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A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
- A. Dull and aching pain in the costovertebral area
- B. Aching and cramplike pain throughout the abdomen
- C. Pain that is sharp and radiating posteriorly to the spinal column
- D. Pain that is excruciating, wavelike, and radiating toward the genitalia
Correct Answer: D
Rationale: The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of the stone's abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a dull ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.
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A client diagnosed with diabetes mellitus is at 36 weeks' gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention?
- A. A contraction stress test
- B. Immediate induction of labor
- C. Hospitalization with continuous fetal monitoring
- D. A return appointment in 2 days to repeat the nonstress test
Correct Answer: A
Rationale: A nonreactive nonstress test after 40 minutes indicates that the fetus did not show the expected heart rate accelerations, which may suggest fetal compromise, particularly in a high-risk pregnancy such as one with diabetes mellitus. The next step is typically a contraction stress test to further assess fetal well-being by evaluating the fetal heart rate response to uterine contractions. Immediate induction or hospitalization may be premature without further evaluation, and repeating the nonstress test in 2 days delays necessary assessment.
The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
- A. In left Sims' position
- B. In reverse Trendelenburg
- C. With the head elevated on a small, flat pillow
- D. With the head of the bed elevated at least 30 degrees
Correct Answer: D
Rationale: The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. The client is log rolled when turned to avoid extreme hip flexion.
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.
The nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis. The nurse should assess for which manifestations of this complication? Select all that apply.
- A. Bradycardia
- B. Distended abdomen
- C. Subnormal temperature
- D. Rigid, boardlike abdomen
- E. Diminished bowel sounds
- F. Inability to pass flatus or feces
Correct Answer: B,D,E,F
Rationale: Peritonitis is an acute inflammation of the visceral and parietal peritoneum, the endothelial lining of the abdominal cavity. Clinical manifestations include distended abdomen; a rigid, boardlike abdomen; diminished bowel sounds; inability to pass flatus or feces; abdominal pain (localized, poorly localized, or referred to the shoulder or thorax); anorexia, nausea, and vomiting; rebound tenderness in the abdomen; high fever; tachycardia; dehydration from the high fever; decreased urinary output; hiccups; and possible compromise in respiratory status.
A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure is not effective?
- A. Code cart
- B. A small-bore needle
- C. Extra-large drainage bottle
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Empyema is the collection of pus within the pleural cavity. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore needle would not effectively allow exudate to drain. Options 1 and 3 are also unnecessary.