Identifying Client Statements in Nursing Case Studies for Health Education, Exercises of Nursing

Download Identifying Client Statements in Nursing Case Studies for Health Education and more Exercises Nursing in PDF only on Docsity! 1 D CAPSTONE MED SURG 1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching? It delivers a present amount of airway pressure throughout the breathing cycle 2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Shortness of breath might be an indication of transplant rejection 3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1.020 4. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? You should avoid taking corticosteroids prior to testing 5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol 1 D 6. A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the clients plan? Select all that apply. Monitor blood glucose levels Maintain NPO status until pain-free Manage acute pain 1 D 14.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance .Which of the following statements should the nurse make? It could be helpful for you to attend a support group for people who have burn injuries. 15.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan? Monitor the client skin under the halo vest. 16.A nurse is caring for a client who has a traumatic brain injury. Which of the following finding should indicate to the nurse the need for immediate intervention? Respiratory rate 30/min 17.A nurse is assessing a client who has meningitis. The nurse should identify which of the following finding as a positive Kerning s sign? After stroking the lateral area of the foot, the client’s toes contract and draw together. After hip flexion, the client is unable to extend their leg completely without pain 18.A nurse is teaching a group of assistive personnel (AP) about caring for client who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching? Provide supervision to prevent a client from becoming injured or lost. 1 D 19.A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching? Keep a padded tongue blade near the bedside. Place a pillow under the client's head while in bed during a seizure. Administer diazepam orally at the onset of seizures. 1 D Position the client on their side during a seizure. 20.A nurse is contributing to the plan of care for a client who has pyelonephritis. Which of the following interventions should the nurse include? Encourage the client to consume caffeinated beverages Avoid the use of acetaminophen for discomfort Monitor the clients the urine for color changes Begin antibiotic therapy after culture and sensitivity results are obtained 21.Nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect? The client reports relief from pain when lying in the prone position. The client reports that her low-back pain radiates upward toward one scapula. The client reports tingling and a burning sensation in one foot. The client reports decreased pain when the affected leg is raised and straightened 22.A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offered the client? Lemonade Tomato soup Gelatin Black coffee 1 D Establish a predictable daily routine for the client. Remind the client of scheduled activities 1 day in advance. 27.A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO 29 mm Hg, and HCO 25 mEq/L. The nurse 1 D should recognize that the client has which of the following acid-base imbalances? 2 3 – Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 28.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during mealtime 29.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side 30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to present transmission of the disease? 1 D Contact precautions Airborne precautions Droplet precautions Protective environment 1 D 35.A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of oce workers. Which of the following instructions should the nurse include? (Select all that apply.) "Raise your chair height so that you lean over to type." "Use a wrist rest when working at a computer station." "Stretch your ngers and wrists periodically while working." "Position your keyboard at shoulder height." "Take breaks from the repetitive activity." 36.A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect? Tracheal deviation to the unaffected side Pleural friction rub Frothy, pink-tinged sputum Increased breath sounds on the affected side 37.A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine 38.A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching? 1 D "I will keep the tablets in the original container." "I should keep the container in my shirt or pants pocket." "I should begin to feel relief within 20 minutes of taking the medication." "I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my pain." 1 D 39.A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take? Review the client's Hgb level prior to administration. Use the Z-tract method when administering the medication. Shake the vial for 30 seconds prior to withdrawing the medication. Ensure the client is not taking iron supplements while on this medication. 40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately? Decreasing leg strength Decreasing voice volume Decreased deep tendon reflexes Decreased sensation in the arm 41.A nurse is assessing a client who has Addison's disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis? Hypothermia Increased deep tendon reflexes Hypotension Erythema of the neck and chest 42.A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority? Provide assistance with ambulation. Facilitate retention of facts by repeating instructions. Place the client in a darkened room. Speak slowly and clearly. 1 D 47.A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus? Urine ketones Hyperglycemia • Halo or ring-shaped dressing drainage Low urine specic gravity 1 D 48.A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling "a migraine coming on." The nurse should expect the client to report which of the following manifestations? Visual disturbances • Photophobia Nasal congestion Phonophobia 49.A nurse is reviewing laboratory values for a client who has Cushing's disease. Which of the following values should the nurse expect? Blood glucose 65 mg/dL • Serum calcium 12.2 mg/dL Potassium 5 mEq/L Sodium 150 mEq/L 50.A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect? Expressive aphasia • Poor impulse control Left hemiparesis Disorientation to place 51.A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.) Bradycardia Vomiting 1 D Drainage from the ear para mi Unequal pupils Pruritus 52.A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching? 