Exam 1: Changes in Health

A client is rushed to the emergency department after demonstrating signs of acute myocardial infarction. History reveals that the chest pain has not been resolved by sublingual nitroglycerin. The client is started on tissue plasminogen activator by infusion. The nurse caring for the client frequently assesses which of the following parameters?

A nurse is giving medication instructions to a client who has been prescribed phenytoin. Which of the following statements, if made by the client, indicates a need for further teaching about taking phenytoin?

A client comes to the emergency department complaining of dyspnea and has a respiratory rate of 30 breaths per minute. The client receives a diagnosis of pneumonia. Which of the following is the initial action of the nurse?

A nurse would see which of the following clients first?

A female client was admitted to the gastrointestinal unit two days ago. The client has been demonstrating signs of decline in gastrointestinal function for the past day and is now ordered to be transferred to the intensive care unit. Before the transfer, which of the following should the nurse do first?

A newlyadmitted male client in an acute manic state kisses a female nurse and asks her to go on a dinner date with him. The nurse's best response is to:

Bandes is a 34 year-old sales agent who has chronic low back pain. He has been taking ibuprofen intermittently for the past two years. Two days ago he experienced shooting pain from the lower back and into the buttocks and left leg. He was admitted to the facility for medical management. During the afternoon shift, he complains of mild but persistent headache. The client appears to be irritable. To ease Mr. Bandes's headache and discomfort, nursing care should include:

Kelly, a nullipara at 34 weeks' gestation, comes to the emergency department saying, "I think I'm about to go into labor." After assessing the client, the nurse alerts the physician for a possible case of pre-term labor. The nurse then initiates nursing interventions that aim to manage pre-term labor. Which of the following findings would be most likely to lead the nurse to suspect pre-term labor?

Simon, a client with a history of congestive heart failure, complains of shortness of breath. He cannot tolerate lying flat on the bed. Physical examination reveals accumulation of fluid in the left lung. Thoracentesis is ordered. The client must be placed in which of the following positions during the procedure?

A physician orders the removal of the client's nasogastric tube. The nurse would instruct the client to do which of the following during tube removal?

An 18-year-old male was admitted to the unit after sustaining a head trauma during a football game. The nurse caring for the client recognizes the client's greater risk for increased intracranial pressure. Which of the following findings should alert the nurse as it is the earliest indication of increasing intracranial pressure?

Andrea, a 23-year-old female, comes to the clinic for her second pre-natal examination. On physical assessment, bluish discoloration of the mucus membranes of the cervix, vagina, and vulva is noted. This probable sign of pregnancy is called:

The physician orders the attachment of a client's nasogastric tube to intermittent suction. The nurse attaches the suction, keeping in mind that the pressure should not exceed: