AH- exam 2 eaqs
creatinine
0.5-1.2 mg/dL
Hemoglobin
12-18 g/dL
Sodium
135-145 mEq/L
Potassium
3.5-5.0 mEq/L
While performing a breast examination on a patient, the nurse identifies that which finding needs further evaluation?
A. Nipple retraction D. Dimpling on the breast skin
The nurse will instruct a patient recently diagnosed with cirrhosis of the liver to avoid which substance to prevent further fibrosis of the liver and allow the liver to heal and regenerate?
Alcohol Cigarettes Illicit drugs Acetaminophen
Which factor may lead to hepatic encephalopathy for a patient with cirrhosis? Select all that apply. One, some, or all responses may be correct.
Constipation Decreased fluid volume GI bleeding
Which statement about the risks of lung cancer indicates a need for further teaching?
D. People who are exposed to air pollutants are not at risk."
The nurse suspects which condition when a patient with RA experiences clinical manifestations of vasculitis, including burning and tingling in the legs and foot drop?
D. Peripheral neuropathy
A patient with a new diagnosis of RA asks the nurse what causes the disease. Which information would the nurse provide?
D. The body's immune system destroys the joint cartilage
The nurse monitors for which consequence of vasculitis in patients with RA?
D. Ulceration in the lower extremities
Which patient condition would cause the nurse to question the use of neomycin for a patient with hepatic encephalopathy?
Kidney failure
The nurse will emphasize avoidance of which drug for a patient with cirrhosis?
NSAIDs
Which method of communicating with a patient who has a hearing impairment is appropriate?
Stand in front of the patient.
Which rationale explains the use of mild diuretics in the treatment of Ménière disease?
They decrease endolymph volume.
Supplementation with which vitamin may be needed for a patient with cirrhosis if the patient is at risk for alcohol withdrawal?
Thiamine
Clay-colored stools and dark urine are typically characteristic of which complication of viral hepatitis?
intrahepatic obstruction
Which statement by a patient with cirrhosis would cause the nurse to suspect that the patient has stage I hepatic encephalopathy?
"I am unable to sleep during the night."
Which statement indicates understanding of how to observe for esophageal bleeding in the patient with cirrhosis?
"Any melena should be reported immediately."
which question does the nurse asked to assess if the patient has vertigo?
"Do you sense a spinning movement at times?"
Which statement by a patient with cirrhosis indicates the need for further instruction about the disease?
"My liver is scarred, but the cells can regenerate themselves and repair the damage."
Which instruction does the nurse provide to reduce a patient's manifestations of vertigo?
"Restrict head motion, and change positions slowly."
Which instruction would the nurse provide during discharge teaching for a patient with acute glomerulonephritis?
"Weigh yourself daily, and take your blood pressure."
Which statement would help a family improve communication with an older adult who has moderate hearing impairment?
-"Speak at a slow pace, with a deeper voice." -"Face the patient while talking to him or her." -"Avoid chewing gum or eating during a conversation."
Which cue indicates that the patient with progressive right-ear hearing loss met the plan of care goal to use other strategies to improve communication?
-Ensures lights are on in the room -Asks for written directions -Turns off the television and radio
Which instruction would the nurse provide to a patient with acute glomerulonephritis to help manage the infection?
-Maintain personal hygiene and handwashing. -Restrict potassium and sodium intake in the diet. -Consume a fluid intake equal to 24-hour urine output plus 500 mL.
Which information would the nurse include when teaching a patient newly diagnosed with SLE about managing the disease and preventing setbacks?
.A. Include aerobic exercise B. Plan frequent rest periods C. Avoid crowded public areas D. Stay in shady areas outdoors E. Use mild, non astringent soap
Ammonia levels
15-45 mcg/dL
Which gene mutation is likely to cause breast cancer?
D. BRCA2
Which sign of uremia would the nurse expect to find when assessing a patient with glomerulonephritis?
Nausea Vomiting Anorexia
Hematocrit
40-50%
WBC count
5,000-10,000/mm3
BUN
7-20 mg/dL
The nursing team consists of a registered nurse (RN), a licensed practical nurse (LPN), and a nursing assistant. Which patient must be assigned to the RN?
A patient with end-stage cirrhosis who needs teaching about a low-sodium diet
The nurse would prioritize care for which patient?
A patient with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse
Which teaching about colorectal cancer screening would a nurse give to a 56 year-old patient who has no familial adenomatous polyposis (FAP) or other risk factors related to CRC?
A. "It is recommended you get a colonoscopy every 10 years."
The nurse performs follow-up care for a group of patients who have previously had TB. Which patient is at high risk for developing secondary TB?
A. A 34-year old with HIV infection D. A 75 -ear old who is recovering from a hip replacement E. A 7-year old who is undergoing chemotherapy for leukemia
Which is a risk factor for colorectal cancer?
