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Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:
- A. Assess the urine output
- B. Place a large bore I.V.
- C. Position onto the left side
- D. Insert a nasogastric tube
Correct Answer: B
Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.
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A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
- A. Dehydration.
- B. Post-dural puncture headache.
- C. Hypertension.
- D. Migraine exacerbation.
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved:
- A. Functional ability.
- B. Emotional stress.
- C. Alertness.
- D. Appetite.
Correct Answer: A
Rationale: Pallidotomy aims to improve functional ability by reducing symptoms like tremors and rigidity. Emotional stress, alertness, and appetite are not primary targets of this procedure.
The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for:
- A. Lymphadenopathy.
- B. Hyperplasia of the gums.
- C. Bone marrow expansion.
- D. Shortness of breath.
Correct Answer: D
Rationale: CML causes an overproduction of white blood cells, leading to symptoms like fatigue, splen enlarge, and shortness of breath due to anemia or hyperviscosity. Shortness of breath is a common finding to assess. Lymphadenopathy, gum hyperplasia, and marrow expansion are less typical.
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse take next?
- A. Press the emergency alarm to call the resuscitation team.
- B. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.
- C. Have all visitors and family leave the room.
- D. Call the surgeon to come to the client's room immediately.
Correct Answer: B
Rationale: Covering exposed intestines with sterile, moist dressings prevents infection and drying of tissues, stabilizing the situation until surgical intervention. This is the immediate priority.