A 20-year-old female female client calls the nurse to repor reportt a lump lump she found in her breast. Whi ch response is the best for the the nurse to provide? A) Check it agai n in one month, an d if it is still there schedule an appointment. B) Most lumps lumps are a re benign benign , but it is alw ays best to come in for an examination. C) Try not to worry too much about it, because usually, most lumps are benign. D) If you are in your menstrual menstrual period period it is not a g ood time to to check for lumps.
A 32-year-old 32-year -old female client complains of se vere abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional histor y should the nurse obtain obt ain that is consistent with the client's complaints? A) Frequent Fr equent urinary tract t ract infections. infectio ns. B) Inability to get pregnant. C) Premenstrual syndrome. D) Chronic use of laxatives.
A 46-year-old 46-year-o ld female client cli ent is admitt ed for acute renal failure secondary to diabetes and hypertension. Which test i s the best indicator of adequate glomerular filtration? A) Serum creatinine. cre atinine. B) Blood Urea Nitrogen (BUN). C) Sedimentation rate. D) Urine specific gravity.
B) Most lumps are benign, but it is always best to come in for an examination. (B) provides the best response because it addresses the client's anxiety most most effectively effectively and encourages prompt and immediate action for a potential problem. (A) postpones treatment if the lump is malignant, and does not relieve the client's anxiety. (C and D) provide false reassurance and do not help relieve anxiety.
B) Inability to get pregnan pregnant. t. Dysmenorrhea, dyspareunia, a nd difficulty or painful painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial endometrial tissue in the dependent dependent areas of the pelvic peritoneum peritoneum.. A history his tory of infertility (B) is a nother common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client w ith endometriosis endometriosis are pain a nd infertility.
A) Serum Serum creatinine. creatinine. Creatinine (A) i s a product product of muscle muscle metabolism that iiss filter fil tered ed by the glomerulus, glomerulus, and blood levels of this substance are not affected by dietary dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration. (B) is also an indicator of renal activity, but it can be affected by by non-renal factors such a s hypovolemia and increased protein intake. (C) is a nonspecific test for acute or chronic inflammatory processes. (D) is useful in assessing hydration status, but not as useful in assessing glomerular function.
B) Dis cuss perimenopause perimenopause and related comfort measures. measures. A 49-year-old 49-year-old female female client arrives at the the clini c for an annual exa m and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? A) Explain the effect of the follicle-stimulating and luteiniz luteinizing ing hormones. B) Discuss Dis cuss perimenopause and related comfort measures. measures. C) Assess Ass ess lung fields and for a c ough productive productive of blood-tinged blood-tinged mucous. D) Ask if a fever above 101º F has occurred in the last 24 hours.
A 51-year-ol d truck driver drive r who smok es two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse nurse to include include in the discharge teaching for this client? A) Information about smoking s moking cessatio n. B) Diet instructions for a low-residue diet. C) Instructions on a weight-loss program. D) The importance of increasing milk in the diet.
The perimenopausal perimenopausal period period begins about 10 years before menopause with the cessa tion of menstruation menstruation a t the average average a ges of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts bursts (surges), w hich trigg ers vasomotor instabili ty, night sw eats, and hot flashes, so discussions about the perimenopausal body's chan ges, comfort measures measures (B), an d treatme treatment nt options sh ould be provided provided.. In-dep In -depth th pathophysiol ogy of the symptoms symptoms (A) may only confuse the client. There is no indication that the client has tuberculosis and an infection, so (C and D) are not indicated.
A) Information about smoking ces sation. Smoking has been associated with ulcer formation, and stopping or decreasi decreasing ng the number number of ciga rettes rettes smoked per per day is an important important aspect a spect of ulcer mana mana gement (A). Di et management includes a reduction in high-fiber/high-roughage foods as well as spicy foods. (B) w ould be indicated indicated for inflammatory bowel bowel disea se. Sodium and caloric in take are not the key elements elements in i n an a n ulcer diet. Although this client does does need (C), the the manag eme ement nt of his ulcer is the key factor at this point. (D) would actually increase gastric acid production.
A 57-year-old 57-year-old male client client is scheduled to have a stress-thallium stress-thallium test the following following morning and is NPO after m idnight. At 0130, he i s agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? A) I'm sorry sir, you have a prescription for nothing nothing by mouth from midnight tonight. B) I will let you have one cracker, but that is all you can have for the rest of tonight. C) What did the healthcare provider tell you about the test you are having tomorrow? D) The test you are having tomorrow requires that you have nothing by mouth tonight.
A 58-year-old client who ha s been post-menopausal post-menopausal for five years is concerned about the the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? A) Osteoporosis is a progressive genetic genetic disease wi th no effective effective treatment. B) Calcium loss from bones can be slowed by increasing calcium intake and exercise. C) Estrogen replacement therapy should be started to prevent the progression osteoporosis. D) Low-dose Lo w-dose corticosteroid treatment treatment effectiv effectively ely halts ha lts the c ourse of osteoporosis.
A 58-year-old client, who h as no n o health problems, problems, asks a sks the nurse about the the Pneumovax vaccine. Th e nurse's response to the client should be based on which information? A) The vaccine is g iven annually before the flu season seaso n to those those over 50 years of age. B) The immunization i s a dministered dministered once to older adults or persons persons with a history of chronic chronic illness. C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D) The Th e vaccine w ill prevent prevent the the occurrence of pneu pneumococcal mococcal pneumonia for up to five years.
A 67-year-old woman who lives alone is admitted admitted after a fter tripping on a rug in her home and fractures her hip. Which predisposing predisposing factor fa ctor probably led to the fracture in the proximal end of her femur? A) Failing Fa iling eyesight eyesight resulting resulting in an unsafe environment. environment. B) Renal osteodystrophy resulting from chronic renal failure. C) Osteoporosis Osteoporosis resulting resulting from hormonal changes. ch anges. D) Cardiovascular changes resulting in small strokes which impair impa ir mental acuity. A 77-year-old 77 -year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, vomiting, and is complaining of a headache. heada che. Her pulse pu lse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client A) have h ave her own teeth or dentures?" B) take aspirin and if so, how much?" C) take nitroglycerin?"
D) The test you are having tomorrow requires that you have nothing by mouth tonight. (D) is the most therapeutic statement because the nurse is responding to the client's question. (A) is not an explanation and the nurse should teach the client why eating is prohibited after midnight, rather than enforcing this requirement without an explanation for it. (B) may result in an inaccurate test result, or may cause the test to be cancelled, cancelled, which could also delay diagnosis and treatment. (C) defers the responsibility for answering the client's question to the healthcare provider, when the nurse could address the si tuation through client teaching.
B) Calcium loss f rom bones can be slowed by increasing increasing calcium intake and exercise. Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight bearing exercise can prevent prevent further bone loss (B). Osteoporosis can be managed with conservative therapy, therapy, such as bone metabolism regulat ors and estrogen r eplacement eplacement therapy (ERT) to improve bone density density,, but it is not a genetic disease disease (A). Although ERT is eff ective in in managing os teoporosis, a n increased risk f or cancer and heart disease should be considered considered for indivi individual dual clients. clients. Cor ticosteroid therapy promotes bone resorption and is counterproductive in maintaining or increasing bone density (D).
B) The immunization is administered once to older adults or persons with a history of chronic illness. illness. It is usually recommende d that persons over 65 years of age and those with a history of chronic illness illness receive the v accine once once in a lifeti me (B). (Some resources recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although Although the vaccine mi ght be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re-vaccination is sometimes required.
C) Osteoporosis resulting from hormonal changes. The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced reduced calcium in the bones a s a result of hormonal changes in later life (C). (A) may or may not have contributed contributed to the accident, but it had nothin g to do w ith the hip being i nvolved. nvolved. (B) is not a common condition of the elderly; it is common in chronic renal failure. (D) may occur in some people, but does not affect the fragi fragility lity of the the bones as os teoporosis teoporosis does.
D) take ta ke digitalis?" Elderly persons are pa rticularly susceptible susceptible to digitalis intoxication (D) which manifest ma nifestss itself itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. p romptly. (A) is irrelev irrelevant. ant.
An 81-year-old 81-year-old male client client has emp hysema. He li ves at home with hi s cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? A) Help the client to determi ne ways to increase his fluid intake. B) Ob tain an appointment for the client to see an ear, nose, and throat specialist. C) Schedule an appointment with an allergist to determine if the client is allergic to the cat. D) Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.
An adult client client is adm itted to the hospital burn unit with partialthickness and full-thickness full-thickness burns over 4 0% of the body surface area. In assessing the potential for skin rege neration, what should the nurse remember about full-thickness burns? A) Regenerative function of the skin is absent because the derm al layer has been destroyed. B) Tissue regeneration will begi n several days following following return of normal circulation. C) Debridement of eschar will delay the body's ability to regenerate normal tissue. D) Normal tissue formation will be preceded by scar formation for the first year.
A) Help the client to to determine determine ways to increase his fluid intake. The nurse sho uld suggest creative methods methods to increase the intake of fluids (A), such as having disposable fruit juices readily available. Clients with COPD should have at least three liters of fluids a day. These cli ents often reduce reduce fluid intake because of sh ortness of breath. (B) is not indicated. indicated. These symptoms symptoms are not indicative of an a llergy (C). Man y elderly elderly depend depend on their pets pets for so ciali zation and self-estee s elf-esteem. m. Humidified oxygen wi ll not n ot relieve relieve these symptoms and increased oxygen levels will stifle the COPD client's trigger to breathe (D).
A) Regenerative Regenerat ive function of the skin sk in is absent because the dermal layer has been destroyed. Full-thickness Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, occur, and skin grafting is necessary necessar y (A). (B, C, and D) D) are simply false.
After checking the u rinary drainage drainag e system system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What Wha t priority nursing action should be implemented? implemented? A) Report R eport the findings to the surgeon. B) Irrigate the indwelling urinary catheter. C) Apply manual pressure to the bladder. D) Increase the IV flow rate for 15 minutes.
A) Report Repor t the findings to the t he surgeon.
After the fourth dose of gentamicin g entamicin sulfate (Garamycin) (Gara mycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A) 15 minutes before and 15 minutes after the next dose. B) One hour before and one hour after the next dose. C) 5 minutes before and 30 minutes after the next dose. D) 30 minutes before and 30 minutes after the next dose.
C) 5 minutes before and 30 minutes after the next dose.
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol? A) Diuretic therapy. therapy. B) Pacemaker implantation. implantation. C) Anticoagulation therapy. D) Cardiac catheterization. catheterization.
