The nurse is performing a physical assessment on a patient with an aortic dissection. Which of the following should the nurse avoid during the physical assessment?
• Deep palpation of the abdomen may cause aortic rupture. The nurse should never perform deep palpation on a patient with an aortic dissection or AAA
• Incorrect: The nurse should inspect the abdomen for ecchymosis, including turning the patient toward the side to inspect the back for any ecchymosis
• Incorrect: The nurse should also auscultate the aorta for bruits
A patient with secondary hyperparathyroidism questions the nurse regarding the need for adequate vitamin D intake. The nurse understands that vitamin D is necessary for the parathyroid hormone to exert its effects because:
A 60-year old woman was diagnosed with breast cancer and has been treated for 5 years. She is considered at high risk for recurrence but currently shows no evidence of the disease. She is a candidate for adjuvant chemotherapy. Which among the following are chemotherapeutic agents?
A patient is admitted to the hospital for an acute exacerbation of heart failure. The nurse questions the patient about his medical and social history. Which of the following would not contribute to this patient's exacerbation?
The nurse is explaining risk factors of heart failure to a client. Which of the following risk factors are considered extrinsic factors?
The nurse is assessing a patient with coronary artery disease who has been hospitalized for 3 days. The nurse notes 3+ edema of the bilateral lower extremities and crackles in the lungs. Which of the following should the nurse do next?
The nurse suspects that a patient has developed a deep vein thrombosis (DVT). To validate the suspicion, the nurse uses what test?
A patient who was admitted to the medical ward has a fever of 103˚ F, nuchal rigidity, pain on extension of the legs, and opisthotonos. Based on these findings, prioritize these nursing diagnoses:
1. Altered comfort: pain
2. Altered cerebral perfusion
4. High risk for injury
A patient has just returned to the nursing unit after undergoing a cardiac catheterization. Which of the following nursing interventions should the nurse perform first?
The nurse is assessing an elderly patient suspected of having a fractured left hip after falling onto the ground. The nurse would expect to note which of the following?
A client diagnosed with decompensated heart failure has the nursing diagnosis of risk for anxiety related to fear of death or debilitation. What nursing interventions will help alleviate anxiety?
A 35-year-old patient with an infratentorial craniotomy for a brain tumor was newly admitted to the ICU. Which of the following should the nurse include in the care plan?
After undergoing a cardiac catheterization, the patient returns to the nursing unit. After assessing the femoral insertion site, the nurse should avoid:
The nurse is reviewing the x-ray of a patient with a fractured tibia. The x-ray shows a fracture diagonal to the bone's long axis. What type of fracture is this?
The nurse is reviewing a physician's note describing the patient's pressure ulcer as stage III. What characteristics would the nurse expect to observe?
A newly admitted patient has sustained deep partial-thickness burns to his face and trunk. Which of the following abnormal values can the nurse expect during the emergent phase?
The nurse is caring for a patient that just underwent a bronchoscopy. The nurse should do which of the following interventions?
While providing discharge instructions to a patient with systemic lupus erythematosus (SLE), the nurse should include which of the following statements:
The nurse is caring for a patient admitted for diabetes insipidus. During the physical assessment, the nurse should expect to note which of the following?
A 5-year-old is being treated for scabies. While reinforcing instructions to the patient's mother, the nurse should include which of the following information?
The nurse is assessing a patient with systemic lupus erythematosus (SLE). Which of the following would the nurse expect to note?
A nurse educator is teaching a group of diabetic patients to perform proper foot care. Diabetics are susceptible to foot problems, especially when sanitary conditions are poor. Which of the following are correct instructions for proper foot care?
The nurse is writing a care plan for a client with symptomatic Paget’s disease. Which of the following interventions should be included to help the patient's symptoms?
The nurse is caring for a patient with an adenoma of the adrenal cortex. The nurse should be alert for symptoms related to the secretion of which substance?