418 Final-Units 1, 3, 4

A nurse is teaching a patient who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching? "You'll continue to experience progressive muscle weakness and sensory deficits." "You'll need to take edrophonium (Tensilon) to treat the disease." "The disease is a disorder of motor and sensory dysfunction." "This disease doesn't cause sensory impairment."

"This disease doesn't cause sensory impairment."

A patient presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as 36% 27% 18% 9%

18%

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury? 3422 6844 2281 4522

3422 (1/2 must be administered in the first 8 hours)

Which patient is most at risk for developing disseminated intravascular coagulation (DIC)? A patient admitted with suspected cocaine overdose A patient with abruptio placentae A patient with a stage IV pressure ulcer A patient with heart failure and renal failure

A patient with abruptio placentae

A patient is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? Take the client's vital signs Apply a cervical collar on the client Insert a urinary Foley catheter Obtain a 12-lead ECG

Apply a cervical collar on the client

A patient with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus? Above-normal urine and serum osmolality levels Below-normal urine and serum osmolality levels Above-normal urine osmolality level, below-normal serum osmolality level Below-normal urine osmolality level, above-normal serum osmolality level

Below-normal urine osmolality level, above-normal serum osmolality level

A nurse is caring for a patient diagnosed with Guillain-Barré syndrome. The patient states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? Call the physician and prepare for intubation Explain the progression of the syndrome Assess lung sounds Encourage the client to cough

Call the physician and prepare for intubation

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process? Atelectasis Consolidation Bronchiectasis Empyema

Consolidation

A patient with disseminated intravascular coagulation (DIC) has a critically low fibrinogen level and is beginning to hemorrhage. To increase the amount of fibrinogen in the body, the nurse anticipates administering which blood product? Cryoprecipitate Fresh frozen plasma Albumin Packed red blood cells

Cryoprecipitate

Which ventilation-perfusion ratio is exhibited by a pulmonary embolus? Low ventilation-perfusion ratio Dead space Silent unit Normal ratio of perfusion to ventilation

Dead space

A patient with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Decreased breath sounds Wheezes

Decreased breath sounds

The nurse is reviewing the laboratory and diagnostic test findings of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following would the nurse expect to find? Elevated serum sodium levels Decreased serum osmolarity Decreased urine sodium levels Elevated urine calcium levels

Decreased serum osmolarity

When the nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial

Deep partial thickness

The nurse should monitor a patient receiving mechanical ventilation for which of the following complications? Gastrointestinal hemorrhage Immunosuppression Increased cardiac output Pulmonary emboli

Gastrointestinal hemorrhage

A patient has experienced several autoimmune disorders over the last 25 years, and lately has developed a new set of symptoms. What assessments would the nurse expect to find with a client with suspected Addison disease? Select all that apply. Weight gain Increased appetite Hypoglycemia Depression Hypotension

Hypoglycemia Depression Hypotension

Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply. Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone) Tizanidine (Zanaflex)

Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone)

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscle spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario? Valium Zanaflex Lioresal Dantrium

Lioresal

A nurse is preparing a teaching plan for a patient diagnosed with amyotrophic lateral sclerosis (ALS) and his family about the disorder and changes that may occur. Which of the following would the nurse least likely include in the discussion? Spasticity Difficulty swallowing Loss of bladder control Speech difficulties

Loss of bladder control

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? Rule of nines Lund and Browder method Hand method Parkland formula method

Lund and Browder method

The nurse is caring for a patient in the immediate post-thoracentesis period. In which position is the client placed? In the supine position Lying on the unaffected side In the high Fowler's position Prone with a pillow under the head

Lying on the unaffected side

Which oxygen administration device has the advantage of providing a high oxygen concentration? Nonrebreathing mask Venturi mask Catheter Face tent

Nonrebreathing mask

The nurse is caring for a patient with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply. Oxygen is dissolved High blood pressure disrupts oxygen transport Oxyhemoglobin circulates to the body tissue All systemic oxygen is available for diffusion Adequate red blood cells are needed for oxygen transport

Oxygen is dissolved Oxyhemoglobin circulates to the body tissue Adequate red blood cells are needed for oxygen transport

Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Pain Fatigue Spasticity Aphasia Depression Numbness

Pain Fatigue Spasticity Depression Numbness

The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply Epistaxis Pallor Rapid respiratory rate Bounding pulse Hypotension