An adult who weighs 132 pound po undss (60 kg) should produce produce about 60 ml of urine hourly (1 ml/k g/hour). Dark, concentrated, and low volume of urine output should be reported t o the surgeon. surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare healthcare provider.
Peak drug serum levels levels are achiev ach ieved ed 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.
C) Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control control therapies to prevent cardioembolic events which result from blood pool ing in the fibrillating atria. (A, B, and D) are not indicated.
D) Digoxin (Lanoxin).
A client experiencing e xperiencing uncontro uncontrolled lled atrial at rial fibril fi brillatio lation n is admitted to the t elemetry unit. unit. What initial medication should the nurse anticipate administering to the client? A) Xylocaine (Lidocaine). B) Procainamide (Pronestyl). C) Phenytoin (Dilantin). D) Digoxin (Lanoxin).
A client has a staging st aging procedure for cancer of the breast and ask the nurse which type of bre ast cancer has the poorest prognosis. Which information should the nurse offer the client? A) Stage II. B) Invasive infiltrating infiltr ating ductal carcinoma. C) T1N0M0. D) Inflammatory with peau d'orange.
A client has been be en taking oral corticoster corti costeroids oids for t he past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White Whit e blood blo od count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger.
A client has taken t aken steroids ster oids for 12 1 2 years to t o help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function function is of greatest importance importance to this client? Assess the t he client's A) pulse rate, r ate, both bot h apically and radially. B) blood pressure, both standing and sitting. C) temperature. D) skin color and turgor. turgor. A client has undergone insert ion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize verbal ize symptoms sympto ms of pacemaker failure." W hich symptoms are most important to teach the client? client? A) Facial flushing. fl ushing. B) Fever. C) Pounding headache. D) Feelings of dizziness.
Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic symptomatic atrial fibrillation fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing slowing the th e ventricular ventricular response, response, decreasing the heart rate, and effecting cardiac output. (A, B, and C) are not indicated in the initial treatment of uncontrolled atrial fibrillation.
D) Inflammatory with peau d'orange. Inflammatory breast cancer, which has a thickened appearance like an orange peel (peau d'orange), is the most aggressive form of breast malignancies (D). Staging classifies cancer by the extension or spread of the disease, and (A) indicates limited local spread. (B) indicates cancer cells have spread from the ducts i nto the surrounding breast tissue only. TNM classification classification is used to indicate the extent of the di sease process according according to tumor size, regional spread lymph nodes involvement, and metastasis, and (C) indicates early cancer with small in situ involvement, no lymph node involvement, and no distant metastases.
C) Purulent sputum. Steroids cause immunosuppression, and a purulent sputum (C) is an indication of infection, so this symptom is of greatest concern. concern. Oral steroids may increase (A) and often cause (D). (B) may remain normal, borderline, or increase while taking oral steroids.
C) temperature. It is very important to check the client's temperature (C). Infection is the most common factor precipitating precipitating respiratory respiratory distress. Clients with COPD who are on maintenance doses of corticosteroids corticosteroids a re particularly particularly predisposed to infection. (A and B) are important data for baseline and ongoing assessment, but they are not as important as temperature measurement for this client who is i s taking steroids. Assess ment of skin color an d turgor turgor is less important important (D). ( D).
D) Feelings of dizziness. Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output (D). (A and C) will not occur as the result of pacemaker failure. (B) may be an indication of infection postoperatively, but is not an indication of pacemaker pacemaker failure.
A client is i s admitted admitte d for further testing test ing to confirm sarcoidosis. Which diagnostic test provides definitive information information that the nurse nurse should report to the t he healthcare healthcare provider? A) Lung tissue bio psy. B) Positive blo od cultures. C) Magnetic resonance r esonance imaging (MRI). D) Computerized tomography (CT) of the thorax.
A client is i s admitted admitte d to the hospital hospi tal with wi th a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A) Lower Low er left l eft quadrant pain and a low-grade fever. fever . B) Severe pain at McBurney's point and nausea. nausea. C) Abdominal pain and intermittent tenesmus. D) Exacerbations of severe diarrhea.
A client is admitted to the hospital with a medi cal diagnosis diagnosis of pneumococcal pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneum onias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A) they occur in the lower lobe lobe alveoli which are more sensiti ve to infection. B) gram-negative organisms are more resistant to antibiotic therapy. C) the y occur in healthy young adults who have have recently bee n debilitated by an upper respiratory infection. D) gram-negative pneumonias usually affect infants and small children.
A client is i s admitted admitte d to the medical me dical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which Which laboratory test r esult should the nurse expect this client to exhibit? A) Elevated Elevat ed LDH. B) Elevated serum amylase. C) Elevated CK-MB. D) Elevated hematocrit.
A) Lung tissue biopsy. Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary pulmonary primary site. Although chest radiography i dentifies sarcoidosis, lung tissue biopsy (A) obtained by bronchoscopy or bronchoalveolar la vage provides provides definitive definitive confirmation. confirmation. (B) does not provide provide results results for sa rcoidosis. Although MRI and CT identify pulmonary lesions, the (C and D) are not necessary and do not provide definitive confirmation.
A) Lower Low er left l eft quadrant pain and a low-grade fever. fever . Left lower l ower quadrant quadrant pain occurs occurs with wit h diverticulitis because the sigmoid sigmoi d colon is the most mo st common area for diverticula, and the inflammation of diverticula causes a low-grade fever (A). (B) would be indicative of appendicitis. (C and D) are symptoms exhibited with ulcerative ulcer ative colitis. col itis.
B) gram-nega tive organisms organisms are more resistant resistant to antibiotic antibiotic therapy. th erapy. The gram-negative gram- negative organisms are resistant resistant to drug d rug therapy (B) which makes recovery very difficult. Gramnegative pneumonias affect all lobes of the lung (A). The mean age for contracting this type of pneumonia is 50 years (C a nd D), and it usually strikes strikes debilitated debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases. C) Elevated CK-MB. The cardiac ca rdiac isoenzyme isoenzyme CK-MB (C) is the most sensiti sensitive ve and most reliable indicator of myocardial damage of all the cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac enzyme that peaks around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be expected in a client with a fluid volume deficit, which is not a typical finding in MI.
A) Review Revie w the electro el ectrocardiogram cardiogram tr acing. A client is i s brought to t o the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement? A) Review the electro el ectrocardiogram cardiogram tr acing. B) Obtain blood for coagulation studies. C) Apply a warming blanket. D) Provide heated PO fluids.
Airway, Air way, breathing, and circulati circulation on are priorit pri orities ies in client assessment and treatment. Continuous cardiac monitoring is indicated (A) because hypothermic clients have an increased risk for dysrhythmias. Coagulations studies (A) and re-warming procedures (C and D) can be initiated after a review of the ECG tracing (A).
A client is placed on a respirator followi ng a cerebral hemorrhag hemorrhag e, and vecuronium bromide bromide (Norcuron) (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which nursing diagnosis is the priority for this client? A) Impaired communication communication related to to paralysis of s keletal muscles. B) High risk for infection related to increased intracranial pressure. C) Potential for inj ury related related to to impaired lung expans ion. D) Socia l isolation is olation related to inability to communica communicate. te.
A client receiving cholesty cholestyramine ramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? A) K. B) B12. C) B6. D) C. A client reports reports unprote unprotected cted sexual in tercourse tercourse one week week ago a nd is worried about about HIV exposure. exposure. An ini tial HIV an tibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies relies on o n antibody a ntibody produ production ction by B lymphocytes lymphocytes after exposure to to the virus. W hen should s hould the nurse recommend the client return for repeat blood testing? A) 6 to 18 months. B) 1 to 12 months. C) 1 to 18 w eeks. eeks. D) 6 to 12 weeks.
A client taking t aking a thiazide diuretic diuret ic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A) The dosage of t he diuretic will wi ll be decreased. B) The diuretic will be discontinued. C) A potassium supplement will be prescribed. D) The dosage of the diuretic will be increased.
A) Impaired communica communication tion related to paralysi paralysi s of skeletal muscles. To increase the cl ient's tolerance of endotracheal in tubation tubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium vecuronium is usually prescribed prescribed.. Impaired communica communication tion (A) is a serious outcome because because the cli ent cannot communicate his /her needs. Although this client might also experience (D), it is not a priority priority when wh en compared to to (A). Infection is not related to to increas ed intracrania l pressure (B). (B). The Th e respirator will ensure that that the lungs are expanded (C).
A) K. Clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency (A). These drugs reduce absorption of the fat soluble (lipid) vitamins A, A , D, E, and K. (B, (B, C, and D) are not fat soluble vitamins.
D) 6 to 12 weeks. Although the th e HIV antigen is detectable approx imately 2 weeks after exposure, seroconvers seroconversion ion to HIV positive positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to repeat the serum screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests positive. (B and C) may provide inaccura te results because because the time frame maybe ma ybe too early to reevaluate the client.
C) A potassium supplement will be prescribed. This client's client's potassium level is t oo low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restor e a normal serum potassium level (C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.
D) At what time do you take your medication?
A client taking t aking furosemide (L asix), reports repor ts difficulty sleeping. What What question is important for the nurse to ask the client? A) What dose of medication are you taking? taki ng? B) Are you eating foods rich in potassium? C) Have you lost weight recently? D) At what time do you take your medication?
The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to
A client who w ho has heart failure failur e is admitted admitt ed with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? A) Give Giv e 20 mEq of potassium potassi um chloride. B) Initiate continuous cardiac monitoring. C) Arrange a consultation with the dietician. D) Teach about the side effects of diuretics.
A client who w ho is fully awak e after a gastroscopy gastros copy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? A) List en to bilateral bil ateral lung and bowel sounds. B) Obtain the client's pulse and blood pressure. C) Assist the client to the bathroom to void. D) Check the client's gag and swallow reflexes.
A client who is HIV positive asks the nurse, "How will I kn ow when I ha ve AIDS?" Which Whi ch response is best for the nurse nurse to provide? A) Diagnos Dia gnos is of AIDS is made when you have 2 positive ELISA ELISA test test results. B) Diagnosis is made when both the ELISA and the Western Blot tests are positive. C) I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister? D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.
A client who is receiving receiving ch emotherapy emotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A) Chemotherapy Chemotherapy affects affects the cells of the body body that grow rapidly, both normal and maligna nt. B) Alopecia i s a common side effect you you will experience experience during long-ter long- term m ster s teroid oid therapy. C) Your hair will grow back completely completely after your course course of chemotherapy is completed. D) The ch emotherapy emotherapy causes permanent permanent al terations terations in your hair follicles that lead to hair loss.
