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The nurse is discussing discharge plans with an older adult client who lives alone and has left sided weakness following a stroke
Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individual who have had a stroke
- B. obtaining an alert system to get help in case of a fall
- C. providing information about available transportation resources
- D. choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: obtaining an alert system to get help in case of a fall. This is the priority for the nurse to discuss because falls can lead to serious injuries, so having a system in place to quickly get help is crucial for the patient's safety. Reviewing support groups (A) is important but not as urgent as fall prevention. Transportation resources (C) and home physical therapy agency (D) are important but secondary to immediate safety concerns.
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A nurse is caring for a client in an outpatient clinic.
Laboratory Results
First office visit:
Erythrocyte sedimentation rate (ESR) 21 mm/hr (up to 20 mm/hr)
Hct 36% (37 to 47%6)
Hgb 12 g/dL (12 to 16 g/dL)
WBC count 6000/mm³ (5,000 to 10,000/mm³)
Uric acid 6.1 mg/dL (2.7 to 7.3 mg/dL)
6-month follow-up:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Antinuclear antibodies (ANA) positive
Hct 35% (37 to 47%)
Hgb 11 g/dL (12 to 16 g/dL)
WBC 4000/mm³ (5,000 to 10,000/mm³)
Uric acid 6,3 mg/dL (2.7 to 7.3 mg/dL)
The client is at highest risk for developing--------- evidenced by the client's--------
- A. Rheumatoid arthritis
- B. decreased Hct and Hgb levels
- C. ESR level
- D. Systemic lupus erythematosus
- E. Anemia evidenced by the client's
- F. Gout evidenced
- G. decreased WBC count
Correct Answer: D,G
Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.
A nurse is reviewing the medical records of four clients.
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who received a Mantoux test 48hr ago and has an induration
- B. A client who is schedule for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8(low INR clotting)
- D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.
Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care. Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care. Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L
A nurse is caring for a client
History and Physical
Day 1,0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean, appears to be listening to unseen others. Skin turgor poor.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
Vital Signs
Day 1, 0905:
Temperature 37.1° C (98,8° F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Select the 4 findings that require immediate follow up
- A. Hallucinations
- B. Heart rate
- C. Sleep patterns
- D. Skin turgor
- E. Hygiene
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Hallucinations (A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (B) could signify a cardiac problem. Disrupted sleep patterns (C) may indicate underlying health conditions. Reduced skin turgor (D) can signal dehydration or malnutrition. Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.
A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
A nurse is caring for a client who is postoperative following a liver biopsy.
In which of the following positions should the nurse place the client immediately following the procedure?
- A. Trendelenburg
- B. Prone
- C. Right lateral
- D. High-fowlers
Correct Answer: C
Rationale: The correct answer is C: Right lateral. Placing the client in the right lateral position immediately following a procedure helps prevent aspiration of secretions or blood, as gravity assists in drainage from the airway. Trendelenburg position (A) is used to increase venous return but is not appropriate post-procedure. Prone position (B) is lying face down and may obstruct airway patency. High-fowlers position (D) is sitting upright at a 90-degree angle, which is not ideal for immediate post-procedure care.