Pallor Rapid respiratory rate Hypotension

A patient who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Pulmonary embolism Myocardial infarction (MI) Heart failure Pneumothorax

Pneumothorax

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. Post thoracotomy Spontaneous pneumothorax Need for postural drainage Chest trauma resulting in pneumothorax Pleurisy

Post thoracotomy Spontaneous pneumothorax Chest trauma resulting in pneumothorax

A nurse is teaching a patient about the functions of the larynx. What should the nurse include in the teaching? Select all that apply. Producing sound Facilitating coughing Preventing infection Acting as a passage way for the respiratory tract Protecting the lower airway from foreign objects

Producing sound Facilitating coughing Protecting the lower airway from foreign objects

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following? Irregular breathing at 14 to 18 breaths per minute Period of cessation of breathing Periods of normal breathing followed by periods of apnea Regular breathing where the rate and depth increase, then decrease

Regular breathing where the rate and depth increase, then decrease

A patient who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: Remove air from the pleural space Remove fluid from the lungs Administer IV medication Ventilate the patient

Remove air from the pleural space

A patient with infective endocarditis is admitted to the hospital. While obtaining a history, what should the nurse ask the client about? Select all that apply. Renal dialysis Intravenous (IV) drug use Nasal piercing Prosthetic cardiac valves Recent urinary tract infection

Renal dialysis Intravenous (IV) drug use Nasal piercing Prosthetic cardiac valves Recent urinary tract infection

A nurse is caring for a patient with Cushing's syndrome. Which interventions would the nurse include in the client's plan of care? Select all that apply. Report systolic BP greater than 139 mm Hg or diastolic BP greater than 89 mm Hg Examine extremities for pitting edema Provide a high sodium diet Administer prescribed diuretics Monitor weight

Report systolic BP greater than 139 mm Hg or diastolic BP greater than 89 mm Hg Examine extremities for pitting edema Administer prescribed diuretics Monitor weight

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis

The nurse is caring for a patient who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by what? Nitrogen narcosis Infection Impaired diffusion Shunting

Shunting

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)? Silent unit Dead space Low verntilation-perfusion ratio Normal ratio of perfusion to ventilation

Silent unit

The nurse is teaching a patient scheduled for an autograft aortic valve replacement. What statements are true about autograft replacement process? Select all that apply. Anticoagulation is necessary The grafts are obtained by excising the client's own pulmonic valves and a portion of the pulmonary artery The autograft is an alternative for children and women of child-bearing age Aortic valve autografts have remained viable for more than 20 years Mitral valve replacements are done with an autograft

The grafts are obtained by excising the client's own pulmonic valves and a portion of the pulmonary artery The autograft is an alternative for children and women of child-bearing age Aortic valve autografts have remained viable for more than 20 years

A patient with sepsis is experiencing disseminated intravascular coagulation (DIC). The patient is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for Deficient Fluid Volume related to bleeding. The most appropriate and measurable outcome for this patient is that the patient exhibits Urine output greater than or equal to 30 mL/hour Decreased bleeding Stable level of consciousness Systolic blood pressure greater than 70 mm Hg

Urine output greater than or equal to 30 mL/hour

The nurse cares for a 30-year-old patient who suffered severe head and facial burn injuries. Which action, if completed by the patient, indicates the patient is adapting to altered body image? Select all that apply Wears hats and wigs Covers face with a scarf Participates actively in daily activities Reports absence of sleep disturbance

Wears hats and wigs Participates actively in daily activities

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply. administer oxygen place the client in an upright position have the client take deep breaths perform chest physiotherapy instruct the client to cough

administer oxygen place the client in an upright position

A client reports extremely frequent urination, sometimes urinating 10 to 12 times each day. What fluid balance disorder would be expected with these symptoms? dehydration diluted urine hyponatremia hypokalemia

dehydration

A patient with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the patient is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with: depression neuropathy hypoglycemia hyperthyroidism

depression

The nurse working in the medical intensive care unit is caring for a patient admitted with mitral stenosis. What will the nurse assess is related to the pathophysiology of mitral stenosis? Select all that apply. high-pitched murmur fatigue low-pitched murmur shortness of breath with activity history of endocarditis

fatigue low-pitched murmur shortness of breath with activity history of endocarditis

A patient who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? hemoconcentration anemia fluid, electrolyte status histamine

hemoconcentration