A client client who is sexually active active with several several par tners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? A) Using Using an IUD offers no protection against sexually tra nsmitted diseases diseases (STD), which which increase increase the risk f or pelvic pelvic inflammator y disease (PID). B) Getting pregnant while using an IUD is common and is not the best contraceptive choice. C) Relying on an IUD may be a safer choice for monogamous partners, but a barrier m ethod provides provides a better option in preven preventing ting STD transmission. D) Selecting a contraceptive device should consider choosing a successful method used in the past.
B) Initiate continuous cardiac monitoring. Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it i s most important for the nurse to to initiate ini tiate continuous continuous cardiac ca rdiac monitoring (B) to identify ventricular ventricular ectopy or other life-threatening dysrhythmias dysrhythmias.. Potassium chloride (A) should be given after cardiac monitoring is initiated so tha t the effects effects of potass ium replacement replacement on the ca rdiac rhythm can be monitored. (C and D ) sh ould be implement implemented ed when the client is stable.
D) Check the client's gag and swallow reflexes. Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway's protective reflexes, gag and swallow reflexes, have returned (D). (A, B, and C) C) are not the prior ity before reintroducing reintroducing oral fluids after a gastroscopy.
D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual. AIDS is di agnosed when one of of several processes defined by the C DC is present in an individual who is not otherwise immunosuppressed (D) (PCP, candidacie s, crytpococcus, crytpococcus, cryptosporidiosis, Kaposi's sarcoma, sarcoma, CNS lymphomas). (A and B) identify the presence of HIV, indicating a high probability that in time the individual will develop AIDS, but do not necessarily denote the presence of AIDS. (C) is telling the client how he/she feels (afraid) and is dismissing the situation to the minister. This client is asking a question and specific medical information needs to be provided.
A) Chemotherapy C hemotherapy affects the cells c ells of the body that grow rapidly, both normal and malignant. The common adverse effects of chemotherapy (nausea, vomiting, vomiting, alopecia, bone marrow depression) depression) are a re due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant (A). ( A). (B ( B and an d D) do not provide correct information about chemotherapy-induced alopecia. Although (D) is a true statement, it does not effectively answer the client's question.
A) Usin g an IUD offers no protection protection aga inst sexuall y trans transmitt mitted ed diseases (STD), which increase the risk for pelvic inflammatory disease (PID). The use of a n IUD provides provides the client w ith no protection protection from STDs (A). While pregnancy rates with the use of an IUD are somewhat higher, hig her, (B) is not therapeutic, therapeutic, but judgmental. judgmental. (C) is judgmental judgmental and does n ot provide provide the client any i nformation about use of an IUD. While talking about contraceptives may include (D), it is does not provide provide the best best information to maintain the client's hea lth.
A client who was in a motor motor vehicle collision was admitted admitted to the hospital and the right knee was placed in skeletal traction. traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? A) Release the traction q4h to provide provide skin care. B) Turn the client for back care whi le suspending traction. C) Provide back and skin care while maintaining the traction. D) Give back care after the client is released from traction.
A client with w ith a 16-year history histor y of diabetes diabete s mellitus mell itus is having renal function tests because of recent fatigue, weakness, elevated el evated blood bl ood urea nitr ogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis.
A client with a completed ischemic i schemic stroke st roke has a blood pressure of 180/90 mm Hg. Which action act ion should the nurse implement? A) Position Posit ion the head of the bed (HOB) (HOB) flat. B) Withhold Wit hhold intravenous fluids. fluids. C) Administer a bolus of IV fluids. D) Give an antihypertensive medications.
C) Provide back and skin care while maintaining the traction. (C) indicates that back care is performed while traction is left intact, which is the correct intervention intervention for maintaining skin integrity. Maintaining skin integrity and providing back care is difficult when a client is in traction, but it cannot be delayed until the client is remove removed d from traction (D). The nurse should never release the traction (A and B). B) N octuria octuria As the glomerular filtration filtration rate decreases d ecreases in in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolyte electrolytes, s, accumulate acc umulate in the blood. blood. In the early stage of renal rena l insufficiency, polyuria results from the inability inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure. D) Give an antihypertensive antihypertensive medications medications . Most ischemic strokes occur during sleep when baseline blood pressure pressure declines or blood visco sity increases due to to minimal fluid intake. Completed Completed strokes usually produce produce neurologic deficits within a n hour, the client's current current elevated elevated blood pressure pressure requ requires ires antihypertensive medication (D). Positioning the HOB flat (A) decreases decreases venous drainag e and contributes contributes to cerebral cerebral edema edema post stroke. Increased blood visc osity during s leep may be related to to reduced reduced fluids, fluids, so (B) is not in dicated. dicated. Increas ing the vascular fluid volume volume increases the blood pressure, pressure, so (C) is not indicated. indicated.
D) Restrict salt sa lt and fluid intake. A client with w ith cirrhosis cirr hosis develops devel ops increasing pedal edema and ascites. What dietary modification is most important for the nurse nurse to teach this client? A) Avoid Avo id high carbohydrate foods. B) Decrease intake of fat soluble vitamins. C) Decrease caloric intake. D) Restrict salt and fluid intake.
A client with with diabetes mellitus mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A) Fluid and electrolyt electrolytee balance. B) Prevention of water toxicity. C) Reduced glucose gluc ose in the urine. urine. D) Adequate cellular nourishment.
Salt and fluid restrictio r estrictions ns are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, ( A, B, and a nd C) will will not impact fluid retention. D) Adeq A dequate uate cellular nourishment. Diabetes mellitus Type 1 is character chara cterized ized by hyperglycemia hyperglycemia tha t precipitates precipitates gl ucosuria a nd polyuria (frequent (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prev prevents ents utilization of g lucose for energy, so the outcome outcome statement statement sh ould include stabiliza tion of adequate adequate cellular nutrition nutrition (D). (D ). (A, B, and C) relate to subsequent subsequent osmolar fluid shifts related to glucosuria, polyuria, and polydipsia.
A client with early breast breast cancer ca ncer receives receives the results results of a breast biopsy biopsy and a sks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A) Lymph node involvement involvement is not significant. significant. B) Small tumors are aggressive and indicate poor prognosis. C) The tumor's estrogen estrogen receptor gu ides treatment treatment options. D) Stage I indicates indica tes metastasis. metastasis.
A client with w ith gastroesophageal gastr oesophageal r eflux disease (GERD) (G ERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is i s most effective to assist the client? A) Losing Los ing weight. B) Decreasing caffeine intake. C) Avoiding large meals. D) Raising the head of the bed on blocks.
C) The tumor's estrogen receptor guides treatment options. Treatment decisions (C) and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are we ll-differe ll-differe ntiated, have a lower chance of recurrence, and are recepti ve to hormonal therapy. Tumor staging designates tum or size and spread of breast cancer cells into axillary lymph nodes, whi ch is one of the most important prognostic prognostic factors in early-stage early-stage breast cancer, not (A). Larger tumors are m ore likely to indicate poor prognosis, prognosis, not (B). Stage I indicates the cancer is localized and has not spread systemically (D).
D) Raising the head of the bed on blocks. Raising the head of the bed on blocks (D) (reverse Trendelenburg Trendelenburg posit p osition) ion) to reduce reflux and subsequent subsequent aspiration is the most effective recommendation for a client experiencing severe severe gastroesophageal reflux during du ring sleep. (A, B and C) may be effective recommendations but raising the head of the bed is more effective for relief during sleep.
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A) Propa nolol (Inderal). B) Captopril Ca ptopril (Capoten). (Capoten). C) Furosemide (Lasix). D) Dobutamine (Dobutrex).
A) Propanolol Pr opanolol (Inderal (Inderal). ).
A client with w ith multiple multi ple sclerosis scle rosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? A) Stay out of direct sunlight. B) Restrict intake of high protein foods. C) Schedule extra rest periods. D) Go to the emergency room immediately. immediately.
C) Schedule extra rest periods.
Despite several eye surgeries, a 78-year-old client client who lives live s alone has persistent persi stent vision vi sion problems. probl ems. The visiting visit ing nurse nurse is i s discussing painting painting the house wit h the client. The nurse suggests that the edge of the steps should be painted which color? A) Black. B) White. C) Light green. D) Medium yellow.
D) Medium yellow.
Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart hear t rate. rat e.
Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. Extra rest periods should be scheduled (C) to reduce the symptoms. (A, B, and D) are not necessary.
Yellow Yellow is the easiest easiest for a person with failing vision vision to see (D). (A) will be almost impossible to see at night because the shadows of the steps will be too difficult to determine, and would pose a safety hazard. (B) is very hard to see with a glare from the sun a nd it could cou ld hurt the th e eyes in in the daytime to look at them. (C) is a pastel color and is difficult for elderly clients to see.
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classi c lassicc symptom should the nurse expect this client client to have? A) Racing R acing pulse with exertion. B) Clubbing of the fingers. C) An increased chest diameter. D) Productive cough with grayish-white sputum. During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? A) Long -term -term relations relations hips wi th healthca re provid providers ers are more more likely. B) There are fewer fewer healthca re provide providers rs to choos e from than than in an an HMO plan. C) Insurance coverage of employees employees is less expensive to employers. employers. D) An individual can become a member member of a PPO without belonging to a group. group.
During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? A) Muscle weakness. we akness. B) Urinary frequency. C) Abnormal involuntary movements. D) A decline in cognitive function.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? A) Use a la ryngoscope to check for a foreign body lodged lodged in the esophagus. B) Reposition the head to vali date that that the h ead is in the proper position to open the airway. C) Turn the client to the the side si de and administer three three back blows . D) Perform a finger sweep of the mouth to remove any vomitus.
During lung assessment assessment,, the nurse places a stethoscope stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A) This is a normal a uscultatory finding. B) May indicate pneumothorax. C) May indicate pneumonia. D) May Ma y indicate severe emphysema. emphysema.
D) Productive Productive cough w ith grayis h-wh ite sputum sputum.. Chronic bronchitis, one of the diseases comprising the diagnosis of COPD, is characterized by a productive cough with grayish-white sputum (D), which usually occurs in the morning and is often ignored by smokers. (A) is not related to chronic bronchitis; howeve how ever, r, it is i ndicative of other problem problemss such s uch as ventricular ventricular tachycardia a nd should sh ould be explored. explored. (B and C) a re symptoms symptoms of emphysema emphysema an d are not consis tent with the other symptom symptoms. s. (C) is usually referred referred to as a "barrel "barrel chest." ch est."
