Cancer/lupus/Cirrhosis/ICP/Pancreatitis
A 25 year old patient is inquiring about the methods or ways to detect cancer earlier. The nurse least likely identify this method by stating: A Annual chest x-ray. Annual Pap smear for sexually active women only. C Annual digital rectal examination for persons over age 40. D Yearly physical and blood examination Question 1 Explanation:
2.Early detection of cancer is promoted by annual oral examination, monthly BSE from age 20, annual chest x-ray, yearly digital rectal examination for persons over age 40, annual Pap smear from age 40 and annual physical and blood examination. Letter B is wrong because it says Pap smear should be done yearly for sexually active women. All women should have an annual pap smear by age 40 and up whether sexually active or not.
Breast self examination (BSE) is one of the ways to detect breast cancer earlier. The nurse is conducting a health teaching to female clients in a clinic. During evaluation the clients are asked to state what they learned. Which of the following statement made by a client needs further teaching about BSE? A "BSE is done after menstruation." "BSE palpation is done by starting at the center going to the periphery in a circular motion." "BSE can be done in either supine or standing position." D "BSE should start from age 20."
: This client needs further teaching as palpation in BSE should start at the periphery going to the center in a circular motion
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A Urine output increases B Pupils are 8 mm and nonreactive C Systolic blood pressure remains at 150 mm Hg D BUN and creatinine levels return to norma
A
A patient is being educated on how to take their anti-thyroid medication. Which of the following statements are INCORRECT?* A. "I will continue taking aspirin daily." B. "I will take this medication at the same time every day." C. "It may take a while before I notice that the medication is helping my condition." D. "I will avoid foods containing high levels of iodine."
A
A patient is receiving radioactive iodine treatment for hyperthyroidism. What will you include in your patient education to this patient about this type of treatment?* A. Taste changes and swollen salivary glands B. Constipation C. Excessive thirst D. Sun protection
A
After undergoing a subtotal thyroidectomy, a female client develops hypothyroidism. Dr. Smith prescribes levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent? A Primary hypothyroidism B Graves' disease C Thyrotoxicosis D Euthyroidism
A
Hepatic encephalopathy develops when the blood level of which substance increases? A Ammonia B Amylase C Calcium D Potassium
A
Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? A "It empties the stomach of fluids and gas." B "It prevents spasms at the sphincter of Oddi." C "It prevents air from forming in the small intestine and large intestine." D "It removes bile from the gallbladder.
A
Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? A Restrict fluids B Encourage ambulation C Increase sodium in the diet D Give antacids as prescribed
A
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet? A Meats and beans B Butter and gravies C Potatoes and pastas D Cakes and pastries
A
Which of the following signs and symptoms causes concern and requires nursing intervention for a patient who recently had a thyroidectomy?* A. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F B. Heart rate of 35, blood pressure 60/43, temperature 95.3 'F C. Soft hair, irritable, diarrhea D. Constipation, drowsiness, goiter
A
Which of the following values is considered normal for ICP? A 0 to 15 mm Hg B 25 mm Hg C 35 to 45 mm Hg D 120/80 mm H
A
You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? A Asterixis B Chvostek's sign C Trousseau's sign D Hepatojugular reflex
A Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure? A Hypoalbuminemia B Increased capillary permeability C Abnormal peripheral vasodilation D Excess rennin release from the kidneys
A Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney's aren't direct ramifications of liver failure.
Nurse Wayne is aware that a positive Chvostek's sign indicate? A Hypocalcemia B Hyponatremia C Hypokalemia D Hypermagnesemia
A Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. If the client's facial muscles twitch, it indicates hypocalcemia. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A Unequal pupil size B Decreasing systolic blood pressure C Tachycardia D Decreasing body temperature
A Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
Which of the following respiratory patterns indicate increasing ICP in the brain stem? A Slow, irregular respirations B Rapid, shallow respirations C Asymmetric chest expansion D Nasal flaring
A Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following? A Hypocalcemia B Hypercalcemia C Hypokalemia D Hyperkalemia
A Question 50 Explanation: The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren't present with hypercalcemia, hypokalemia, or hyperkalemia.
Radiation therapy is used to treat colon cancer before surgery for which of the following reasons? A Reducing the size of the tumor B Eliminating the malignant cells C Curing the cancer D Helping the bowel heal after surgery
A Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn't curative, can't eliminate the malignant cells (though it helps define tumor margins), can could slow postoperative healing.
Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? A Tetany B Hemorrhage C Thyroid storm D Laryngeal nerve damage
A Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A Evaluate urine specific gravity B Anticipate treatment for renal failure C Provide emollients to the skin to prevent breakdown D Slow down the IV fluids and notify the physician
A Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
You are developing a care plan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? A Administering a lactulose enema as ordered B Encouraging a protein-rich diet C Administering sedatives, as necessary D Encouraging ambulation at least four times a day
A to reduce ammonia levels
A 34-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client? A She should have had a baseline mammogram before age 30. She should eat a low-fat diet to further decrease her risk of breast cancer. She should perform breast self-examination during the first 5 days of each menstrual cycle. D When she begins having yearly mammograms, breast self-examinations will no longer be necessary.