1 D "I will allow him to assume a position of comfort." "I will elevate the head of the bed 10 degrees." "I will place him in a left side-lying position." "I will sit him up in bed." 57.A nurse is teaching a client who has asthma about using a peak ow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions? Take another peak ow meter reading in 15 min. Take prescribed relief medication. Call for emergency transport to a hospital. Inhale through pursed lips. 58.A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence? Stress Urge Functional Overow 59.A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effect of the medication? Alopecia Yellowing of the sclera Report of constipation Report of insomnia 1 D 60.A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dyslexia? Monitor bowel movement regularity. Use a fan to promote air circulation in the client's room 1 D Tuck the top bedsheet tightly around the client's torso. Monitor for cerebrospinal fluid leakage 61.A nurse is caring for a client who is using a ventilator when the low- pressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube. Check the ventilator tubing connections. Administer intravenous sedation and analgesia. Reassure the client and instruct them not to bite on the tube. 62.A nurse is caring for a client who has renal calculi. Which of the following prescriptions by the provider is the priority action for the nurse to take? Strain all urine. Schedule a retrograde pyelography. Monitor intake and output. Schedule a kidney ultrasound. 63.A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? "When I'm exercising, I'll include bent-leg raises." "I'll use my reaching device to help me pick up objects I drop on the oor." "I can stop physical therapy when I quit using my walker." • "I'll sleep on my back with my knees close together." 1 D A client who is being admitted with bilateral Stage 3 pressure injuries on both heels A client who has a systemic infection and an oral temperature of 39.1° C (102.4° F) 1 D 69.A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A? A client who is hepatitis B positive A client who had a kidney transplant in 1990 A client who has a history of intravenous street drug use A client who has recently done volunteer work in a developing country 70.A nurse is providing education regarding the prevention of urinary tract infections (UTIs) to a client who has a history of cystitis. Which of the following statements by the client indicates that the teaching has been effective? "I will limit my fluid intake to 1 liter per day to prevent frequency and urgency." "I will empty my bladder every 2 to 3 hours throughout the day." "I will use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth." "I will take a hot bath after sexual intercourse." 71.A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include? "Tube drainage should be rust-colored." "Nutrition will be provided through the tube." Para mi "The tube decreases pressure within the stomach." "The tube should be irrigated with sterile water." 1 D 72.A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following precautions should the nurse take? (Select all that apply.) Keep a suction apparatus at the bedside. Keep a padded tongue blade next to the bed. Keep the bed in the lowest position. Keep oxygen equipment at the bedside. Keep safety restraints near the bedside. 1 D Place the client in a Sims' position. Keep the client's neck in a midline position. Maintain exion of the client's hips at a 90° angle 78.A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? Apply an ice pack directly to the affected area. Immobilize the affected extremity with a splint. Place a tourniquet above and below the affected area. Elevate the affected extremity 79.A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? "This medication can cause your urine to turn a dark color." "Expect immediate relief after taking this medication." "Take the medication with a high-protein food." "Skip a dose of the medication if you experience dizziness." 80.A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend? Low-potassium diet High-ber diet Low-fat 1 D diet Low-sodium diet 81.A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching? 1 D "I should not wash my hair prior to the procedure." "I will receive a sedative 1 hour before the procedure." "I should avoid eating prior to the procedure." "I will be exposed to ashes of light during the procedure." 82.A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection. The surgical site will heal in 3 to 4 weeks after surgery. Begin 45 min of moderate aerobic exercise per day following discharge 83.A nurse is caring for a client who has been experiencing repeated tonic- clonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer? Diazepam IV Lorazepam PO Diltiazem IV Clonazepam PO 84.A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? "I should take my medicine with orange juice." "A bedtime snack will prevent heartburn." 1 D 88.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan? 1 D Inspect the pin site every 48 hr. Monitor the client's skin under the halo vest. Ensure two personnel hold the halo device when repositioning the client. Apply powder frequently to the client's skin under the vest to decrease itching. 89.Nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration? Pitting edema of bilateral lower extremities Hypoactive bowel sounds in all four quadrants Weight is the same as the day before Bilateral posterior lung sounds are diminished 90.A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer? Lidocaine Adenosine Atropine Verapamil 91.A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate? 1 D Respiratory therapy Hospice care Occupational therapy 1 D 95.A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries? Flail chest Hemothorax Pulmonary contusion Pneumothorax 96.A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following ndings should the nurse expect? Decreased deep-tendon reexes Positive Trousseau's sign Hypoactive bowel sounds Sticky mucous membranes 97.A nurse is providing teaching to a client who is scheduled for electromyography (EMG). The nurse should include which of the following information in the teaching? "You will receive a xed dose of radioisotope 2 hours before the procedure." "Momentary ushing will occur at the beginning of the procedure." "You should inform your provider if you are claustrophobic." "You should expect insertion of small needle electrodes into the muscles." 1 D 98.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. 1 D Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during meal time. 99.A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hr ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) ✓ Use an electric shaver. ✓ Avoid crowds. Take temperature weekly. ✓ Consume a low-residue diet. ✓ Monitor for bruising. 100. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10. Administer oxygen to a client who has an oxygen saturation of 91%. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery. 101. A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?