Author: Anonymous

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient’s gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?

The nurse has implemented a bladder retraining program for an older adult client. The nurse places the client on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the client typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurse’s best response to this finding?

The nurse is auscultating the breath sounds of a client with pericarditis. What finding is most consistent with this diagnosis?

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client’s mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse’s most appropriate action?

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

The nurse has completed the admission assessment of a client and has determined that the client’s body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client?

A client’s electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate:

A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client’s health complaint?

During the care conference for a client who has multiple chronic conditions, the case manager has alluded to the principles of the interface model of disability. What statement is most characteristic of this model?

A client with diabetes is attending a class on the prevention of associated diseases. What action should the client perform to reduce the risk of osteomyelitis?