Reduction of Risk Potential

Patients with which characteristics are at increased risk for infective endocarditis? Select all that apply.

Following an industrial accident, the patient is immobile. The student nurse is creating a care plan for the patient to prevent respiratory decompensation. Which intervention, if included in the care plan for this nursing diagnosis, would prompt the nurse to provide additional education to the student nurse?

The patient presents to the emergency department (ED) complaining of a severe headache that has not responded to nonsteroidal anti-inflammatory drugs, caffeine, hydration, or rest. The patient also reports transient syncope and weakness of the right side of the body. During the initial assessment, the patient becomes increasingly confused. The nurse prepares the patient for which test?

Which term is used to describe this visual field test result?

The patient has the following visual field test for the left eye in which the black spots represent where the patient cannot see. Which interpretation of the test result is correct?

The patient has been diagnosed with an arteriovenous malformation (AVM) and is scheduled to undergo surgery in the morning. Which nursing intervention is the most important to promote safety in the patient?

The patient presents to the emergency department (ED) with unilateral facial paralysis. Comprehensive testing rules out cerebrovascular accident. The nurse prepares the patient for which test?

The patient with migraines undergoes an MRI and is found to have a cerebral aneurysm in the Circle of Willis. The nurse is vigilant for which symptoms that would indicate the patient is experiencing a life-threatening complication of the cerebral aneurysm? Select all that apply.

The patient with ascending weakness that began in the legs undergoes a lumbar puncture for evaluation of the cerebrospinal fluid (CSF). Which CSF results are consistent with a diagnosis of Guillain-Barré syndrome?

The patient is brought to the emergency department (ED) after being found on the floor in the garage by his wife. His right cheek balloons with each expiration and his right leg drags when he walks. While being assisted to the magnetic resonance imaging suite, the patient’s facial drooping resolves and he no longer walks with a limp. Which action does the nurse take first?

The patient is hospitalized following a cerebrovascular accident (CVA). The patient calls out to report a sudden, pounding headache. Which assessments are the priority? Select all that apply.

During a comprehensive neurologic exam, the provider brushes a wisp of cotton over the patient’s cornea, which causes the patient to blink. The nurse notes that which cranial nerve is intact based on this test?

The nurse is testing the patient’s eyes for accommodation by holding a finger in front of the eyes and asking the patient to look at a point over the nurse’s shoulder then look at the finger. The nurse documents which bilateral response as normal?

The nurse utilizes the ophthalmoscope to assess the patient’s retina and notes narrowing in the vessels where the arteries and veins cross. Which vital sign is consistent with this finding?

The nurse is preparing the patient for a pneumotonometry test. Which instruction does the nurse give the patient?

Which test is used to assess the retina and fundus of the patient with severe cataracts?

The nurse assesses the patient for which signs of complications of a parathyroidectomy?

Which statement does the nurse include in discharge teaching to the parents of the 9-year-old who underwent tonsillectomy and adenoidectomy?

Which statement by the woman in her third trimester of pregnancy is most concerning to the nurse?

The nurse is providing safety teaching to the woman who has just tested positive for human chorionic gonadotropin. Which statement by the woman indicates the teaching was successful?

Which is indicated by a positive urea breath test?

The patient presents to the emergency department with left leg pain after landing from a transcontinental flight. Which assessments prompt the nurse to suspect a deep vein thrombosis? Select all that apply.

Which statement is true regarding the indirect Coombs test?

The nurse is vigilant for which symptoms of a life-threatening complication of the woman's precipitous vaginal delivery?

Following a scleral buckling procedure, the patient complains of nausea. Which action does the nurse take?

The patient walks into to the emergency department (ED) complaining of significant pain in the right eye. It appears red and swollen. The pupils are not equal in size or reactivity – the right pupil remains dilated despite the bright exam room and the flash light. The patient cringes from the bright light, though, and complains the bright lights are hurting his head. He reports that over the last week, both eyes have been aching and he has been seeing halos around lights. The nurse prepares for which test to be performed first?

