Physiological Adaptation

The nurse is assigned to a patient who has long-standing type 1 diabetes mellitus who is being hospitalized for severe pneumonia. During the course of the patient’s hospitalization, he acutely develops polydipsia, polyuria, fatigue, generalized weakness, abdominal pain and nausea, as well as significantly elevated blood glucose level, hyperkalemia, and urine ketones. Which of the following best describes this patient’s condition?

One week following a total hysterectomy, a patient presents to the emergency department with a temperature of 104° F, heart rate 118, blood pressure 100/68 mmHg, new onset confusion and delirium, and flushed, warm skin. On assessment, the patient has positive bowel sounds, the patient’s abdomen is soft and non-tender, she has mild to moderate subcostal and intercostal retractions, and her breath sounds are clear and equal bilaterally. The nurse anticipates which diagnosis?

The patient who resides in a long term care facility is admitted to the hospital for an acute decrease in level of consciousness, confusion, and dehydration due to anorexia. The patient’s arterial blood gas, temperature, heart rate, respiratory rate, breath sounds, and bowel sounds are all within normal limits. The nurse anticipates which diagnosis?

A patient in the ICU following a motor vehicle accident has been intubated for 72 hours. Over the previous 12 hours, the patient’s oxygen requirement has increased, tidal volumes have decreased, and the patient’s endotracheal secretions have increased in quantity, thickness, and the color has changed from cloudy to green. The patient’s lab values are significant for a worsening respiratory acidosis and leukocytosis. Which diagnosis is most appropriate for this patient?

A hospitalized patient receiving antibiotic therapy develops severe, foul-smelling diarrhea. A stool culture reveals Clostridium difficile. The nurse is aware the patient is at risk for which complications of a C. difficile infection? Select all that apply.

A patient is brought to the emergency department unresponsive following an opioid overdose. The nurse anticipates the patient’s arterial blood gas results will reflect which condition?

A 10-year-old patient in the pediatrician’s office has dropped from 65 pounds to 55 pounds since last seen in the office three months ago. The patient’s mother tells the nurse, “I just don’t understand how that’s possible. She eats constantly and is always thirsty. My other concern is that she has to urinate frequently; her teacher contacts me weekly to tell me she goes to the bathroom more than her peers.” The nurse anticipates this patient will be diagnosed with which condition?

A patient presents to the emergency department in diabetic ketoacidosis. The nurse is aware that which intervention is the priority?

A patient who is recovering from diabetic ketoacidosis (DKA) has bacterial pneumonia with a positive sputum culture. Which organism is most likely responsible for this patient’s DKA?

A child with type 1 diabetes is undergoing treatment for diabetic ketoacidosis. For which life-threatening complications of treatment should the nurse be vigilant? Select all that apply.

A patient with type 1 diabetes mellitus asks the nurse what causes his hyperglycemia. Which response by the nurse is most appropriate?

The nurse is providing education to the parents of a 4-year-old child newly diagnosed with type 1 diabetes mellitus. Which statement by the parent indicates a need for further teaching?

The nurse educates the patient with newly-diagnosed type 2 diabetes mellitus about which long-term complications of poorly-controlled diabetes? Select all that apply.

The nurse is planning care for a patient who has been diagnosed with type 2 diabetes mellitus. Which intervention is likely to be most effective for this patient?

A patient has a blood pressure of 135/86 mm/Hg which was taken after the patient rested quietly in a room for 30 minutes. Using the AHA guidelines, how does the nurse classify this patient’s blood pressure?

A patient is found to have hypertension. Which conditions, if present in the patient, indicate the patient has had hypertension for years without being diagnosed? Select all that apply.

A 35-year-old man presents to the emergency department following an unrestrained head-on collision where his chest struck the steering wheel. During the initial assessment, the patient abruptly begins complaining of incredibly severe chest pain that feels like ripping in the anterior chest. He states, “I’m going to die, I know it!” The nurse alerts the provider immediately due to suspicion for which condition?

A patient is brought to the emergency department with right-sided weakness, right-sided facial drooping, slurring of the words, and aphasia. The nurse is most suspicious for which condition?

An infant is brought to the emergency department with abdominal distention, currant-jelly stools, dark-green emesis, and lethargy. Upon assessment, the nurse notes a palpable sausage-shaped mass in the right upper quadrant. The nurse suspects which condition?

A 22-year-old patient complains of frequent diarrhea, mucous discharge, rectal bleeding, lower abdominal pain, and tenesmus. On endoscopy, inflammation is found only in the descending colon and rectum with no healthy mucosa between the lesions. The nurse begins planning education for the patient about which condition?

