A 53-year-old was admitted for treatment of Guillain-Barré syndrome (GBS). Prioritize these nursing diagnoses:
1. Ineffective airway clearance
2. Risk for emotional distress
3. Fluid volume deficit
4. Potential for injury
• Remember your ABCs- Airway, Breathing, Circulation. Priority is given to the airway of a patient with GBS. The condition involves muscles weakness which can lead to respiratory muscle paralysis, making the patient unable to cough effectively
• The patient with GBS is at high risk if he/she is unable to cough effectively to clear the airway or has difficulty swallowing. This can cause aspiration of saliva and precipitate acute respiratory failure
• Fluid volume ("Circulation") may become a problem later on as muscle paralysis may lead to low blood pressure, but this is not the top priority
• The patient may be at risk for injury due to the inability to use the muscles to protect oneself, but this is once again not the top priority
• Emotional distress would be lowest priority, after the physiological and safety needs have been addressed
The nurse is caring for a patient who underwent a thyroidectomy. Which of the following items should the nurse keep at the patient's bedside?
The nurse is caring for a patient with Cushing's syndrome. The nurse should instruct the patient to:
When caring for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), the nurse anticipates which electrolyte abnormality characteristic of this disease?
A nurse is preparing discharge instructions for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which of the following should the nurse include in the discharge instructions?
A patient returns to the surgical unit after undergoing a transurethral resection of the prostate (TURP). The nurse prepares for continuous bladder irrigation using:
A patient is seen in the emergency department for symptoms of severe acute respiratory syndrome (SARS). The nurse initiates what type of isolation precautions?
A patient with herpes zoster (shingles) is concerned about spreading the infection to her husband. Which of the following statements is true regarding the spread of shingles?
A patient is seen in the emergency department after a bee sting caused bronchospasms and severe pruritis. The nurse understands that this type of hypersensitivity reaction is:
The nurse is interviewing a patient suspected of having systemic lupus erythematosus (SLE). Which of the following features of SLE is correct?
The nurse is caring for a woman with human immunodeficiency virus (HIV) considering having a child. Which of the following statements is false?
The patient is to undergo insertion of a chest tube. Which statement shows that the patient needs further teaching?
The nurse is caring for a patient with urolithiasis. The patient needs to be evaluated to determine the type of stone before treatment can begin. The nurse would use which of the following to assist this process?
The nurse is reviewing the x-ray of a patient with a fractured femur. The x-ray shows a fracture through the shaft with multiple bone fragments. What type of fracture is this?
The nurse is assessing the hepatojugular reflux in a patient with congestive heart failure. To perform this assessment technique correctly, the nurse should:
The nurse is caring for a patient with a closed ulna fracture after the application of a cast. After the patient complains of severe pain, the nurse administers an analgesic and applies an ice pack. When the patient states that the medication provided no relief, the nurse should be alert to the possibility of:
The nurse is providing interventions to a patient with a deep vein thrombosis (DVT). Which of the following interventions should be avoided?
An elderly woman with rheumatoid arthritis informs the nurse that most of her friends have osteoarthritis and asks what the difference is between the two diseases. The nurse should understand that:
The nurse assesses a patient complaining of chest pain that radiates down the left arm. He looks diaphoretic and short of breath. What should the nurse do next?
A female student is seen by the school nurse who suspects cystitis. Which of the following symptoms would support the nurse's diagnosis?
A patient is admitted to the hospital after his urinalysis showed significant proteinuria. The nurse determines that the patient is suffering from nephritic syndrome, rather than nephrotic syndrome, because of:
A patient with chronic renal failure is being evaluated for peritoneal dialysis. Which of the following comorbidities would make peritoneal dialysis the treatment of choice?
The nurse is examining a patient at an internal medicine clinic. Which of the following clinical manifestations would support a diagnosis of systemic lupus erythematosus (SLE)?
The nurse is assessing a patient after she underwent a renal arteriogram. The nurse is palpating the right groin access site for complications when the patient suddenly complains of right calf pain. What should the nurse do first?