A. Age older than 50 years C. Family history of cancer D. History of Crohn disease E. Heavy alcohol consumption
To prevent possible HIV transmission, which is the nurses's priority action after getting stuck by a hallow-bore needle through a latex glove?
A. Bleed the wound and wash it for at least 1 full minute
The nurse expects that which diagnostic test will be prescribed for a patient who is suspected of having breast cancer?
A. Breast biopsy
When caring for a patient admitted with a flare-up of SLE receiving IV corticosteroids, which assessment would the nurse include related to this medication?
A. Daily weights B. Blood glucose C. Blood pressure D. Intake and output
When caring for a patient who receives chronic steroid therapy to treat RA, the nurse monitors for which complications associated with the medication?
A. Diabetes mellitus B. Decreased immunity C. Fluid and electrolyte imbalances D. Hypertension E. OsteoporosisF. Glaucoma
Which sign or symptom would the nurse teach a patient newly diagnosed with SLE to reports to the HCP?
A. Edema B. Weight gain D. Decreased output
Which finding would the nurse expect during the assessment of a patient with new onset RA?
A. Fatigue
The nurse expects which symptom in an adult with an acute infection that has occurred within 4 weeks of first being infected with HIV?
A. Fever B. Night sweats D. Muscle aches
A patient with rheumatoid arthritis asks the nurse how to relieve pain without taking medications. Which interventions would the nurse include in the teaching plan? Select all that apply.
A. Imagery B. Hot packs C. Acupuncture D. Heated paraffin E. Stress management
For which population may pre-exposure prophylaxis (PrEP) for the HIV be appropriate? Select all that apply.
A. Injection drug users B. Men who have sex with men C. Non monogamous heterosexually active men and women E. Adults who are HIV negative and in a relationship with a partner who is HIV positive
The nurse anticipates that which medication will be prescribed for a premenopausal patient diagnosed with breast cancer who will be receiving hormonal therapy?
A. Leuprolide
Which is a common mode of transmission for cancer metastasis?
A. Lymphatic B. Bloodborne D. Extension into surrounding tissues
Which statement pertaining to cancer development is correct?
A. Mutated normal cells may become neoplastic cells C. Secondary prevention is screening for early detection E. Primary prevention is preventing exposure to causes of cancer
How is the TNM classification of T is N0Mx for a patient with lung cancer interpreted?
A. No metastasis B. Carcinoma in situ E. Presence of metastasis cannot be assessed
Which action does the emergency department nurse take when a female patient with a benign breast disorder states that she wants only women providing care for her?
A. Respect this request
Which disease manifests as fever, weight loss, generalized weakness, fatigue, and the inflammation of the PIP and MCP joints of the hands?
A. Rheumatoid arthritis (RA)
The health care provider prescribed laboratory testing for a patient with suspected RA. Which positive test result would support this diagnosis? Select all that apply.
A. Rheumatoid factor (RF) B. Antinuclear antibody (ANA) C. Erythrocyte sedimentation rate (ESR) D. Elevated white blood cell (WBC) count E. High-sensitivity C-reactive protein (hsCRP)
A patient with SLE presents to the clinic for a 3-month follow up visit after beginning treatment with hydroxychloroquine. Which finding would lead the nurse to conclude the patient understands disease maintenance?
A. Scheduled an eye examination in 3 months
A 60-year-old adult with type 2 diabetes, who had a respiratory illness 1 week ago, presents to the emergency department coughing up blood with difficulty breathing and generalized edema. The patient's vital signs are temperature 99.9°F (37.7°C), pulse 98 beats/min, respiratory rate 26 breaths/min, blood pressure 158/100 mm Hg, and oxygen saturation 88%. Which condition is the nurse concerned about in this patient?
Acute glomerulonephritis
Portal hypertension related to cirrhosis can result in which complication?
Ascites Hemorrhoids Esophageal varices
A patient who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the patient is most important to communicate to the health care provider ?
B. "My legs are numb and weak."
Which nursing action is most appropriate for a patient with metastatic breast cancer who experiences severe nausea and vomiting after chemotherapy and is unable to eat?
B. Administer antiemetic medications as prescribed
Which information would the nurse include when conducting a community health education class on diet and cancer risk reduction?
B. Avoid beef and processed meats C. Increase consumption of whole grains E. Eat "colorful fruits and vegetables," including greens
Which hepatitis virus may cause liver cancer?
B. B C. C
When is the best time for the nurse ti begin discharge planning and a community-based plan of care for a patient with prostate cancer?
B. Before surgery
Which laboratory changes are most likely in a patient whose immune system is being overwhelmed by the HIV?
B. CD4+ T-cell counts fall, viral numbers rise
When repositioning a patient with metastatic cancer, which precaution would the nurse keep in mind?