The patient with a sore throat has tested positive for group A beta-hemolytic Streptococcus pyogenes. The nurse educates the patient to complete the entire course of antibiotics in order to prevent which complications? Select all that apply.

The nurse is performing an assessment on the patient with long, thin limbs and fingers who presents for a yearly check-up in no acute distress. The patient is extremely thin and has pectus excavatum. For which assessment finding is the nurse most vigilant in this patient?

The nurse anticipates which alteration in heart sounds in the patient with chronic obstructive pulmonary disease?

The patient has a history of mitral valve stenosis. In which position does the nurse place the patient to properly auscultate for this condition?

Upon auscultating the patient’s heart, the nurse notes an S3 heart sound in the mitral area. How does the nurse interpret this assessment?

The patient first experienced chest pain 12 hours ago and was diagnosed with a myocardial infarction. The patient’s myoglobin level is noted to be roughly 5 times the normal level. The nurse makes which prediction about the patient’s myoglobin level in 12 hours from the current level?

The patient who is hospitalized for a knee replacement develops sudden onset crushing chest pain, tachycardia, and tachypnea. On 12-lead electrocardiogram (EKG), ST-segment elevation is noted. Labs are drawn within 30 minutes of onset of chest pain. The nurse anticipates an elevation in which result to confirm diagnosis of acute myocardial infarction?

The patient presents to the emergency department (ED) after a hard workout lifting weights complaining of chest pain. An electrocardiogram is performed and cardiac enzymes are drawn. The patient’s myoglobin level is found to be elevated. Which interpretation of this result is most appropriate?

Which lab result is best for differentiating between myocardial and skeletal muscle damage?

The patient has been ordered to wear a Holter monitor for the next 24 hours. Which statement by the patient indicates a need for further teaching about the test?

During a well-child visit for the 4-month-old child, the nurse palpates hard nodules where each rib joins the sternum. The nurse reports this finding to the provider and requests which lab studies for this patient? Select all that apply.

The nurse is creating a presentation on rickets in the community. The nurse focuses on which group of individuals for this teaching?

The 4-year-old child is brought to the emergency department (ED) with concern for a broken arm after a fall at the playground. The nurse notes the legs are bowed with curved femurs, the abdomen protrudes, and the upper spine is curved forward, giving the child a humpback appearance. The nurse anticipates testing will lead to which diagnosis?

The patient presents to the clinic complaining of abdominal pain in the left lower quadrant that happens every few days with irregular fecal elimination patterns (constipation alternating with diarrhea). Diverticulosis is suspected. Which test will confirm this diagnosis?

The patient has a peritoneal dialysis catheter. The nurse notes the dressing is saturated and prepares to change it. Upon removing the dressing, the nurse notes a foul odor and purulent drainage around the site, which is red. Which action does the nurse take next?

The nurse is providing discharge teaching to the patient who will be discharged with a peritoneal dialysis catheter. Which statement indicates a need for further teaching?

The nurse is assessing the arteriovenous fistula in the patient’s right arm; it is without thrill or bruit. Which action does the nurse take next?

Following abdominal surgery, the patient remains intubated in the postanesthesia care unit (PACU). Which assessment indicates the patient is ready to be extubated?

The patient with type 2 diabetes mellitus complains of worsening vision. Retinal changes are noted on ophthalmoscopic examination. The nurse prepares the patient for which test for diagnostic confirmation?

The nurse is caring for a patient with left-sided weakness in the hospital who had vocal cord surgery this morning. Which intervention is most important to promote safety?

The patient has a diagnosis of Cor pulmonale. The nurse anticipates which result from the echocardiogram?

The patient has Cor pulmonale related to idiopathic pulmonary arterial hypertension. Which lab value is expected?

The patient newly diagnosed with Cor pulmonale is found to have a hematocrit of 55%. Which statement is true regarding this information?

The patient with a history of hypertension and atherosclerosis presents to the emergency department (ED) complaining of severe lower back pain. Which question by the nurse is most important?