The nurse is providing discharge instructions to a patient with a nasogastric (NG) tube. If the NG tube becomes clogged, the nurse should instruct the patient to:
A patient is being evaluated for abdominal pain. The nurse elicits Murphy's sign, or pain in the right upper quadrant along the costal margin. A positive Murphy's sign is indicative of:
A patient with dark skin is experiencing respiratory distress due to an asthma exacerbation. The nurse assesses the patient for cyanosis by inspecting the:
A patient with chronic renal failure will have lab work to evaluate his kidney function. The nurse knows that which of the following are most accurate in predicting kidney function?
The nurse is admitting a patient suspected of having an acute myocardial infarction. The physician orders lab tests to confirm the diagnosis. An increase in the isoform of creatine kinase (CK-MB) is expected how soon after the onset of chest pain?
A patient walks into the emergency department after being bitten by a deer tick. The patient is nervous about Lyme disease. The nurse informs the patient that:
The nurse is caring for a patient with a GI bleed who is short of breath but has clear lung sounds and an oxygen saturation of 98%. Which of the following is the most probable cause for the patient's symptoms?
The nurse is caring for a patient with thrombocytopenia who has developed epistaxis. In order to stop the bleeding, the patient should:
A patient has developed pyelonephritis after being treated for a UTI. Which of the following interventions is most important?
The nurse is infusing blood products into a patient with anemia. The patient suddenly complains of itching and chest pain. The nurse notes urticaria and hypotension. Which type of hypersensitivity reaction is occuring?
One of the primary interventions for promoting and maintaining fluid balance is client teaching. Select all appropriate health teaching a nurse must include in the care plan.
The nurse is assessing a patient with type 1 diabetes mellitus. The patient is confused and light-headed. The nurse should administer:
A nurse is assessing a patient's goiter. Which should she consider doing for the most accurate assessment?
The nurse is performing a physical assessment on a patient after undergoing a total knee replacement. Which of the following findings requires the nurse to notify the physician?
The nurse who is caring for an older client with severe dehydration knows that the best indicators of hydration status are:
A patient with Cushing's syndrome is being treated in the hospital. Which of the following is an appropriate nursing intervention to help prevent complications?
A nurse is providing education to a patient recently diagnosed with psoriasis. Which of the following is not a component of typical psoriasis treatment?
A nurse is caring for a client with gastroenteritis and is documenting the clinical manifestations indicating dehydration. What would indicate the patient is dehydrated?
A patient was involved in
A client who was diagnosed with colorectal cancer received radiation therapy during the course of his treatment. The nurse explains the uses of radiation therapy by saying it may be used as:
The nurse is reviewing the treatment plan for a patient with pernicious anemia. Which of the following statements regarding treatment is correct?
A patient has just been diagnosed with osteoarthritis and is instructed to take an NSAID to manage pain and inflammation. Which of the following health care professionals should be consulted to help manage the patient's condition?
The nurse is assessing a 66-year-old patient with osteoarthritis. The patient also has a history of emphysema and Raynaud's phenomenon. The nurse would expect to observe which of the following symptoms?
A 72-year-old patient verbalized that he has very loud, overpowering ringing in both ears, intermittent hearing loss on the right side, and severe vertigo with nausea. The nurse assessing the patient suspects that he has:
A patient is seen in the emergency room for a myocardial infarction. The patient's chest pain began around 11 AM after doing morning chores. By 1 PM, the pain did not improve, so his wife drove him to the emergency room. The nurse anticipates that the physician will order:
The nurse is caring for a patient she suspects has pulmonary edema. The nurse notes bilateral crackles, orthopnea, edema, and shortness of breath. After notifying the physician, the nurse should avoid which of the following while waiting for the physician to arrive?
The goal of nursing care management in a client with osteoarthritis is
The nurse is assessing a patient for coronary artery disease (CAD) risk factors. Which of the following modifiable risk factors has the most impact on the development of CAD?
The nurse is providing
The nurse is assessing a patient with a stable abdominal aortic aneurysm (AAA). The nurse should suspect an extending aneurysm when she notes:
The nurse is providing medical information to an adult patient with amyotrophic lateral sclerosis (ALS). The patient understands the nature of the disease if he or she asks which of the following questions?