C) Insurance coverage of employees employees is less expensive to employers. employers. The financial advantage of (C) is the feature of a PPO that is most relevant relevant to the average con sumer. sumer. The Th e nurse must have knowl edge about PPOs, which whi ch provide discounted discounted rates to large employers who provide insurance coverage for their their employees. employees. In return, return, the insurance company receives a la rge pool of clients for their facilities. (A, B, and D) are not accurate representations of the PPO.
A) Muscle weakness. we akness. Amyotrophic Amyot rophic late ral sclerosis scle rosis (ALS) is character ized by a degeneration degenerati on of motor neurons in the brainstem and spinal cord and are manifested by muscle weakness (A) (A ) and wasting. ALS does not manifest (B and C). In ALS, the client remains cognitively intact, not (D), while the physical status deteriorates.
B) Reposition the head to validate that the head is in the proper position to open the airway. The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the a irway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action.
C) May indicate pneumonia. This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. auscultation. Normally, the spoken word i s not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is i ndicative of some sort of consol consolidation idation process (e.g., tumor, pneum onia) (C ), and i s not a normal finding (A). When lung tissue is filled with more air than normal, the voice sounds are absent or very diminished (e.g., pneumothorax, severe emphysema) (B and D).
During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? A) Notify N otify the healthcare p rovider rovider for reinsertion. reinsertion. B) Attempt to reinsert the tracheost trach eostomy omy tube. C) Position the client in a lateral position with the neck extended. D) Ventilate client's tracheostomy stoma with a manual bag-mask.
Dysrhythmias are a concern for any client. However, the presence of a dysrhythmia is more serious serious in an elderly person person because A) elderly elderly persons persons usually live alone and cannot summon help when symp s ymptoms toms appear. appear. B) elderly elderly persons persons are more likely to to eat hig h-fat diets whi ch make them susceptible susceptible to hea rt disease. C) cardiac s ymptoms, ymptoms, such a s confusio n, a re more more difficult to to recognize in the elderly. elderly. D) elderly persons persons are intolerant of decreased cardiac output output whic h may result in dizziness and falls.
An elderl y client is admitted admit ted with wit h a diagnosis diagnosis of o f bacterial bacteri al pneumonia. The nurse's nurse's assessment o f the client is most lik ely to reveal which sign/symptom? sign/symptom? A) Leukocytosi Leuk ocytosiss and febrile. B) Polycythemia and crackles. C) Pharyngitis and sputum sputum production. pro duction. D) Confusion and tachycardia. t achycardia.
B) Attempt to reinsert the tracheosto trach eostomy my tube. The nurse should a ttempt to reinsert reinsert the trac heostomy heostomy tube (B) by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed. (A, C, and D) place the client at risk of a irway obstruction. obstruction.
D) e lderly persons are intolerant of of decreased cardiac output which m ay result in di zziness and falls. Cardiac output is decreased with aging ( D). Because of loss of contractility contractility and elasticity, blood flow is decreased and tachycardia is poorly poorly tolerated. Therefore, if an elderly person experi ences dysrhythmia (tachycardia or bradycardia), further compromising their cardiac output, they are m ore likely to experie nce syncope, falls, falls, transient ischemi c attacks, attacks, and possibly dementi a. Most elderly persons do not eat high-fat diets (B) and most are not confused confused (C ). Although many elderly pe rsons do live live alone, inabi lity to summon help (A) cannot cannot be assumed .
D) Confusion and tachycardia. t achycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased increased heart rate or increased increased respiratory r ate (D). (A, B, and C) are often absent in the elderly with bacterial bacteri al pneumonia.
An elderly male client comes comes to the geriatric geriatric screening cli nic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. thrombophlebitis. Wh ich type of pain sh ould further further confirm this s uspicion? A) Pain in the calf aw akening him from a sound sleep. sleep. B) Calf pain on exertion which stops when standing in one place. C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity. extremity. D) Pain upon arising in the morning which is relieved after some stretching and exercise.
C) Pain in the calf upon exertion which is relieved by rest and elevating elevating the th e extremity. extremity.
A female client is brought brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. visit. She has poor personal personal hygiene a nd inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. Wha t action sh ould the the nurse implement? implement? A) Notify social s ervices ervices immediately immediately of suspected suspected elderly elderly abuse. B) Discuss the need for mental health counseling with the daughter. C) Explain to the client that s he needs to take better better care of herself. D) Coll ect further further data to determine determine whether self-neg lect is occurring.
D) Collect further data to determine whether selfneglect is occurring.
Thrombophlebitis pain is relieved by rest and elevation of the extremity (C). It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place (B). (A and D) describe pain that is not common with thrombophlebitis.
Changes in weight and hygiene may be indicators of self-neglect self-neglect or neglect neglect by family members. Further assessment is needed (D) before notifying social services (A) or discussing a need for counseling (B). Until further information is obtained, explanations about the client's needs are premature (C).
A female client receiving re ceiving IV vasopressin vasopressi n (Pitressin) (Pitr essin) for esophageal esophageal varice rupture report s to t he nurse nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse nurse initiate? A) Start Star t an IV nitroglycerin nitrogl ycerin infusion. B) Nasogastric lavage with cool saline. C) Increase the vasopressin infusion. D) Prepare Pre pare for endotracheal endotracheal intubation. intubation.
A) Start a n IV nitroglycerin infusion. infusion. Vasopressin Vasopressin is used to promote vasoconstriction, vasoconstriction, thereby thereby reducing bleeding. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may be needed if respiratory distress occurs (D). B) An a ccurate menstrual menstrual cycle diary for the past 6 to 12 months.
A female client requ requests ests information about using the calendar method method of contraception. Wh ich a ssessment sses sment is most important important for the nurse to obtain? A) Amount of weigh t gain or weigh t loss during during the previous previous year. B) An a ccurate menstrual menstrual cycle diary for the past 6 to 12 months. C) Skin pigmentation a nd hair ha ir texture texture for evidence evidence of hormonal changes. D) Previous birth-control methods methods a nd beliefs about the calendar method.
A female client taking taking oral contraceptives contraceptives reports reports to the the nurse that that she is experiencing calf pain. What action should the nurse implement? A) Determine Determine if the client has al so experienced breast tender tenderness ness and weight gain. B) Encourage Encourage the cli ent to begin begin a regular, dai ly program of walking wal king a nd exercise. C) Advise the client to notify the healthcare provider for immediate medical medical attention. attention. D) Tell the cli ent to stop taking taking the medication medication for a week to see if symptoms subside.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. indigestion. Wh at intervention intervention should the th e nurse implement? A) Administer 30 minutes minutes before before eating. B) Evaluate the effectiveness effectiveness 1 hour after adminis a dministration. tration. C) Instruct the client to swallow the tablet whole. D) Question the healthca re provider's prescription. prescription.
Healthca re workers must protect protect themselves themselves aga inst becoming infected with HIV. The Center for Disease Control has issued guidelines for heal thcare workers in relation to protection protection from HIV. These guidelines include which recommendation? A) Place HIV positive clients in strict isolation a nd limit visitors. visitors. B) Wear gloves when coming in contact with the blood or body fluids of any client. C) Conduct mandatory HIV testing of those who work with AIDS clients. D) Freeze HIV blood specimens at -7 0° F to kill the virus.
The fertile period, period, which occurs 2 weeks prior to the onset of menses, i s determined determined using a n accurate a ccurate record record of the number number of days of the menstrual menstrual cycles for the past 6 months, months, so it i t is most important important to emphas emphas ize to the client that accuracy and complianc y of a menstrual diary (B) is the basis of the calendar method. (A and C) may be partially related to to hormonal ho rmonal fluctuations but are not indicators for using the calendar method. (D) may demonstrate demonstrate client understanding understanding and compliancy but is not the most important important aspect.
C) Advise the cl ient to notify the h ealthcare provider provider for immediate medical medical attention. attention. Calf pain is indicative of thrombophlebitis, a serious, lifethreatening complication associated with the use of oral contraceptives contraceptives wh ich requires further further assess ment and possibly immediate immediate medical in tervent tervention ion (C). (A ) are a re symptoms symptoms of oral contraceptive contraceptive use, but are of less immediacy immediacy tha n (C). (B) may cause an embolism embolism if thrombophlebitis thrombophlebitis is present. present. By not seeking immediate immediate attention, (D) is potentially potentially dan gerous to the client.
D) Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with renal r enal failure due to t o the risk r isk of o f hypermagnesemia, so this prescription should be questioned questio ned by the nurse (D). ( D). (A, B, and and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox).
B) Wear gloves when coming in contact with the blood or body fluids of any client. The CDC guide g uidelines lines recommend recommend that healthca re workers use gloves when coming in contact with blood or body body fluids fluids from ANY client (B) since H IV is infectious before the client becomes becomes aw are of symptoms. symptoms. (A) is not n ot recommend recommended, ed, nor is i t necessary. (C) is very very controversial, controversial, difficult to to enforce, a nd is not recommended recommended by CDC. (D) does not g uarantee to to kill the virus. virus. Additionally, the purp purpose ose of the blood specimen specimen will wi ll determine determine how it is s tored tored and han dled. dled.
How should the nurse position position the electrodes electrodes for modified chest lead one ( MCL I) telemetry telemetry monitoring? monitoring? A) Positive Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. B) Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. C) Positive Positive polarity right chest nipple line, nega tive polarity left chest nipple line, ground left shoulder. D) Negative N egative polarity left shoulder, positive positive polarity right chest nipple line, ground left chest nipple line.
In assessing a client diagnosed with primary hyperaldosteronism, hyperaldosteronism, the nurse expects the laboratory test results r esults to ind i ndicate icate a decreased serum serum level of which substance? A) Sodium. B) Antidiuretic hormone. C) Potassium. D) Glucose.
In assessing cancer risk, the nurse identifies which woman as being at greatest great est risk r isk of o f developing bre ast cancer? A) A 35-year-old 35-year -old multi para who never br eastfed. B) A 50-year-old whose mother had unilateral breast cancer. C) A 55-year-old whose mother-in-law had bilateral breast cancer. cancer. D) A 20-year-old whose menarche occurred at age 9.
In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis (thromboangiitis oblit erans), which which referral is most important? A) Genetic Genet ic counseling. B) Twelve-step recovery pro gram. C) Clinical nutritionist. D) Smoking cessation program.
In preparing preparing to administer intravenous intravenous al bumin bumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) A) Set the infusion pump pump to to infuse the albumin albumin within wi thin four hours. hours. B) Compare Compare the client's blood type type with the label on the albumin. C) Assign Ass ign a UAP UA P to monitor blood pressure pressure q15 q15 minutes. D) Administer through a large gauge catheter. E) Monitor hemoglobin a nd hematocrit levels. levels. F) Assess for increased bleeding after administration.
