Chapter 02: Overview of Health Concepts for Medical-Surgical Nursing Flashcards
A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best?
The client is trying to get rid of excess body acids.
The client is acidotic, and the respiratory system is attempting to compensate by “blowing off” excess acid in the form of carbon
dioxide.
A client had a recent thromboembolism and must resume work which requires frequent car and plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client
Get up and walk around at least every 2 hours while traveling
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can take several measures to reduce
their risk of further problems. One measure is to get up and walk frequently when sitting for a long period of time.
A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20–pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)
An 88-year-old client 3 days post-hemorrhagic stroke
There are many risk factors for impaired cognition including advanced age and diseases and disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk for impaired cognition. The nurse
assesses this client first
The assistive personnel (AP) reports to the registered nurse that a postoperative client has a pulse of 132 beats/min and a blood
pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
Assess the client for pain.
The “fight-or-flight” syndrome can occur from sympathetic nervous stimulation due to acute pain. Symptoms can include nausea,
vomiting, diaphoresis, tachycardia, tachypnea, hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to
believe that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it.
A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met?
Skin in perineal area is intact without redness on inspection
Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact without redness shows that a major
goal for this client has been met.
The registered nurse asks the nursing assistant why a cardiac client’s morning weight has not yet been done. The nursing assistant
says, “I’ll get to it, what’s the big deal?” When deciding how to respond, the nurse considers what information about weight?
Weight is the most accurate noninvasive indicator of fluid status.
Weight is the best (noninvasive) indicator of fluid status.
The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange
abnormalities first?
Brought in unconscious by roommate after opioid overdose
Opioid medications can cause respiratory depression, so this client is most at risk for gas exchange problems. Diminished
respirations will allow a buildup of carbon dioxide in the blood.
The nurse caring for a client with malnutrition assesses which laboratory value as the priority?
Prealbumin
Both albumin and prealbumin are indicators for nutrition. Prealbumin changes more rapidly with decreased nutrition, so
it is the better test.
A nurse is planning primary prevention measures for community-dwelling adults to prevent visual impairment. What action by the nurse will best meet this objective?
Offer a healthy lifestyle class.
Primary prevention activities are those designed to actually prevent the onset of a disease or health problem. Secondary prevention focuses on screening and early diagnosis/detection. Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy lifestyle through classes may help prevent diabetes, a common cause of visual impairment, and is a primary prevention measure.
The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate?
“Find a trusted friend and role play.”
Discussing sexuality and sex is difficult for most people. Since it is important to be able to assess this aspect of people’s lives, the
nurse needs to become comfortable. Role-playing with a trusted friend will build confidence and comfort.
A nurse is planning a community education event-related to impaired cellular regulation. What teaching topics would the nurse
include in this event? (Multiple Response)
Ways to minimize exposure to sunlight
Resources available for smoking cessation
Creative cooking techniques to increase dietary fiber
Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to minimize the risk of developing
cancer include decreasing exposure to sunlight, smoking cessation, and increasing dietary fiber
A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify as having a risk for impaired immunity? (Multiple Response)
HALT
86 years old
Has type 2 diabetes
Taking prednisone
Low socioeconomic status
Risk factors for impaired immunity include but are not limited to: older adults (diminished immunity due to normal aging changes), low socioeconomic groups (inability to obtain proper immunizations), nonimmunized adults, adults with chronic illnesses that weaken the immune system, adults taking chronic drug therapy such as corticosteroids and hemotherapeutic agents, adults
experiencing substance use disorder, adults who do not practice a healthy lifestyle, and adults who have a genetic risk for decreased
or excessive immunity.
The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address
potential complications? (Multiple Response)
Perform a depression screen once a day.
Consult physical therapy for range of motion.
Increase fiber in the client’s diet.
There are many complications of immobility including depression, pressure injuries, constipation, urinary calculi, and muscle
atrophy. The nurse would address these by assessing for depression, consulting physical therapy for activities such as range of
motion the client can do, and increase fiber so the client does not become constipated.
A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve
wound healing. What diet selections does the nurse evaluate as good understanding by the client? (Mulitple Response)
Chicken breast
Orange juice
Boost supplement
Spinach salad
Protein and vitamin C are important for wound healing. Foods high in protein include meat sources such as chicken and nutritional
supplements. Foods high in vitamin C include orange juice and spinach.
The nurse would expect a patient with respiratory acidosis to have an excessive amount of
Hydrogen ions.
Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many
hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis).
