. Which laboratory finding alerts you to the possibility of an acute bacterial infection? A. number and percentage of macrophages are not listed. B. total white blood cell count is 19,000/mm3. C. neutrophils outnumber the lymphocytes. D. monocytes are 2% of the total count.
The nurse assesses a high eosinophil count in a pediatric patient. The nurse recognizes that this elevation is an indicator of ____________________.
For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administering aspirin if the temperature exceeds 102° F (38.8° C) B. Inspecting the skin for petechiae and bleeding once every shift C. Providing for frequent rest periods D. Placing the client in strict isolation
Which situation or factor represents a modifiable variable that influences the client’s tolerance of pain? A. Age and gender B. Anxiety and fear C. An introverted personality D. Previous pain experience
Mr. Y is isolated because he has pulmonary tuberculosis. The nurse notes that the client seems angry but knows this is a normal response to isolation. The best intervention is to: A. Provide a dark, quiet room to calm the client. B. Explain the isolation procedures and provide meaningful stimulation. C. Reduce the level of precautions to keep the client from becoming angry. D. Limit family and other caregiver visits to reduce the risk of spreading the infection.
For a female client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client? A. “Client will verbalize feelings of anxiety.” B. “Client will not guess at prognosis.” C. “Client will use any effective method to reduce tension.” D. “Client ill stop seeking information.”
What question by you, the nurse, would best assess a client’s pain tolerance? A. “Do you take pain medication frequently?” B. “How intense is the pain you feel right now on a scale of 1 to 10?” C. “What activities help distract you so that you do not feel the need for medication?” D. “At what point, on a scale of 0 to 10, do you feel that you must have pain medication?”
Mr. R., a 45 year-old client undergoing chemotherapy, telephones the clinic to complain of a nosebleed. His last treatment was 2 days ago. Select the most appropriate nursing diagnosis for Mr. R. A. altered nutrition less that body requirements B. high risk for injury related to low platelet count C. self-image disturbance related to effects of chemotherapy D. pain related to pressure from the cancerous tumor
When a client is receiving radiation therapy, the skin over the radiated area is inspected daily for signs of A. redness, ulceration, and infection B. tumor regression C. dryness, hair loss, and scaling D. radioactivity
A client has a PCA (Patient Controlled analgesia) and is receiving morphine for postoperative pain control. When you enter the room, the client is complaining of pain. What should you do? A. Call the physician for further orders B. Speak to the client in a quiet tone of voice and reassure the client that the pain will ease C. Increase the amount of morphine administered to the client D. Assess the client and ask him to describe the pain
. If an analgesic is not administered promptly and pain is allowed to reach maximum intensity A. the client may find that the pain begins to decrease in intensity B. hypertension and bradycardia may be seen C. the analgesic will not be as effective as when it is given before the pain becomes intense D. the analgesic will be more effective if the client waits until he really needs it
For a 5 year old male diagnosed with a fractured ankle what kind of pain scale should be used?
What the most important nursing activitiy performed prior to the administration of a narcotic analgesic?
Mr. Loss, 29, suffered a traumatic amputation of his left foot in a motorcycle accident. He is receiving Demerol 75mg IM for pain q3h prn pain. He complains to you of burning sensation in his left foot. You explain that
A chemotherapy client states she has noticed painful, bleeding ulcerations in her mouth. The most appropriate nursing instructions you can give her regarding mouth care is to
Mr. A has been diagnosed with a terminal lung cancer. She tells you, “If God will just let me live to see my children finish school, I will never smoke another cigarette.” This illustrates which stage of grief?
A client recently sprained his ankle, what is the best instruction by the nurse
Mr. T had a kidney transplant and begins to immediately show signs and symptoms of rejection. This type of rejections is termed: A. Hyper-acute graft rejection B. Acute graft rejection C. Chronic rejection D. Hyper- Chronic graft rejection
During an anaphylactic reaction, the nurse must: A. Check for contraindications of epinephrine prior to administration B. Administer high flow O2 and epinephrine IM C. First establish 2 IV lines at separate sites D. Immediately place patient on a cardiac monitor
Mrs. R has been recently screened for HIV/AIDS. In order to confirm the diagnosis, the next test would be:
Mrs. J has lupus (SLE). The nurse knows that autoimmune disorders… A. The immune system loses the ability to recognize “self” and turns on its own tissue B. The immune system is able to recognize itself and is capable of recognizing itself C. The immune system eventually recognizes itself over time and does not attack itself D. The immune system decreases the immunoglobulin IgA
What is the most common cause of long term disability?
Mr. Y begins to notice pain at a 4/10 on the pain scale. He can no longer endure the pain at a 7/10 on the pain scale. Which is the threshold & which is the tolerance level?
What medication is contraindicated with Mr. K’s bowel obstruction
total white blood cell count is 19,000/mm3.
Allergy
Inspecting the skin for petechiae and bleeding once every shift
Anxiety and fear
Explain the isolation procedures and provide meaningful stimulation.
“Client will verbalize feelings of anxiety.”
“At what point, on a scale of 0 to 10, do you feel that you must have pain medication?”
high risk for injury related to low platelet count
redness, ulceration, and infection
Assess the client and ask him to describe the pain
the analgesic will not be as effective as when it is given before the pain becomes intense
picture scale
Checking the client’s respiratory rate
this is phantom limb sensation which is not clearly understood
brush her teeth with a soft-bristled toothbrush using gentle motions
Bargaining
Apply ice for the 1st 24-48 hours to decrease swelling
Hyper-acute graft rejection
Administer high flow O2 and epinephrine IM
The Western Blot
The immune system loses the ability to recognize “self” and turns on its own tissue
Chronic pain
4/10 represents the pain threshold and 7/10 represent the pain tolerance
Opioids because of decreased peristalsis
