Physiological Adaptation

Which assessment in the patient with bladder cancer indicates the patient is experiencing a complication of the disease?

Which assessment prompts the nurse to suspect intussusception in the 10-month-old patient? 

The patient who underwent an upper gastrointestinal radiographic study requires which post-procedure instruction?

The patient presents to the emergency department with chest pain. Which description of the pain prompts the nurse to suspect a myocardial infarction?

Which statement by a patient recently diagnosed with congestive heart failure indicates an understanding of the teaching provided by the nurse?

Which statement by the family member of a patient who has Guillain-Barré Syndrome indicates that they understand the nurse’s teaching on the disease process?

Which statement by the patient with placenta accreta indicates they understand the nurse’s teaching?

Which patient requires the most immediate attention?

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

The patient is experiencing syndrome of inappropriate antidiuretic hormone. The nurse recognizes malfunction of which structure is responsible for this disorder?

Following brain surgery, the patient is producing massive volumes of dilute urine. The nurse suspects which structure was inadvertently harmed during the surgery?

The nurse is providing education to the parents of a child with nephrotic syndrome. Which statement indicates an understanding of the teaching?

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

The nurse assesses the patient’s capillary refill time to be 5 seconds. Which inference from this assessment is most appropriate?

The neonate born at 34-weeks estimated gestational age had Apgar scores of 3 and 7 at 1 and 5 minutes, respectively and is taken to the nursery for observation due to a need for continuous positive airway pressure (CPAP). Significant oral secretions are noted and an orogastric tube is unable to be placed because it meets resistance and comes back out the mouth. The nurse suspects which condition?

The 3-week-old neonate has failed to return to birth weight due to projectile vomiting partially-digested breast milk after most feedings. Upon assessment, an olive-shaped mass is palpated in the upper right abdominal quadrant. The nurse anticipates which diagnosis?

The neonate born at 41 weeks gestation is diagnosed with persistent pulmonary hypertension of the newborn (PPHN). Which information does the nurse give the mother about this condition?

Which statement by a patient newly diagnosed with type 1 diabetes mellitus indicates understanding of the nurse’s discharge teaching?

Which statement by the patient with acute kidney injury (AKI) requires correction by the nurse?

Which events may lead to acute kidney injury (AKI)? Select all that apply.

A 41-year-old male complains of sudden onset of severe chest pain and describes it as a constant tearing sensation that radiates to his lower back. The nurse is most suspicious of which condition?

The nurse suspects that a patient has Ludwig’s angina. Which action does the nurse take first?

The patient has a 20 gauge IV in the left antecubital fossa and is receiving D5W at 150 mL/h. Upon assessment, the nurse notes the site is swollen and cool to the touch; there is no erythema. Which term does the nurse use to document this finding? 

The patient is pale and dizzy following a gunshot wound to the groin. Minimal bleeding is noted at the site. Vital signs are notable for a heart rate of 125 bpm and a blood pressure of 73/39 mm Hg. Two unsuccessful attempts have been made to establish an IV site. He loses consciousness. Which action does the nurse take next?

Which assessment finding in a patient complaining of back pain requires immediate action?

Which statement by the patient with systolic heart failure indicates an understanding of discharge teaching?

A patient with severe chronic obstructive pulmonary disorder (COPD) is receiving 3 liters per minute of oxygen via nasal canal. Which oxygen saturation indicates respiratory support is adequate?

The patient is diagnosed with new, rapid atrial fibrillation and thinks the problem has been going on for two weeks. Which statement by the patient indicates an understanding of teaching about the diagnosis?

A 21-year-old male presents with sudden onset shortness of breath. He has no history of smoking, alcohol use, recent injuries or trauma. He is 5’11” tall, weighs 130 pounds, and works as a forklift driver. His vital signs are: BP 115/64 mm Hg, HR 104 bpm, RR 26, Temp 99.0 F, and O2 Sat 91%. The nurse suspects which condition?

