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NR 661 Week 4 VISE Assessmet,APN Capstone Practicum
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NR 661 Week 4 VISE Assessmet,APN Capstone Practicum/NR 661 Week 4 VISE Assessmet,APN Capstone Practicum
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NR 661Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide
(Naturetin) Demecarium
bromide (Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem. Instruct the client to attempt to avoid situations that
cause irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem. Instruct the client to attempt to avoid situations that
cause irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse
applies a cooling blanket and administers an antipyretic medication. The nurse explains that
the rationale for these interventions is to:
Promote equalization of osmotic
pressures. Prevent hypoxia associated
with diaphoresis. Promote integrity of
intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every
12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile
water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should
be added to the 50 mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and
repositioning Impaired skin integrity, related to the effects of
pressure and shearing force
1
,A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue
down to the underlying fascia. The nurse should document the assessment finding as which
stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageabl
e
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be
removed before the wound can be staged. A stage I pressure ulcer is defined as an area
of persistent redness with no break in skin integrity. A stage II pressure ulcer is a
partial-thickness wound with skin loss involving the epidermis, dermis, or both; the
ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III
pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to
ensure that a medication reconciliation is completed? Select all that apply.
After reporting severe
pain On admission to the
hospital
Upon entering the operating room
Before transfer to a rehabilitation
facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is
taking and comparing it to the health care provider's prescriptions on admission or
when there is a transfer to a different setting or service, or discharge. A change in
status does not require medication reconciliation. A medication reconciliation should be
completed long before entering the operating room. Total hip replacement is elective
surgery, and scheduling takes place before admission; medication reconciliation takes
place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for
which of the following laboratory values?
White blood cell (WBC) count of 15,000
mm3 Negative protein in the urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0
seconds
White cell counts can increase with this drug. The expected range of the WBC count is
5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not
necessary and these are normal values.
2
,Often when a family member is dying, the client and the family are at different stages of
grieving. During which stage of a client's grieving is the family likely to require more
emotional nursing care than the client?
Ange
r
Denia
l
3
, Depressio
n
Acceptanc
e
In the stage of acceptance, the client frequently detaches from the environment and
may become indifferent to family members. In addition, the family may take longer to
accept the inevitable death than does the client. Although the family may not
understand the anger, dealing with the resultant behavior may serve as a diversion.
Denial often is exhibited by the client and family members at the same time. During
depression, the family often is able to offer emotional support, which meets their
needs.
The client asks the nurse to recommend foods that might be included in a diet for
diverticular disease. Which foods would be appropriate to include in the teaching plan?
Select all that apply.
Whole grains
Cooked fruit and
vegetables Nuts and
seeds
Lean red
meats Milk
and eggs
With diverticular disease the patient should avoid foods that may obstruct the
diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked
fruits and vegetables. Milk and eggs have no fiber content but are good sources of
protein. In clients with diverticular disease, nuts and seeds are contraindicated as they
may be retained and cause inflammation and infection, which is known as diverticulitis.
The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in
the knee. What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the
bedside table Pain pattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
Accurate pain assessment includes pain history with the client's identification of pain
location, intensity, and quality and helps the nurse to identify what pain means to the
client. The pattern of pain includes time of onset, duration, and recurrence of pain and
its assessment helps the nurse anticipate and meet the needs of the client. Assessment
of the precipitating factors helps the nurse prevent the pain and determine it cause.
4
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