D) Negative N egative polarity left shoulder, positive positive polarity right chest nipple line, ground left chest nipple line. In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest (D). The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. (A, B, and C) describe incorrect placement of electrodes for telemetry monitoring.
C) Potassium. Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia)--hypertension is the most prominent and universal sign. (A) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (B) is decreased with diabetes insipidus. (D) is not affected by primary aldosteronism.
B) A 50-year-old whose mother had unilateral breast cancer. The most predictive risk factors for development of breast cancer are over 40 40 years of a ge and a positive family history (occurrence (occurrence in the immediate immediate family, i.e., mother or sister). Other risk factors include nulliparity, no hi story of breastfeeding, breastfeeding, early menarche a nd late menopause. Although a ll of the w omen described described have one of the risk factors for developing developing breast ca ncer, (B) ha s the greater risk over (A, C, and D).
D) Smoking cessation program. Buerger's Buerger's diseas e is strongly related to smoking. The most effective effective means of controlling symptoms and disease progression is through smoking cessation (D). The cause of Buerger's disease is unknown; a genetic predisposition is possible, but (A) will not be of value. The client w ith Buerger's Buerger's dis ease does no t need referr referral al to a 12-step 1 2-step program any more than than the general population population ( B). Diet is n ot a significant factor in the disease, and general healthy diet guidelines can be provided by the nurse (C).
A) Set Set the infusion pump pump to infuse the albumin within four hours. D) Administer through a large g auge catheter. E) Monitor hemoglobin a nd hematocrit levels. F) Assess for increased bleeding after administra tion. (A, D, E, and F) ar e the correct selections. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining a fter four hours should be discarded (A). Albumin administration does not not require blood blood typing (B). (B). Vital signs should be monitored periodicall y to assess for fluid volume overload, but every every 15 minutes is not necessary (C). This frequency frequency is often used during during the first hour o f a blood transfusion. A l arge g auge catheter (D) all ows for fast infusion ra te, which may be necessary. necessary. Hemodilution Hemodilution may decrease hemoglobin and hematocrit levels (E), while increased blood volume and blood pressure may cause bl eeding eeding (F).
B) Evaluate his blood pressure, pulse, and respiratory status. A male client receives receives a local a nesthetic during during surgery. During the post-operative post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? A) Determine Determine the client is anxi ous and allow him to sleep. sleep. B) Evaluate his blood pressure, pulse, and respiratory status. C) Review the client's pre-oper pre-operative ative history for alcoh ol abuse. a buse. D) Continue to monitor the client for reactivity to to anesthesia. an esthesia.
A male client cl ient who has never smoked smo ked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer? A) Adenocarcinoma. B) Oat-cell carcinoma. C) Malignant melanoma. D) Squamous-cell carcinoma.
A middle-aged male client with di abetes continues to eat an abundance abundance of foods foods that are high i n sugar and fat. According According to the Health Belie f Model, which event is m ost likely to increase the client's willingness to become compliant with the prescrib ed die t? A) He vi sits his diab etic brother who just had surgery to amputate an infected foot. foot. B) He is provided with the most current information about the dangers of untreated diabetes. C) He comments on the community service announcements about preventing complications associated associated with diabetes. D) His wife expresses a sincere willingness to prepare meals that are within hi s prescribed di et.
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding should the nurse consider an indication of progressive hepatic encephalopathy? A) An increase in abdominal girth. gir th. B) Hypertension Hypert ension and a bounding pulse. C) Decreased bowel sounds. D) Difficulty in handwriting.
The nurse formulates the nursing diagnosis of, Urinary retention related to to sensorimotor sens orimotor deficit deficit for a cli ent with multiple sclerosis. Which Whic h nursing i ntervention ntervention should the nurse nurse implement? implement? A) Teach the client techni technique quess of intermitte intermittent nt self-catheterization. self-catheterization. B) Decrease fluid intake to prevent over distention of the bladder. C) Use incontinence briefs to maintain hygiene with urinary dribbling. D) Explain that anticholinergic drugs will decrease muscle spasticity.
Slurred Slurred speech in the post-operative post-operative client wh o received a loca l anesthetic is an atypical finding and may indicate neurological deficits that require require further further assessment, s o obtaining the client's vital sign s (B) will provide information about possi possible ble cardiovascular complications, such as stroke. The client's anxiety (A), a history of alcohol abuse abuse (D), or local a nesthesia nesthesia (D) are unrelated to to the cl ient's s udden udden onset of slurred speech. speech.
A) Adenocarcinoma. Adenocarcinoma is the only l ung cancer cancer not rel ated to cigarette smoking (A). It has been found to be directly relate d to l ung ung scarring and and fibrosis from preexisting pulmonary disease such as TB or COPD. Both (B and D) are malignant lung cancers related to cigarette smoking. (C) is a skin cancer and is related to exposu e xposure re to t o sunlight, not not to t o lung problems.
A) He visits vis its his diabet ic brother brot her who just had surgery to amputate an infected foot. The loss of a limb by a family member (A) will be the strongest event or "cue to action" and is most likel y to inc i ncrease rease the perceived seriousness seriousness of the t he disease. (B, C, and and D) may influence his behavior but do not have the personal impact of (A).
D) Difficulty in i n handwrit handwriting. ing. A daily record r ecord in handwriting may provide evidence e vidence of progression or reversal of hepatic encephalopath encephalopathy y leading to coma (D). (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level which is the primary cause of hepatic encephalopathy.
A) Teach the client techniques of intermi ttent self-catheterization. self-catheterization. Bladder control control is a common problem for clients with multiple sclerosis. A client with urinary retenti on should should receive i nstructions about about selfcatheterization (A) to prevent bladder distention. Adequate hydration, not (B), is i mportant to reduce the risk of urinary tract infe ctions by promoting elimination which reduces the time microorganisms spend in the bladder and by diluting the number of microorganisms in the bladder. Self-catheterization helps prevent dribbling, so (C) i s unnecessary. Cholinergic drugs improve bladder muscle tone and help with bladder em ptying, not (D).
The nurse nurse is as sessing a client who ha s a h istory istory of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? A) Loss of short-term short-term memory memory,, facia l tics and grimaces, a nd constant writhing movements. B) Shuffling gait, masklike facial expression, and tremors of the head. C) Extreme muscular weakness, easy fatigability, and ptosis. D) Numbness of the extremities, loss of balance, and visual disturbances.
B) Shuffling gait, masklike facial expression, and tremors of the head. (B) are a re common common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia myasthenia gravis, gr avis, and (D) of multiple sclerosis. C) Normal Normal s kin coloring.
The nurse is assessing a client who smokes cigarettes and has been diagnosed diagnosed with wit h emphysema. Which finding should the nurse expect this client to exhibit? A) A decreased decre ased total tot al lung capacity. B) Normal arterial blood gases. C) Normal skin coloring. D) An absence of sputum.
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates indicates the client may have developed septic emboli? A) Cyanosis of the fingertips. fi ngertips. B) Bradycardia and bradypnea. br adypnea. C) Presence Pres ence of S3 and S4 heart sound so unds. s. D) 3+ pitting edema of the lower extremit ies.
The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the nurse to respond to first? A) Potassium Pota ssium 6.0 mEq. B) Daily urine output of 400 ml. C) Peripheral neuropathy. D) Uremic fetor.
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads le ads the nurse to suspect that the client cl ient is experiencing tumor lysis syndrome (TLS)? A) Serum PTT PT T of 10 seconds. B) Serum calcium of 5 mg/dl. C) Oxygen saturation of 90%. D) Hemoglobin of 10 g/dl.
The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms symptoms of emphysema emphysema (n ormal color but puffing puffing respirations) from those those exh ibiting s ymptoms ymptoms of chronic bronch itis (edematous, (edematous, cyanotic, shallow respirations) (C). Total lung capacity is increased in emphysema sin ce these clients ha ve hyperinflated hyperinflated lungs (A). Arterial blood gases are typically abnormal (B). (D) is indicative of bronchitis, while clients with emphysema usually have copious amounts of thick, white whi te sputu sputum. m.
A) Cyanosis of the fingertips. fi ngertips. Septic emboli secondary to meningitis commonly lodge in the the small arterioles o f the extremities, causing a decrease in circulation to the hands (A) which may lead to gangrene. (B, C, and D) are abnormal findings, but do not indicate the development development of septic emboli.
A) Potass ium 6.0 6.0 mEq. Hyperkalemia Hyperkalemia (n ormal serum level, level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular tubular destruction. destruction. In CRF, an a n increase in crease in serum nitrogenous nitrogenous was te product products, s, electrolyte imbalances , and demyelination demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath related to the accumulation of blood urea nitrogen and is a common complication of CRF, but not as significant as hyperkalem hyperkalemia. ia.
B) Serum calcium of 5 mg/dl. TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS.
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? A) Place Pl ace a chair at a right angle t o the bedside. be dside. B) Encourage deep breathing prior to standing. C) Help the client to sit and dangle legs on the side of the bed. D) Allow the client to sit with the bed in a high high Fowler's position. The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of ca re? A) Flush the tube with 50 ml of water q 8 hours. B) Check for tube placement and residual volume q4 hours. C) Obtain a daily x- ray to verify tube placement. D) Position on left side with head of bed elevated 45 degrees. The nurse nurse is ca ring for a client with a str oke resulting in right-sided right-sided paresis and aphasia. The client attempts t o use the left hand for feeding feeding a nd other self-care a ctivities. ctivities. The spouse becomes becomes f rustra ted and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client? A) Situational Situational low self-esteem related to f unctional unctional impairment and change change in role function. function. B) Disabled family coping coping r elated to dissonant coping coping s tyle of s ignificant ignificant person. C) Interrupted family processes related to shift in health status of family member. D) Risk for ineffective ineffective therapeutic therapeutic regimen management related to complexity of care.
D) Allow the client to sit with the bed in a high high Fowler's position. The first step is to raise r aise the head of the bed to a high Fowler's position (D), which allow venous return to compensate from lying flat and vasodilating effects of perioperative drugs. (A, B, and C) are implemented after (D).
B) Check for tube placement and residual volume q4 hours. Tube placement and residual volume should be checked before each feeding feeding (B). Tube placement placement is checked by aspiration of stomach contents and measurement of pH. It is i mportant mportant to check for residual volume because because gastric g astric emptying emptying is often delayed during during illness. There is an increased risk for aspiration of the feeding with increased residual volume. (A, C, and a nd D) are not correct proced procedure uress to follow.