A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman's risk of breast cancer. A baseline mammogram should be done between ages 30 and 40. Monthly breast self-examinations should be done between days 7 and 10 of the menstrual cycle. The client should continue to perform monthly breast self-examinations even when receiving yearly mammograms.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate? A Apply sunscreen only after going in the water. B Avoid peak exposure hours from 9am to 1pm C Wear loosely woven clothing for added ventilation Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
A sunscreen with a SPF of 15 or higher should be worn on all sun-exposed skin surfaces. It should be applied before sun exposure and reapplied after being in the water. Peak sun exposure usually occurs between 10am to 2pm. Tightly woven clothing, protective hats, and sunglasses are recommended to decrease sun exposure. Suntanning parlors should be avoided.
A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate? "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." B "Annual x-rays will increase your risk for cancer because of exposure to radiation." C "Insurance companies do not authorize yearly x-rays just to detect early lung cancer." D "Frequent x-rays damage the lungs and make them more susceptible to cancer."
A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.
Which of the following are treatment options for hyperthyroidism? Please select all that apply:* A. Thyroidectomy B. Methimazole C. Liothyronine Sodium "Cytomel" D. Radioactive Iodine
ABD
. A patient with hypothyroidism is having pain 6 on 1-10 scale in the right hip due to recent hip surgery. Which of the following medications are NOT appropriate for this patient? Select all that apply:* A. Fentanyl B. Tylenol C. Morphine D. Dilaudid
ACD
Vanessa, a community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer? Alopecia B Back pain Painless testicular swelling D Heavy sensation in the scrotum .
Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. Options B, C, and D are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes
A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. A Decerebrate posturing B Dilated nonreactive pupils C Deep tendon reflexes D Absent corneal reflex
B C D A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.
Nausea and vomiting are common adverse effects of radiation and chemotherapy. When should a nurse administer antiemetics? 30 minutes before the initiation of therapy. B With the administration of therapy. C Immediately after nausea begins. D When therapy is completed.
Antiemetics are most beneficial when given before the onset of nausea and vomiting. To calculate the optimum time for administration, the first dose is given 30 minutes to 1 hour before nausea is expected, and then every 2, 4, or 6 hours for approximately 24 hours after chemotherapy. If the antiemetic was given with the medication or after the medication, it could lose its maximum effectiveness when needed.
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A Vomiting continues B Intracranial pressure (ICP) is increased C The client needs mechanical ventilation D Blood is anticipated in the cerebrospinal fluid (CSF
B
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? A Place her in a jacket restraint B Wrap her hands in soft "mitten" restraints C Tuck her arms and hands under the draw sheet D Apply a wrist restraint to each arm
B
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A Abnormal flexion of the upper extremities and extension of the lower extremities B Rigid extension and pronation of the arms and legs C Rigid pronation of all extremities D Flaccid paralysis of all extremitie
B
A patient was recently discharged home for treatment of hypothyroidism and was ordered to take Synthroid for treatment. The patient is re-admitted with signs and symptoms of the following: heart rate 42, blood pressure 70/56, blood glucose 55, and body temperature of 96.8 'F. The patient is very fatigued and drowsy. The family reports the patient has not been taking Synthroid since being discharged home from the hospital. Which of the following conditions is this patient most likely experiencing?* A. Thryoid Storm B. Myxedema Coma C. Iodism D. Toxic Nodular Goiter
B
Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated? A Calcium B Glucose C Magnesium D Potassium
B
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? A Sternal rub B Nail bed pressure C Pressure on the orbital rim D Squeezing of the sternocleidomastoid muscle
B
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
B A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective? A Pruritus B Dyspnea C Jaundice D Peripheral Neuropathy
B Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient's breathing. The others are signs of cirrhosis that aren't relieved by paracentesis
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A Position the client flat in bed B Check the fluid for dextrose with a dipstick C Suction the nose to maintain airway patency D Insert nasal and ear packing with sterile gauze
B Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A To reduce intraocular pressure B To prevent acute tubular necrosis C To promote osmotic diuresis to decrease ICP D To draw water into the vascular system to increase blood pressure
B Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
The nurse is teaching a postmenopausal patient with breast cancer about the expected outcomes of her cancer treatment. The nurse evaluates that the teaching has been effective when the patient says A "After cancer has not recurred for 5 years, it is considered cured." "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured." C "Cancer is considered cured if the entire tumor is surgically removed." "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."
B The risk of recurrence varies by the type of cancer; for breast cancer in postmenopausal women, the patient needs at least 20 disease-free years to be considered cured. