A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
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Solution
Ineffective health maintenance
Option A: Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
Nurse Maureen would expect a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
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Solution
Pulmonary
Option D: When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.
Nurse Hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
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Solution
Myocardial damage
Option B: Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
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Solution
Elevate the scrotum using a soft support
Option C: Elevation increases lymphatic drainage, reducing edema and pain.
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
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Solution
Distention of the lower abdomen
Option B: This indicates that the bladder is distended with urine, therefore palpable.
Kenneth who was diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
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Solution
Flapping hand tremors
Option A: Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
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Solution
Cottage cheese
Option D: One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
Nurse Maureen knows that the positive diagnosis of HIV infection is made based on which of the following:
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Solution
Positive ELISA and western blot tests
Option B: These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
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Solution
Increase the flow of normal saline
Option A: The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
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Solution
Steroids
Option C: Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.