Which of the following conditions can cause exophthalmos? Select all that apply.

The G2P1 patient who is 33 weeks pregnant is brought via ambulance to the emergency department due to significant vaginal bleeding and abdominal pain. Which action does the nurse take first?

The nurse is caring for a 60-year-old male with congenital spinal stenosis, who is diagnosed acute herniated disc. Which of the following conditions is most likely to occur as a result of the patient’s condition?

The patient with cholestasis complains of significant pruritus. The nurse bases the explanation on which understanding of the pathophysiology behind the patient's pruritus?

The 38-year-old gravida 1 para 1 patient presents to the clinic in the 8th week of gestation.The patient’s fasting blood sugar test result is 130 mg/dL. The nurse anticipates which diagnosis? 

Following a motor vehicle accident, the patient is brought to the emergency department with a head injury. Upon assessment, the nurse notes otorrhea and mastoid bruising. The nurse reports the findings to the provider and suspects further testing will reveal which injury? 

The nurse is caring for a 22-year-old patient who is experiencing sickle-cell crisis. Which is the priority nursing consideration?

The nurse notes inspiratory stridor upon auscultating the breath sounds of a 2-year-old child and suspects obstruction at which structure?

The patient is diagnosed with primary amebic meningoencephalitis. Which organism is the culprit behind this condition?

The new mother reports the baby makes snoring noises while trying to breastfeed. The nurse anticipates an examination will reveal narrowing at which level of the airway?

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The nurse is providing discharge teaching to the patient who has experienced episodes of atrioventricular nodal reentry tachycardia (AVNRT). Which patient drink selection(s), if chosen by the patient, indicate a need for further teaching? Select all that apply.

The patient who experiences frequent episodes of atrioventricular nodal reentry tachycardia (AVNRT) that do not cause hemodynamic compromise is being discharged. The nurse is supervising the student nurse providing discharge teaching to the patient. Which method for self-treatment of AVNRT, if taught by the student nurse, would prompt the nurse to intervene immediately?

The nurse is providing preoperative teaching to the parents of a neonate diagnosed with short-segment Hirschsprung disease. Which statement by the patient’s mother indicates an understanding of the education?

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

The 32-year-old patient presents to the emergency department complaining of difficulty breathing, cough, and chills. Vital signs are notable for a temperature of 38.4°C, heart rate 118 bpm, respiratory rate 24, oxygen saturation 87% on room air, and blood pressure of 98/62 mmHg. Upon assessment, the nurse notes nasal flaring, diminished breath sounds in the right upper lobe, and subcostal retractions. Capillary refill time is 4 seconds. The patient admits waking up in a pool of vomit after binge drinking 3 nights ago. Which orders does the nurse anticipate? Select all that apply.

The patient was intubated in the field following a severe motor vehicle accident and is being managed in the intensive care unit. One day after the accident, increased oxygen requirement and diminished lung sounds are noted, and a radiograph is obtained. The chest x-ray reveals consolidation in bilateral lower lobes. The nurse anticipates which diagnosis for this patient?

The oncoming nurse learns the patient has a right chest tube for the treatment of a chylothorax. The nurse anticipates which color of drainage in the chest tube chamber?

The patient with pneumonia who is intubated, sedated, and chemically paralyzed has developed a pleural effusion that is causing significant respiratory decompensation. The nurse assists the provider to insert the chest tube in which location?

During hourly rounding assessment of the patient with a chest tube for treatment of a pneumothorax, the nurse notes the patient’s chest and neck are markedly more edematous than on previous assessment. Upon palpation, crepitus is noted. Which action does the nurse take first?

Upon assessment of the patient with a chest tube, the nurse notes intermittent bubbling in the water-seal chamber that follow the patient’s respirations. During rounds the provider instructs the nurse to clamp the chest tube in preparation for removal later in the day. Which response by the nurse is appropriate?