Nursing Questions

An 85-year-old client is bought to the emergency department after a fall at home. The client appears confused, malnourished, and is severely dehydrated. The client appears reluctant to explain how the fall happened. The client's daughter speaks for the client and does not allow the client to answer questions. Based on this information, which nursing intervention is a priority?Interview the client alone and assess for abuse. Take the history from the daughter because the client is confused. Provide the daughter with nutritional counseling. Request a psychiatric evaluation for the client.

he nurse reviews the Patient Bill of Rights with a client on admission, and then uses a patient-centered care model throughout the admission assessment nursing process. Which Bill of Right aspect is the nurse protecting? Safe, private care. Assistance with discharge arrangements. Assistance with financial responsibilities. Care planning participation.

The nurse assesses a client's bowel sounds. The nurse listens to all four quadrants of the abdomen over one full minute and does not detect any audible sounds. What should the nurse do next?Gently palpate the abdomen for distention. Document the absence of bowel sounds. Assess for the presence of rebound tenderness. Continue to listen for the presence of bowel sounds.

uring a routine assessment, the nurse plans to assess a client for vertigo. Which assessment technique should the nurse use?Listen for changes in speech patterns. Measure blood pressure while standing. Assess orientation to person, place, and time. Ask about sensations of spinning around.

When counseling a family about a loved-one diagnosed with dementia, it is most important that the nurse address which concern with the family prior to discharge?Ineffective thermoregulation. Suicidal thoughts. Impaired skin integrity. Self-care deficit.

A client with pneumonia is brought to the emergency department with a history of not taking their medication for hypothyroidism and is suspected to have myxedema coma. Which expected outcome should the nurse expect to find during assessment?Diarrhea. Poor memory. Heat intolerance. Manic behavior.

The nurse is assessing a client with stage 4 chronic kidney disease and partially compensated metabolic acidosis. Which arterial blood gas result should the nurse anticipate?PaCO2 26, HCO3 19, pH 7.30. PaCO2 52, HCO3 24, pH 7.25. PaCO2 41, HCO3 20, pH 7.38. PaCO2 42, HCO3 25, pH 7.40.

Which medication should the nurse anticipate will be prescribed for a client diagnosed with Parkinson's disease? Carbidopa/levodopa. Chloroquine. Sulfasalazine. Sulfamethizole.

An arterial blood gas (ABG) analysis is drawn for a client. The results show pH of 7.30; PaCO2 of 68 mm Hg and an HCO3 of 24 mEq/L. What should the nurse interpret this blood gas as?Compensated metabolic alkalosis. Uncompensated respiratory acidosis. Compensated metabolic acidosis. Uncompensated respiratory alkalosis.

The community health nurse is assessing an older client and notices that the client walks with short, hesitant steps. The client walks with a slow, shuffling motion and with very little arm movement. At rest, the client has tremors. The nurse also notes that the client speaks in a very soft, low-pitched voice and has difficulty finding the right words. Which condition most likely explains the client's behaviors? Fibromyalgia. Polyneuropathy. Parkinson's disease. Wernicke-Korsakoff Syndrome.

A client status-post 48 hours external fixation placement of their (L) femur suddenly becomes anxious and restless. Assessment findings include increased RR to 28 breathes/minute and HR to 110 beats/minute; (L) foot and toes are pink and warm to touch; capillary refill is +2, with slight swelling present and a slight macular rash present on the client's upper arms, chest and neck. Based on their presenting clinical signs and symptoms which condition is the client most likely experiencing? Acute osteomyelitis. Post-traumatic stress. Fat embolism syndrome. Compartment syndrome.

A client is having a surgical procedure to relieve their lower back pain caused by a herniated disk. Which surgical procedure if repeated several times may necessitate the client to have a spinal fusion?Allografts. Diskectomy. Laminectomy. Laser thermodiskectomy.

A 28-year-old client is exhibiting signs and symptoms of confusion, severe muscle weakness, tachycardia and hypotension and episodic of vomiting and constipation. The client has asthma and has been prescribed prednisone (Rayos, Winpred) and albuterol inhaler for the past year. Their vital signs are T- 97.8° F (36.6° C); P- 90; B/P 86/48 with lab values of sodium 130mmol/L; potassium 5.9mmol/L and calcium 10.3mg/dL. Which condition is the client most likely experiencing? What have you eaten in the last 24 hours? How often do you have to use your albuterol inhaler? Are you currently taken any SSRI's or MAOIs medication? When was the last time you took the prednisone medication?

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?Observe gait while walking. Assess for spinal scoliosis. Palpate for joint nodules. Compare shoulder symmetry.

The nurse is assessing a client with history of plaque psoriasis. Which medication has most likely been prescribed for this client?Minoxidil (Rogaine). Ustekinumab (Stelara). Miconazole nitrate (Lotrimin AF). Benzoyl perioxide (Clean and Clear).

When teaching a client about irritable bowel syndrome (IBS) with constipation, which dietary instructions should the nurse include? Avoid high fiber foods. Drink fruit juices. Increase cruciferous vegetables. Consume fiber supplements.

The clinic nurse receives a call from a client who is at 32 weeks' gestation. The client states, "I'm having some pain and burning when I urinate." Which action should the nurse take? Suggest the client increase her fluids until the symptoms subside. Instruct the client that these symptoms often occur in pregnancy. Advise the client to come to the clinic immediately for further evaluation. Reinforce perineal hygiene with the client.

The nurse is caring for a client who takes carbidopa/levodopa for treatment of Parkinson's symptoms. What side effect of this medication should the nurse be aware of when helping the client ambulate?Shortness of breath. Incontinence. Syncope. Uncontrolled bleeding.

A client presents with pain that extends from the midepigastric region and radiates posteriorly to the right shoulder blade. Which condition should the nurse suspect?Cholecystitis. Appendicitis. Diverticulitis. Renal calculi.

The critical care nurse is completing a physical assessment on a client admitted with diabetic ketoacidosis. Which assessment finding should the nurse anticipate?Cool, clammy skin. Hypertension. Kussmaul respirations. No change in LOC.