A 58-year-old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care?
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Solution
Maintaining usual ways of accomplishing task
Option B: The nurse should focus more on developing less stressful ways of accomplishing routine task.
A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment?
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Solution
Measuring urine output hourly
Option D: Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.
A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal?
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Solution
Red blood cells
Option A: The adult with normal cerebrospinal fluid has no red blood cells.
Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?
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Solution
Metabolic alkalosis
Option D: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.
Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present?
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Solution
Thick and immobile tympanic membrane
Option B: Otoscopic examination in a client with mastoiditis reveals a dull, red, thick and immobile tympanic membrane with or without perforation.
The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of infection?
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Solution
Presence of “hot spot” on the cast
Option D: Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others.
A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture?
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Solution
“Is the pain sharp and continuous?”
Option A: Fractured pain is generally described as sharp, continuous, and increasing in frequency.
A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to report?
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Solution
Night sweats
Option C: Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.
The nurse is assessing a client with pleural effusion. The nurse expects to find:
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Solution
Reduced or absent of breath sounds at the base of the lung
Option B: Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is:
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Solution
Respiratory movement
Option C: There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.