1) A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period?
Vital signs
Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or ...
1 a preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma the nurse would most closely monitor which item in the preoperative period vital signs hypertension is the hallm
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Strategy - Maslow's Hierarchy of Needs Theory
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Maslow's Hierarchy of Needs Theory
Strategy - Maslow's Hierarchy of Needs
Theory
1) A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The
nurse would most closely monitor which item in the preoperative period?
Vital signs
Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a
stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments
for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood
pressure.
2) A mother brings her child to the emergency department. Based on the child's sitting position,
drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse
should plan for which priority intervention?
Providing assisted ventilation and obtaining the necessary equipment
The highest priority with epiglottitis is to have assisted ventilation available because the highest risk with
this child is complete airway obstruction. Therefore, interventions related to airway are the priority.
Physiological interventions continue to have the highest priority, with assessment of breath and heart
sounds and then obtaining pulse oximetry being priorities. Once the airway is stabilized, the
temperature, weight, and a chest x-ray can be obtained. The last priority is asking about precipitating
events, which is done once physiological needs are met.
3) The nurse gives a dose of diazepam to an assigned client. What is the most important action to
be taken by the nurse before leaving the room?
Instituting safety measures
Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The
nurse should institute safety measures before leaving the client's room to prevent injury as a result of
medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are
useful but not essential to the client's safety in this situation.
4) An understanding of borderline personality disorder should help the nurse determine that
which problem is the priority for the client?
Risk for self-harm
Clients with borderline personality disorder are most often hospitalized because of impulsive attempts
at self-mutilation or suicide. The nursing intervention of constant close observation is usually initiated to
protect the client from impulsive behavior. If any of the other options exist, they are of lesser priority.
, Maslow's Hierarchy of Needs Theory
5) The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The
client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration
for this client?
Client pain level
The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and
hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate
postpartum period. There are no data in the question that indicate inadequate urinary output, the
presence of client perception of body changes, and potential for imbalanced body fluid volume.
6) A clinic nurse is performing an admission assessment on an African American client scheduled for
cataract removal with intraocular lens implantation. Which question should the nurse avoid asking
on the initial assessment?
"Do you have any family problems?"
In the African American culture, it is considered to be intrusive to ask personal questions on the initial
contact or meeting. African Americans are highly verbal and express feelings openly to family or
friends, but what transpires within the family is viewed as private. The psychosocial assessment would
be of lowest priority during the initial admission assessment. Additionally, because cardiovascular,
renal, and gastrointestinal assessments are physiological, they are the priority assessments.
7) The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to
address which problem as the priority?
Risk for infection
The client with immunodeficiency has inadequate or no immune bodies and is at risk for infection. The
priority concern would be risk for infection. The question presents no data indicating that the client is
experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective
isolation, but these are not the priority problems for this client. Infection can be life-threatening and is
the priority.
8) A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking
antipsychotic medications, and complaining of abdominal fullness and discomfort. Which
intervention addresses the priority sign/symptom?
Encourage frequent fluid intake and a high-fiber diet.
Constipation is a common elimination problem with clients in a manic phase of bipolar disorder.
Constipation may occur as the result of a combination of factors, including taking antipsychotic
medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic
activity level. The symptoms listed in the question in combination with antipsychotic medications are
indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.
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