B) Disabled family coping related to dissonant coping style of significant person. person. A stroke affects affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing contributing to the client's care. H er help is noted as being incong ruent ruent with wi th attempts attempts of s elf-care by the client thereby thereby disabling family coping (B). The scenario does not discuss the client's self-esteem (A), interrupt interrupted ed family processes (C) or the ris k for ineffective therapeutic regimen (D).
A) Loss of of thirst, weight gain.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? A) Loss Los s of thirst, thirs t, weight gain. B) Dependent edema, fever. C) Polydipsia, polyuria. D) Hypernatremia, tachypnea.
The nurse is completing an admission interview and assessment on a client with with a history of Parkinson's disease. Which quest question ion should provide information information relevant to the client's plan of care? A) Have you ever ever experienced experienced any paralysis of your arms arms or legs? B) Have you ever sustained a severe head injury? C) Have you ever been been 'frozen' in one spot, unable to move? D) Do you have headaches, especially ones with throbbing pain?
SIADH occurs occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than than 20 ml/hour, and dilutional hyponatremia. Other i ndications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH defi ciency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremi a, not (D).
C) Have you ever been 'frozen' in one spot, unable to move? Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not cause ca use (A). Parkinson's disease disease is not usually associated with (B), nor does it typically cause (D).
The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history history presents the greatest r isk for developing a cerebral vascular accident (CVA)? A) Diabetes Diabet es mellitus. mell itus. B) Hypothyroidism. C) Parkinson's disease. D) Recurring pneumonia.
A) Diabetes mellitus mellitus.. A history history of of diabetes mellitus mellitus poses poses the the greatest risk for developing a CVA (A). (B, C, and D) may place the client client at some risk due to immobility, but do not present a risk as great as (A). ( A). B) Risk for injury related to denial of deficits and impulsiveness.
The nurse nurse is planning care for a client who ha s a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? A) Impaired physical mobility related to right-sided hemiplegia. B) Risk for i njury related related to denial of deficits a nd impulsiveness. impulsiveness. C) Impaired verbal verbal communication related to speech-lang uage deficits. D) Ineffect In effective ive coping related to to depressi depression on a nd distress a bout disability.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify i dentify before befor e beginning the teaching session? A) Present Pr esent knowledge k nowledge relate re lated d to the sk ill of injection. B) Intelligence and developmental level of the client. C) Willingness Willingness of the client to learn the injection sites. D) Financial resources available for the equipment.
The nurse is planning care to prevent complication for a client wit h multiple myeloma. Which intervention is most important for the nurse to include? A) Safety pr ecautions during activity. B) Assess for changes in size of lymph nodes. C) Maintain a fluid intake of 3 to 4 L per day. D) Administer narcotic analgesic around the clock.
The nurse is planning to initiate a socialization group for older residents residents of a long-term facility. Which information is most most useful to the th e nurse when p lanning a ctivities ctivities for the group? A) The length of time each group g roup member has resided resided at at the nursing home. B) A brief description of each resident's family life. C) The age of each group member. D) The usual activity patterns of each member of the
With ri ght-brain damage, a client experience di fficulty in judgme nt and spatial perception and is more likely to be impulsive and move quickly, which placing the client at risk for falls falls (B). Although clients clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical imp airments on the contralateral contralateral side of the body, not the same side (A). The client with a left-brain injury may manifest right-sided hemiplegia with speech or language deficits (C). A client with left-brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D).
C) Willingness of the client to learn the injection sites. If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching (C). To determine determine learning needs, the nurse should assess (A), but this is not the most important important fa ctor for the nurse nu rse to assess. (B and D) are factors to consider, but not as vital as (C).
C) Maintain a fluid intake of 3 to 4 L per day. Multiple myeloma i s a malignancy of plasma cells that that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to to 2 L per day re quire s an intake of 3 to 4 L (C ) to promote excretion of serum calcium. calcium. Although Although the client is at ri sk for pathologic pathologic fractures due to diffuse osteoporosis, osteoporosis, mobilization and weight beari ng (A) should be encouraged to promote bone reab sorption of of circulating calcium, calcium, which can cause renal complications. (B) is a component of ongoing assessment. Chronic pain management (D) should be included in the plan of care, but pre vention of complications complications related to hypercalcemia is most important.
D) The usual activity patterns of each member of the group. An older person's level level of activity activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described described in the th e options might be useful to the nurse, but the most useful information initially would be an assessment of each individual's adjustment to the aging process.
The nurse is preparing a teaching plan for a client who is newly diagnosed wit h Type 1 diabetes diabete s mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A) Sweating, Sweati ng, trembling, tachycardia. B) Polyuria, polydipsia, polyphagia. C) Nausea, vomiting, anorexia. D) Fruity breath, tachypnea, chest pain.
A) Sweating, Sweat ing, trembling, trembli ng, tachycardia. tachycardia. Sweating, dizziness, and trembling are signs of hypoglycemic hypoglycemic reactions related to the r elease of epinephrine as a compensatory response to the low blood bloo d sugar (A). (B, C, C, and D) do not describe common symptoms of hypoglycemia.
B) Increase intake of soluble fiber to 10 to 25 grams per day. The nurse is providing dietary instructions instructions to a 68-year-old client who is i s at hig h risk for developme development nt of coronary heart disease (CHD). Which information should the nurse include? A) Limit dietary dietary selection of cholesterol to to 300 mg per per day. B) Increase intake of s oluble fiber to 10 to 25 grams per day. C) Decrease plant stanols and sterols to less than 2 grams/day. D) Ensure saturated fat is less than 30% of total caloric intake.
To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber (B) should be increased to between between 10 and an d 25 gm. Choles Ch olesterol terol intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total daily c alories. alories. D) If the client's wound is infected.
The nurse is receiving receiving report report from surgery surgery about a client w ith a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important important for the nurse to obtain? A) If suctioning wi ll be needed needed for drainag e of the the wound. B) If the family would prefer a private or semi-private room. C) If the client also has a Hemovac® in place. D) If the client's wound is i nfected. nfected.
The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective subjective information is most important for the nurse nurse to note? A) A history hist ory of o f obesity. obesit y. B) An allergy to sulfa drugs. C) Cessation of smoking three years ago. D) Numbness in the soles of the feet.
The nurse is teaching a client with maple syrup urine disease (MSUD), a n autosomal recessi ve disorder, disorder, about the the inh eritance pattern. pattern. Wh ich information sh ould the nurse provide? provide? A) This recessive disorder disorder is carried only on the X chromosome. chromosome. B) Occurrences Occurrences main ly affect males an d heterozygous heterozygous females. C) Both genes o f a pair must be abnormal for the disorder to to occur. D) One O ne copy of the abnormal gene is required required for this disorder.
Penrose drains provide a sinus tract or opening opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain drain should al ert the the nurse to the possi bility that the client is infected. infected. To a void contamination of a nother postoperative postoperative client, it is most important important to place place an a n infected client in a private room (D). A penrose drain drain does not require require (A). A lthough (B) is information that s hould be considered, it does not ha ve the priority priority of (D). (C) is used to drain fluid from a dead space and is n ot important in choosing a room.
B) An allergy to sulfa drugs. An allergy al lergy to sulfa drugs may make make the client unable unable to use some of the most common common an tihyperglycemic tihyperglycemic agents (s ulfonylureas). ulfonylureas). The nurse needs to highlight this allergy for the healthcare provider. (A) is common and warrants counseling, but does not have the importance importance of (B). (C) does increase the risk for vascular disease, but it is not as important to to the treatm treatment ent regimen regimen as (B). Dia betic betic neuropathy, as indicated by (D), is common with diabetics, but when the serum glucose is decreased, new onset numbness numbness can ca n possibly improve.
C) Both genes of a pair must be abnormal for the disorder to occur. Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A and B) dominant or recessive recessive disorder disorder or an a n autosomal a utosomal dominant inheritance disorder. Both genes of a pair, not (D), must be present.
The nurse is teaching a female client about the best time to plan sexual sexual intercourse in order to conceive. Which information should the nurse pr ovide? A) Two weeks w eeks before menstruatio n. B) Vaginal mucous discharge is thick. C) Low basal te mperature. D) First thing in the morning.
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which informati on should should the nurse include? (Se lect all all that apply.) A) Remove the di aphragm im medi ately after intercourse. B) W ash the di aphragm wi th an alcohol alcohol solution. solution. C) Use the diaphragm to prevent conception during the menstrual cycle. D) Do not leave the di aphragm in place longer longer than 8 hours after intercourse. E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears. F) Replace the old diaphragm every 3 months.
The nurse is working with a 71-year-old obese client with bilateral bilateral osteoarthritis osteoarthritis (OA) of the hips. What Wh at recommendation recommendation should the nurse make tha t is most beneficial beneficial in protecting p rotecting the client's joints? joints? A) Increase Inc rease the amount of c alcium intake in the d iet. B) Apply alternating heat and cold therapies. C) Initiate a weight-reduction diet to achieve a healthy body weight. D) Use a walker for ambulation to lessen lessen weight-bearing on the hips.
The nurse knows that lab values s ometimes ometimes vary for the the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80 -year-old male? A) Increased WBC, decreased decreased RBC. RBC. B) Increased serum serum bilirubin, sli ghtly increas ed liver liver enzymes. C) Increased protein protein in the urine, slig htly increased serum glucose levels. D) Decreased D ecreased serum serum sodium, an increased urine specific gra vity. vity.
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery surgery in two h ours is dated two years ago. The client reports reports that he h as a history h istory of "heart trouble trouble," ," but has n o problems problems at present. present. H ospital protocol requires requires tha t those over 50 years of age have a recent ECG prior to to surgery. What nursing action is best for the nurse to implement? implement? A) Ask the client wha t he means means by "heart troub trouble." le." B) Call for an ECG to be performed immediately. C) Notify surgery that that the ECG is over two two years old. D) Notify the cli ent's surgeon i mmediately. mmediately.
A) Two weeks before menstruation. menstruation. Ovulation typicall typicall y occurs 14 days before menstruation menstruation begins (A ), and sexual sex ual intercourse intercourse sh ould occur within 24 hours of ovulation for conception to occur. Hig h estrogen l evels evels occur during during ovulation and inc rease the vagina l mucous membrane membrane character chara cteristics, istics, which whi ch become more "slippery" "slippery" and stretchy, stretchy, not n ot (B). A rise in basal temperature, not (C), signals ovulation. The timing during the day is not as significant in determining conception as the day before before and a fter fter ovulation (D).
