Nokea
A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?
- A. Prefers not to look at the stoma site
- B. Participates in performing ostomy care
- C. Denies feelings of sadness about the ostomy
- D. Accepts that sexual activity will decrease
Correct Answer: B
Rationale: Participating in ostomy care demonstrates acceptance and adaptation to the altered body image.
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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Changed mental status
- B. Temperature 37.3°C (99.1°F)
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: A
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
Day 1, 1100:
Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.
Day 4, 1000:
Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.
Physical exam:
General: Appears more comfortable, not grimacing.
HEENT: Mucous membranes moist.
Cardiovascular: S1, S2, no murmur.
Respiratory: Bilateral breath sounds clear.
Gastrointestinal:
Mild tenderness to palpation.
Bowel sounds present and more regular, less high-pitched.
Skin: No jaundice noted, skin warm and dry.
The nurse continues to assist with the care of the client.
The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?
- A. Fluid intake
- B. Temperature
- C. Wound findings
- D. Pain level
- E. Report of nausea
- F. Bowel sounds
Correct Answer: D,E,F
Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Restrict visitors to family members until the client is able to wear a prosthesis.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Instruct the client to ignore phantom pain sensations.
- D. Suggest that family members bring clothing for the client from home.
- E. Ask the client to describe her feelings about the loss of the affected limb.
Correct Answer: B,D,E
Rationale: Peer support, familiar clothing, and addressing feelings promote psychological adjustment and rehabilitation; restricting visitors or ignoring phantom pain is not therapeutic.
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. Hct
- B. INR
- C. BUN
- D. LDL
Correct Answer: B
Rationale: INR (International Normalized Ratio) is monitored for warfarin therapy to assess clotting time and ensure therapeutic anticoagulation levels.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced.
The nurse is assisting in the plan of care for the client who has compartment syndrome. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Open the splint
- B. Place the client on NPO status
- C. Place the client's right leg in a dependent position
- D. Obtain a urinalysis
Correct Answer: A (anticipated), B (anticipated), C (contraindicated), D (anticipated)
Rationale: Opening the splint relieves pressure in compartment syndrome; NPO status prepares for surgery; a dependent position worsens swelling; urinalysis assesses for rhabdomyolysis.