An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

The client is a 70-year-old female training for a triathlon. She was hit by a car while jogging and has an abrasion that is 25 cm by 12 cm on her right leg and a liver laceration. She underwent an exploratory laparotomy to repair the liver laceration and to search for other internal injuries.

The client has no chronic medical conditions and is in good health. She takes a calcium and magnesium supplement daily. She denies smoking or drinking alcohol.

What age-related factors may factor into this client's wound healing? Select all that apply.

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

A 7-year-old female child admitted to pre-op for scheduled surgery. Focused assessment completed. Lung sounds are clear to auscultation (CTA), heart sounds clear with normal sinus rhythm, skin clear with no breakdown.

• Abdomen soft with bowel sounds heard in all 4 quadrants.
• A feeding tube is present on the abdomen
• Site is clean and clear.
• Consents for surgery signed by parent at preadmission visit.
• Peripheral IV (PIV) 22 gauge inserted in right forearm with assistance from another nurse.
• Cried throughout procedure.
• Comforted by parent and use of touch music.
• IV fluids at 75 mL/hr started.

Client transported to operating room (OR) and The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-operatively, what will be the priority?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dl (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L).

When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?

Reference Ranges

• Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L)
• Glucose (Reference Range: 0 to 50 years: 74 to 106 mg/dl. (4.1 to 5.9 mmol/L))
• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?