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Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
- A. Husky voice and complaints of hoarseness.
- B. Warm, soft, moist, salmon-colored skin.
- C. Visible swelling of the neck, with no pain.
- D. Central-type obesity, with thin extremities.
Correct Answer: D
Rationale: Central-type obesity with thin extremities is a hallmark of Cushing's syndrome due to cortisol-induced fat redistribution and muscle wasting, making it a key finding to document.
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After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Avoiding high-fat foods like whole milk and ice cream prevents exacerbation of cholecystitis, demonstrating effective understanding of dietary restrictions.
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Apical heart rate of 100 to 110 beats/minute.
- B. Redness and edema noted at the incision site.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 1 to 10.
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.
An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?
- A. Teach the client relaxation techniques.
- B. Determine the client's food preferences.
- C. Maintain a patent intravenous site.
- D. Keep room temperature cool.
Correct Answer: C
Rationale: Maintaining a patent IV site allows administration of fluids, electrolytes, and nutrients, addressing the critical dehydration and malnutrition in Grave's disease, which takes precedence over other supportive measures.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.