D) Do not leave the diaphrag diaphrag m in place longer than 8 hours after intercourse. E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears. Correct selections are (D and E). The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but but should not remain for longer than 8 hours (D) to avoid the risk of TSS. If a sudden fever occurs, the client client should notify the healthcare healthcare provider provider (E). (A) increases t he risk of pregnancy, pregnancy, and (B) can reduce the integrity of the barrier contraceptive but neither prevents the risk of TSS. The diaphragm should not be used during menses (C) because it obstructs the menstrual flow a nd is not not indicated indicated because conception conception does not occur during during t his time. (F) is not necessary.
C) Initiate a weigh t-reduct t-reduction ion diet to ach ieve a heal thy body weigh t. Achieving Achi eving a healthy weig ht (C) is critical to protect protect the joints of clients with OA. Increasing the amount of calcium in the client's diet (A) will not protect protect hip joints from the effects effects of OA . Thermal therapies may lessen pain and stiffness from OA but are not protective of the joints (B). Assistive devices such as a walker may be beneficial beneficial to help avoid falls an d assis t in ambulation ambulation but are not protectiv protectivee aga inst OA 's effects (D).
C) Increased protein in the urine, slightly increased serum glucose levels. In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.
B) Call for an ECG to be performed immediately. Clients over the age of 40 and/or with a hi story of cardiovascular cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (B) should be implemented to ensure that the client's current cardiovascular status is stable. Additional data might be valuable (A) , but since time is limi ted, the priority i s to obtain obtain the needed ECG. Documentation of vital signs is im portant, but does not not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (D).
C) serum potassium level is 3.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific s pecific instruction fro m the healthcare healt hcare provider if t he client's A) serum ser um digoxin level is 1.5. B) blood pressure is 104/68. C) serum potassium level is 3. D) apical pulse is 68/min.
The nurse nurse working in a postoperat postoperative ive surgical surgical clinic is assessing a woman w ho ha d a left radical mastectomy for breast breast cancer. Which Whic h factor puts puts this client at greatest risk for develop developing ing lymphedema? A) She sustained an ins ect bite bite to to her left arm yesterd yesterday. ay. B) She has lost twenty pounds pounds since si nce the surgery. C) Her healthca re provider provider now prescribes prescribes a c alcium cha nnel blocker for hypertension. hypertension. D) Her hobby is playing class ical music on the piano.
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What Wha t action should the nurse implement? implement? A) Prepare Prepa re the client for transcutaneous pacemaker. p acemaker. B) Shock the client with 200 joules per hospital policy. C) Use a magnet to deactivate the implanted pacemaker. D) Observe the monitor until the onset of ventricular fibrillation.
Physical examination of a comatose client reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding? A) A cerebral cer ebral infectious process proces s is causing the posturing. B) Severe dysfunction of the cerebral cortex has occurred. C) There is a probable dysfunction of the midbrain. D) The client is exhibiting signs of a brain tumor.
A postmenopausal postmenopausal cli ent asks the nurse why she is experiencing discomfort during during intercourse. Wha t response is best for the nurse to provide? A) Estrogen deficiency deficiency causes the vagina l tissues to become become dry dry and thinner. B) Infrequent Infrequent intercourse intercourse results results in the vagina l tissues l osing their elasticity. C) Dehydration from inadequate fluid fluid intake ca uses vulva tissue dryness. D) Lack La ck of adequate stimulation stimulation is the most common common reason for dyspareunia.
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous da ngerous dysrhythmias (normal potass pota ssium ium level level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
A) She sustained an insect bite bite to her left arm yesterday. yesterday. A radica l mastectomy interrupts interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases increases the risk risk for the occ urrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema-(D) would not.
B) Shock the client with 200 joules per hospital policy. The client must be externally shocked (B) to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning. (A) will not be effective during ventricular ventricular ta chycardia, chycard ia, since it is used for asystole. asystole. Since the defibrillator is not functioning, (C) is not warranted. The client should be treated immediately to restore cardiac output (D).
B) Severe dysfunction of the cerebral cortex has occurred. Decorticate posturing posturing (adduction (adduction of a rms at sho ulders, ulders, flexi on of arms on chest with wrists flexed and hands fisted and extension and addu a dduction ction of extremities) extremities) is i s s een with severe severe dysfunction dysfunction of the cerebral cortex (B). (A) is characteristic of meningitis. (C) is character chara cterized ized by decerebrat decerebrate e posturing (rigi d extension and pronation of arms and legs). A client with (D) may exhibit decorticate decorticate posturing, depending depending o n the posi tion of the tumor tumor and the condition of the client.
A) Estrogen deficiency cau ses the the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier (A), and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. Dyspareunia is not related to (B or C). While (D) can contribute to discomfort discomfort during
Small bowel obstruction is a condition characterized by which finding? A) Severe fluid and electrolyte imbalances. imba lances. B) Metabolic acidosis. C) Ribbon-like stools. D) Intermittent lower abdominal cramping.
A splint is i s prescribed prescri bed for nighttime nightti me use by a client clie nt with rheumato id arthritis. arthri tis. Which state ment by the nurse provides the most accurate explanation for use of the splints? A) Preventio Pr evention n of deformities. deformiti es. B) Avoidance of joint trauma. C) Relief of joint inflammation. D) Improvement in joint strength.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? A) Apply Ap ply sequential sequential compression devices devices (SCDs) bilaterally. bilaterally. B) Assess for a positive Homan's sign in each leg. C) Pad all bony prominences on the affected leg. D) Advise the client to remain in bed with the leg elevated.
A) Severe fluid and electrolyte imbalances. imba lances. Among the findings fi ndings characterist chara cteristic ic of a small bowel obstruction is i s the presence of severe severe fluid and electrolyte imbalances (A). (B, C, and D) are findings associated with large bowel obstruction. A) Preventio Pr evention n of deformities. deformiti es. Splints may be used at night by clients with rheumatoid rheumatoid arthritis t o prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as nonsteroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
D) Advise the client to remain in bed with the leg elevated. elevated. The client is exhibiting symptoms symptoms of deep vein vein thrombosis (D VT), a complication of immobility. The initial care includes bedrest and elevation of the extremity (D). SCDs are used to prevent thrombophlebitis, thrombophlebitis, not for treatment, treatment, when a clot cl ot might be dislodged (A). Once a client has thrombophlebitis, (B) is contraindicated because of the possibility of dislodging a clot. (C) is indicated to prevent pressure ulcers, but is not a therapeutic action for thrombophlebitis.
C) Use daily reminders reminders to take immunosuppressants.
What discharge instruction instr uction is most i mportant for a client after a kidney transplant? A) Weigh Wei gh weekly. weekl y. B) Report symptoms of secondary Candidiasis. C) Use daily reminders to take immunosuppressants. D) Stop cigarette smoking.
After renal tr ansplantation, acute rejection is is a r isk for several months, so immunosuppressive immunosuppressive therapy, such as cor ticosteroids and a zathioprine (Imuran), is essential in preventing rejection, so the priority instruction includes includes measures, s uch as daily reminders (C), to ensure the client client takes these medications regularly. Daily weights, not weekly (A), provides a better indicator indicator of weight ga in related to rejection. rejection. Although fungal infections related to the immunosuppression immunosuppression should be reported (B), it is more importa nt to ensure medication compliance to prevent rejection. Although smoking (D) increases the risk of atherosclerotic vascular disease which which is common in clients clients with an or gan tr ansplant, (C) remains the priority.
D) Perform a breast self-exam (BSE) procedure monthly.
What Wha t instruction should the nurse give a client who is diagnosed with fibrocystic fibrocystic changes chang es of the breast? A) Observe Observe cyst size fluctuations as a sign of malignancy. B) Use estrogen supplements to reduce breast discomfort. C) Notify the healthcare provider if whitish nipple discharge occurs. D) Perform a breast self-exam (BSE) procedure monthly.
Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irrita irrita tion. These changes changes obscure typical diagnostic tests, such as mammog raphy, due to an increased breast density. Women with fibrocystic fibrocystic breasts should be instructed to carefully perform monthly BSE (D) and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer (A). Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen (B), which is not indicated. Nipple discharge associated with fibrocystic breasts is often milky or watery-milky and is an
What Wha t is the correct procedure for performing an ophthalmoscopic examination on a client's right retina? A) Instruct the th e client to look at examiner's nose and not move his/her his/her eyes during the exam. ex am. B) Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C) From a distance of 8 to 12 inches and slightly to the side, shine the light into the client' c lient'ss pup il. D) For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
What types of medications medica tions should the nurse expect to administer to a client client during an an acute respiratory distress episode? A) Vasodilators Va sodilators and hormones. B) Analgesics and sedatives. C) Anticoagulants and expectorants. D) Bronchodilators and steroids.
When preparing preparing a client who ha s had ha d a total total laryngectom la ryngectomy y for discharge, which instruction is most important for the nurse to include in the discharge teaching? A) Recommend Recommend that the the client carry suction suction equipment equipment at all times. times. B) Instruct the client to have writing materials with him at all times. C) Tell the client to carry a medic alert card stating that he is a total neck breather. D) Tell the cli ent not to travel travel alone.
When providing discharge teaching teachi ng for a client with wi th osteoporosis, the nurse should reinforce which home care activity? A) A diet d iet low in phosphates. B) Skin inspection for bruising. C) Exercise regimen, including swimming. D) Elimination of hazards to home safety.
When teachin g diaphrag matic breathing breathing to a client with ch ronic obstructive pulmonary disease (COPD), which information should the nurse provide? A) Place a s mall book or magazin e on the abdomen abdomen and make make it rise while in haling deep deeply. ly. B) Purse the lips while inhaling as deeply as possible and then exhale through the nose. C) Wrap a towel a round the the abdomen and push ag ains t the towel while whi le forcefully forcefully exhal ing. D) Place one hand on the chest, one hand the abdomen and make both hands move outward. outward.
D) For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope ophthalmoscope should be set on the 0 lens to begi n (creates no correction at the the be ginning of the exam) , and should be held in front of the examiner's left eye when examining the client's right eye. For optimum vi sualization, the the ophthalmoscope ophthalmoscope should be kept wi thin one to three inches of the client's eye (D). (A and B) describe incorrect methods for conducting an ophthalmoscopic ophthalmoscopic exam ination. (C) should illicit a red r eflex as the light travels through the crystalline lens to the retina.
