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A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
- A. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days
- B. Heart rate of 100 beats per minute after ambulating 200 feet
- C. Urine output of 2,000 mL in 24 hours
- D. Weakness and numbness in the lower extremities
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
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A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
- A. Treatment of recurrent malignant effusion.
- B. Diagnosis of underlying disease.
- C. Palliation of symptoms.
- D. Relief of acute respiratory distress.
- E. Removal of the cancer cells.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (B), palliates symptoms like dyspnea (C), and relieves acute respiratory distress (D). It does not treat recurrent effusions or remove cancer cells.
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
- A. Anemia.
- B. Osteoporosis.
- C. Weight loss.
- D. Local joint pain.
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
- A. The rehabilitation plan will be guided by it.
- B. Functional status before the stroke will help predict outcomes.
- C. It will help the client recognize his physical limitations.
- D. The client can be expected to regain much of his functioning.
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.
The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation?
- A. Impaired mobility related to spasticity and fatigue.
- B. Risk for falls related to muscle weakness and sensory loss.
- C. Risk for seizures related to muscle tremors and loss of myelin.
- D. Impaired skin integrity related bowel and bladder incontinence.
Correct Answer: C
Rationale: Seizures are not a common manifestation of MS, as tremors and myelin loss do not directly cause seizures. The other diagnoses are valid, as MS commonly causes mobility issues, fall risks, and skin integrity concerns.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.