B. Extra care must be taken to avoid fractures
The nurse suspects which diagnosis when a patient presents with symptoms of hoarseness, change in respiratory pattern, persistent cough, blood-streaked sputum, dyspnea, clubbing of the fingers, and fever?
B. Lung cancer
The nurse expects which laboratory finding in a. Patient who presents with symptoms of RA?
B. Positive ANA
The nurse is reviewing the results of a patient's prostate-specific antigen (PSA) test and notices an elevation in the findings. Which finding may this represent?
B. Prostate cancer
Which issue is often foremost in the minds of men who have been diagnosed with prostate cancer and must be addressed by the nurse?
B. Sexual function after treatment
Which sign/symptom will the nurse include when teaching a patient about cancer warning signs?
B. Unusual bleeding and discharge C. Change in bowel or bladder habits D. Nagging cough or a hoarse voice
A 52 year-old patient relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic?
C. "Finding a cancer in the early stages increases the chance for a cure."
The nurse offers some immediate nonpharmacologic advice for pain management for a patient with inflammatory pain caused by RA. Which is the most effective advice for the patient?
C. Cold applications
Which sign or symptom is a CNS indication of ADIS?
C. Dementia D. Confusion
Which type of kidney disorder may occur in a patient diagnosed with SLE?
C. Glomerular disease
When the HIV enters the patient's CD4+ T-cell, which is the new role served by the immune cell?
C. HIV factor
Which action does the nurse take when a patient with RA reports cervical pain radiating down one arm?
C. Notifies the PCP immediately
After teaching a patient with SLE ways to manage disease-related pain by decreasing inflammation, which action made by the patient indicates a need for further instruction?
C. Uses acetaminophen for pain
The nurse will make which recommendation when providing dietary teaching to a patient with hepatitis?
Consuming increased carbohydrates and moderate protein
Which nursing occurrence is a cause for post exposure prophylaxis (PEP) with combination antiretroviral therapy (cART)? Select all that apply.
D. Being stuck by a contaminated sharp needle E. Being a victim of sexual assault
When a patient with RA is prescribed hydroxychloroquine, the nurse instructs the patient to reports which clinical manifestation, which may indicate the most serious adverse effect associated with the medication?
D. Blurred vision or headache
Which cancer may the patient with familial polyposis be at risk for developing in the future?
D. Colorectal cancer
Which instruction does the nurse include in education for a patient with breast cancer about how to prevent side effects associated with tamoxifen?
D. Eat flaxseed regularly
During an annual wellness check, a 21 year-old female patient states, "I experience a lot of pain in my breasts right before my menstrual cycle begins. When my cycle is over, the pain goes away, but then it returns during the next cycle."Which benign breast disorder is the patient most likely experiencing?
D. Fibrocystic changes (FCCs)
Which finding in a patient with RA supports the nurses's conclusion of vasculitis?
D. Ischemic skin lesions around the nail base
Which is a late manifestation of RA?
D. Morning stiffness
How should the nurse communicate with a patient who has impaired hearing?
Get the patient's attention before speaking.
Which condition is the nurse concerned about for a patient with cirrhosis who has a weight gain of 2 kg, distention of the abdomen, a heart rate of 92 beats/min, and a blood pressure of 88/58 mm Hg?
Hypovolemia
The nurse will notify the health care provider about which assessment finding for a patient with cirrhosis and profound ascites?
Inaudible breath sounds
Which statement by a nurse indicates understanding of acute glomerulonephritis (GN)?
It may cause edema of the eyelids.
Which assessment is the priority when caring for an unconscious patient brought to the emergency department who has a history of Laennec cirrhosis and esophageal varices?
Noting the presence of bloody emesis or stool
For a patient with an underlying history of Ménière disease, which assessment would the nurse include when admitting the patient with pneumonia?
Pain Balance Hearing Ear ringing Pupil reaction
Lactulose may be prescribed for which purpose for a patient with cirrhosis?
Promote GI excretion of ammonia
When taking the health history of a patient with acute glomerulonephritis (GN), the nurse would question the patient about which related cause of the problem?
Recent respiratory infection
Which action will the nurse take immediately for a patient with severe cirrhosis of the liver who has a urine output of 400 mL for the past 2 days, despite adequate IV fluid administration?
Request an order for blood urea nitrogen (BUN) and serum creatinine levels.
Which laboratory result would the nurse use as the best indicator of kidney function when providing care for a patient who developed glomerulonephritis after a streptococcal infection?
Serum creatinine
Which instruction about dietary supplements would the nurse include in discharge teaching for a patient with cirrhosis?.
Use only supplements prescribed by the health care provider
Which is a common means of HIV transmission? Select all that apply.
a. sexual c. perinatal e. Parenteral
Which finding would the nurse expect for a patient with late-stage cirrhosis?
icterus