D) Bronchodilators and steroids. Besides supplement supplemental al oxygen, the ARDS cli ent needs medications medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, i.e., bronchodilators and steroids (D). (A) w ould not help the condition. (B) would further further depress depress the client and compromise the ability to breathe. breathe. Anticoa gulants w ould be contraindica contraindica ted since clotting of the blood is not yet yet a problem, problem, and expectorants are not appropriate appropriate for this critically i ll cli ent (C).
C) Tell the client to carry a medic alert card stating that he is a total neck breather. It is imperative imperative that total neck breathers ca rry a medic alert notice (C) so tha t if they have a cardiac arrest, mouth-to-neck mouth-to-neck breathing can be done. Mouth-to-mout Mouth-to-mouth h resuscitation w ill not n ot help them. They do not need to carry (A) nor refrain from (D). Th ere are many alternative means of communication for clients who have had a laryngectomy; depending depending on (B) is probably probably the leas t effective. effective. How do you know he can read and write?
D) Elimination of hazards to home safety. Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures can be given (D). A low phosphorus diet is not recommended in the treatment of osteoporosis (A). Bruising (B) is not a related symptom to osteoporosis. Weight-bearing exercise is most beneficial for clients with osteoporosis. Swimming (C) is not a weight-bearing exercise. exercise.
A) Plac e a small book or magazi ne on the abdomen abdomen and make it rise while i nhaling deep deeply. ly. Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. rate. The client sh ould protrud protrudee the abdomen on inhalation and contract it with exhalation, so (A) helps the client visualize the rise and fall of the abdomen. The client should purse the lips while exhaling, not (B). (C and D) are ineffective.
Which assessment finding by the nurse during a client's client's clinical breast examination examination requires followup? A) Newly retracted ret racted nipple. B) A thickened area where the skin folds under the breast. breast . C) Whitish nipple discharge. D) Tender lumpiness noted bilaterally throughout the breasts.
A) Newly retracted retracted nipple. nipple. A newly retracted retracted nipple nipple (A), compared to a life-long finding , may be an indication of breast cancer and require requiress additional follow -up. The inframammary ridge (B) is a normal anatomic finding. Up to 80% of women may experience an intermitte intermittent nt nipple discharg e (C), especially related to recent recent stimulation, stimulation, and in most cases, nipple discharge is not related to malignancy. (D) is a classic finding for fibrocystic breast disease, a benign condition.
B) Obese older male client with a short, thick neck.
Which client should the nurse r ecognize as most likely to experience sleep apnea? A) Middle-aged female femal e who takes tak es a diuretic diuret ic nightly. B) Obese older male client with a short, thick neck. C) Adolescent Adolescent female with wit h a history of tonsillectomy. D) School-aged male with a history of hyperactivity disorder.
Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. With obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B). (A, C, and D) are not typically prone to sleep apnea.
B) Sudden, stabbing, severe pain over the lip and chin.
Which description of symptoms sympt oms is characteristi character isticc of a client diagnosed with trigeminal neuralgia (tic douloureux)? A) Tinnitus, vertigo, vert igo, and hearing difficultie difficulties. s. B) Sudden, stabbing, severe pain over the lip and chin. C) Facial weakness and paralysis. D) Difficulty in chewing, talking, and swallowing.
Which finding finding should should the nurse identify identify as most significant for a client diagnosed diagnosed with polycystic polycystic kidney kidney disease disease (PKD)? A) Hematuria. Hematuria. B) 2 pounds weight gain. C) 3+ bacteria in urine. D) Steady, dull flank pain.
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branch branches es of the trigeminal nerve nerve (5th cranial) (B). (A) would be characteristic of Méniére's disease (8th cranial nerve). (C) would be characteristic of Bell's palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal cranial nerve (12th).
C) 3 + bacteria in urine. Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine (C) is the most significant finding at this time. (A) is an expected finding from the rupture of the cysts. (B) does not provide a time frame to determine if the weight gain is a significant fluid fluctuation, which is determined within a 24 -hour -hour time frame. Although kidney pain can also be abrupt, episodic, and colicky related related to bleedi ng into the cysts, (D) i s more likely an early symptom in PKD.
C) Consume adequate foods rich in calcium.
Which healthcare practice practi ce is most important import ant for the nurse to teach a postmenopausal client? A) Wear layers layer s of clothes clot hes if experiencing exper iencing hot flashes. B) Use a water-soluble lubricant for vaginal dryness. C) Consume adequate foods rich r ich in calcium. D) Participate in stimulating mental exercises.
Bone density loss associated with osteoporosis osteoporosis increases at a more rapid rate when estrogen levels begin to fall, so the the m ost important healthcare practice during menopause is ensuring an adequate calcium (C) intake to help maintai n bone density and prevent osteoporosis. osteoporosis. Although practices such as (A and B) may redu ce some of the discomforts for a postmenopausal female, calcium calcium i ntake is more i mportant than comfort comfort measures. Although social and and me ntal exercises stimulate thought, there is no scientific evidence that mental exercises (D) prevent dementia or common forgetfulness associated associated with reduced hormonal levels.
Which information about mammograms is most most important to provide a post-menopausal female client? A) Breast self-examinations are not needed if a nnual mammograms are obtained. B) Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. C) Yearly mammograms should be done regardless of previous normal x-rays. D) Women at high risk should have annual routine and ultrasound mammograms.
C) Yearly mammograms should be done regardless of previous normal x-rays. The current breast screening recommendation is a yearly mammogram after age 40 (C). Breast self-exam (A) continues to be a priority recommendation for all women because a small lump (or tumor) is often first felt by a woman before a ma mmogra m is obtained. The radiation exposure exposure fr om a mammog ram is low, so (B) is not normally provided. provided. The frequency frequency of using routine and ultrasound mammogr ams (D) in women women with high-risk high-risk variables, such as a history of breast cancer, the presence of BRC1 and BRC2 genes, or 2 first-degree r elatives elatives with breast cancer, should be recommended recommended and followed closely by the healthcare provider.
Which intervention intervention should the nurse implement implement for a female client diagnosed with p elvic elvic relaxation disorder? A) Describe proper administration administration of vaginal vagina l suppositories and cream. B) Encourag e the client to p erform Kegel Kegel exercises 10 10 times daily. C) Explain the importance of using condoms when having sexua l intercourse. intercourse. D) Discuss the importance of keeping a diary of daily temperature and menstrual menstrual cycle events. events.
B) Encourag e the client to p erform Kegel Kegel exercises 10 10 times daily.
Which intervention intervention should the nurse plan to implement implement when caring ca ring for a client who has just undergone und ergone a right above-the-knee amputation? A) Maintain Ma intain the residual limb on three pillows pillows at all a ll times. B) Place a large tourniquet at the client's bedside. C) Apply constant, direct pressure to the residual limb. D) Do not allow the client to lie in the prone position.
B) Place a large tourniquet at the client's bedside. bedside.
Which milestone milest one indicates to t he nurse successful achievement of young adulthood? A) Demonstrates Demonstr ates a conceptualization conceptualizati on of death and dying. B) Completes education and becomes self-supporting. C) Creates a new definition of self and roles with others. D) Develops a strong need for parental support and approval.
Which postm postmeno enopausal pausal client's complaint should the nurse refer to the healthcare provi pr ovider? der? A) Breasts feel lumpy when when palpated. B) History of white nipple discharge. C) Episodes of vaginal bleeding. D) Excessive Ex cessive diaphoresis diaphoresis occurs at night.
Pelvic Pelvic relaxa tion disorders are structural disorders disorders resulting from weakening support tissues of the pelvis. (B) helps strengthen the surrounding muscles. Medication will not help correct a cystocele, cystocele, rectocele, or uterine prolapse (A). (C) will help prevent sexually transmitted diseases. (D) is used to identify fertile times during the woman's menstrual cycle.
A large tourniquet tourniquet should be be placed in plain s ight igh t at the the client's bedside bedside (B). If severe severe bleeding bleeding occurs, the tourniquet tourniquet should be be readily availa ble and a pplied to to the residual li mb to control hemorrhage. The residual limb should not be placed on a pillow (A) because a flexion con tracture tracture of the hip may result. result. (C) should s hould be avoided avoided because because it may comprom compromise ise wound healin g. (D) (D ) should be encouraged encouraged to stret stretch ch the flexor muscles muscles a nd to prevent prevent flexion contracture of the hip.
B) Completes education and becomes self-supporting. Transitioning through young adulthood is characterized by establis establishing hing independence as an adult, a nd includes includ es developmental tasks such as completing education, beginning a ca reer, and becoming self-supporting (B ). (A ( A and C) are characteristic of adolescence. Although strong bonds with parents are an a n expected exp ected finding for this age a ge group, the need for support and approval (D) indicates dependency, which is a developmental delay.
C) Episodes of vaginal bleeding. Postmenopausal vaginal bleeding (C) may be an indication of endometrial cancer, which should be rep orted to the healthcare provider. Compared to a new-onset of a single lump, breasts that feel lumpy (A) overall may be a normal variant or a finding consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B), dependi ng on sexual stimulation or hormonal levels, and is no longer recommended as a reportable symptom when discovered during breast self-exam (BSE). The client may need further teaching concerning (D), a disturbing symptom, but it is not as important as (C).
Which reaction should the nurse i dentify in a client who is responding re sponding to stimulation stimulat ion of the sympathetic sympat hetic nervous system? A) Pupil constr iction. B) Increased heart rate. C) Bronchial constriction. D) Decreased blood pressure.
B) Increased heart rate. Any stressor stre ssor t hat is perceived percei ved as threatening threat ening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a flight-or-fight response, which includes an increase in heart rate (B). (A, C, and D) are responses of the parasympathetic nervous system.
B) Headache, diaphoresis, and palpitations.
Which symptoms should the nurse e xpect a client to to exhibit who is known to have a pheochromocytoma? A) Numbness, tingling, and and cramps in the extremities. B) Headache, Headache, diaphoresis, diaphoresis , and palpit palpitations. ations. C) Cyanosis, fever, and classic signs of shock. D) Nausea, vomiting, and muscular muscular weakness. w eakness.
While working work ing in the emergency emerge ncy room, the nurse is exposed to a client with wit h active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? A) Immediatel y after the t he exposure. B) Within one week of the exposure. C) Four to six wee ks after the t he exposure. D) Three months after the exposure.
(B) is the typical triad of symptoms of tumors of the adrenal medulla (symptoms depend on the relative proportions of epinephrine and norepinephrine secretion). (A) lists the signs of latent tetany, exhibited by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism.
C) Four to six weeks after the exposure. A tuberculin skin skin test test is effective 4 to 6 weeks weeks after an exposure exposure (C), (C), so the individual with a known exposure should wait 4 to to 6 weeks weeks before before having having a tuberculin skin test.