A patient hospitalized with ulcerative colitis develops worsening abdominal pain, a fever of 103 °F, heart rate of 132 bpm, and blood pressure of 82/54 mmHg. Her labs are notable for an elevated white blood cell count. What is the nurse’s first action?

A patient has been diagnosed with toxic megacolon. Which interventions are appropriate for this patient? Select all that apply.

A patient is admitted with concern for heart failure. Which symptom is a major criterion of heart failure according to the Modified Framingham clinical criteria for the diagnosis of heart failure?

A patient with heart failure is unable to walk from the kitchen to the bedroom without becoming dyspneic. However, the dyspnea resolves with rest. The nurse recognizes this patient has which class of heart failure according to the New York Heart Association classification system?

A patient has been diagnosed with heart failure. The nurse educates the patient about which nonpharmacological treatments?

A patient presents to the emergency department complaining of weakness, fatigue, and nausea. The nurse observes distended neck veins and auscultates rales. The patient states, “I’ve had such trouble sleeping lately, but sleeping in my recliner seems to help.” The nurse anticipates the patient will be diagnosed with which condition?

A patient has been diagnosed with right-sided heart failure. The nurse expects the patient to exhibit which symptom(s)? Select all that apply.

A patient with heart failure requests assistance ordering a meal tray. Which meal does the nurse recommend for this patient?

The nurse is providing diet education to a patient with left-sided heart failure. Which meal, if ordered by the patient, indicates the teaching has been effective?

A patient presents to the dermatology office with complaints of several areas of pruritic silver-gray patches on the elbows, knees, and trunk. The nurse anticipates which diagnosis will be made?

The infiltration of which type of cells into the epidermis causes the characteristic symptoms of plaque psoriasis?

The 3-year-old patient is diagnosed with atopic dermatitis. The nurse provides information to the parents about which condition(s) the patient is likely to experience as he ages? Select all that apply. 

After speaking with the child’s mother, a pediatrician choses non-pharmacologic interventions for a child diagnosed with atopic dermatitis. Which treatments does the nurse recommend to the child’s mother? Select all that apply.

An individual develops anaphylaxis after a bee sting. Which class of immunoglobulin is responsible for the associated symptoms?

An individual experiencing anaphylaxis due to ingestion of peanuts has received epinephrine via autoinjector. Following the injection, the individual’s respirations have become less labored. In which position should the individual be placed while waiting for emergency medical personnel to arrive?

The nurse is providing discharge education to a patient diagnosed with immune thrombocytopenic purpura. Which statement by the patient indicates a need for further teaching?

A fetus is diagnosed in utero with autosomal recessive polycystic kidney disease. The mother is noted to have severe oligohydramnios. Which statement is most accurate for the prognosis of the fetus?

The nurse is attending the delivery of a full-term neonate whose mother received poor prenatal care. The neonate has cyanosis, increased work of breathing, a barrel chest, and a scaphoid abdomen. The nurse auscultates the patient’s lung fields and notes bowel sounds over the left side of the chest. The nurse suspects which condition in this neonate?

A pregnant patient with pre-eclampsia is receiving a magnesium sulfate infusion. Which early symptom, if present in the patient, indicates the patient’s magnesium level is becoming toxic?

The 25-year-old patient presents with new onset focal seizures; history is negative for traumatic events and the patient is otherwise healthy. The nurse suspects which condition as the cause of the seizure?

The patient’s wife tells the nurse, “Even though he had atrial fibrillation, he seemed fine. Why did he have a stroke?” Which response by the nurse is appropriate?

Following a cerebrovascular accident (CVA), the patient is able to speak but the words are nonsensical. The nurse attributes this patient’s symptoms to an infarction of which area of the brain?

The patient is undergoing therapeutic hypothermia following a severe cerebrovascular accident (CVA). The nurse bases education for the spouse on an understanding of which mechanism?

Which symptom of an arteriovenous malformation (AVM) is most common?

The patient with bacterial meningitis exhibits papilledema. The nurse attributes this symptom to inflammation of which cranial nerve?

The botulinum neurotoxin acts on which neurotransmitter to produce flaccid paralysis?

The nurse receives report about a neonate with an unrepaired meningocele and anticipates observing which assessment finding?

The client presents to the emergency department following a blow to the abdomen during a baseball game. He is unresponsive with a blood pressure of 82/48 mmHg, heart rate of 118 bpm, a respiratory rate of 18, and an oxygen saturation of 95% on room air. The nurse anticipates taking which action first to treat this patient?

The nurse on the telemetry floor is reviewing EKG readings of the patients. The nurse notes one patient, who is taking digoxin, to have peaked T waves and a prolonged PR interval. The nurse contacts the provider to report concerns for which possible impending condition?

The nurse assesses for which skill in the 6-month-old infant?