperthermia?

The patient has sustained a complete spinal cord injury at the C3 level. The patient’s wife asks the nurse what his life will be like. Which of the following responses by the nurse is most appropriate?

The nurse is participating in long-term care planning for a patient who sustained a spinal cord injury at C8. Which of the following long-term goal(s) of care are most appropriate for this patient? Select all that apply.

The nurse is providing discharge teaching to an individual who suffered a spinal cord injury at T11. Which of the following statements by the patient indicates a need for further teaching?

The nurse is caring for a patient who sustained a C4 spinal cord injury one year ago. This patient is most likely at risk for which of the following pulmonary complications?

The nurse is caring for a patient who sustained a spinal cord injury at T6, three weeks ago. The patient abruptly complains of a severe headache. On assessment, the nurse notes the patient is diaphoretic. Vitals are significant for a heart rate of 45 bpm, blood pressure 156/98 mmHg, respirations of 16 breaths per minute, and 94% oxygen saturation on room air. Which of the following is the next best step in management?

The nurse learns that a patient is in neurogenic shock after a high cervical spinal cord injury. Which of the following set of vital signs is most consistent with this condition?

The nurse is providing education to a patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following body positions does the nurse teach the patient to assume to help him breathe more easily?

The nurse is assessing the patient with a right-sided chest tube and notes rapid bubbling in the water seal chamber. Which of the following is the next best step in management?

The patient with a chest tube on suction becomes delirious and climbs out of bed causing the chest tube to become dislodged. Which of the following actions should the nurse take first?

The nurse is performing an admission assessment on a bedridden patient transferred from an assisted living facility. The nurse notes an area, 10 cm by 12 cm, on the patient’s sacrum that is intact but maroon in color. Which of the following is the most appropriate term for the nurse to use when documenting this finding?

During hourly rounds, the nurse notes a patient’s right heel has an erythematous area that is warm to the touch. The skin is intact but does not blanch with pressure. Which of the following terms is most appropriate for the nurse to use when documenting this finding?

The nurse is assessing the skin of a patient who uses a wheelchair for mobility. The nurse notes an area over the patient’s left ischium that is shiny and pinkish-red with a serous exudate. The area measures 5 cm x 4 cm and depth of the wound is insignificant. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?

A patient is admitted to hospital with a wound on her sacrum. The nurse notes the wound bed is beefy red with areas of shiny white tissue. The center of the wound is covered in black, hardened tissue with yellow, foul-smelling soft tissue surrounding it. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?

The nurse removes the dressing from a patient’s stage IV pressure injury and notes a foul odor and yellow drainage on the dressing and from the wound bed. Which of the following is the most appropriate next course of action?

The nurse is changing the dressing of a patient with a stage IV pressure injury. Upon removal of the gauze dressing, the nurse notes the wound bed appears dry. The wound bed is clear of slough or eschar. The nurse cleans and measures the wound. Which of the following is the best wound care strategy for this patient?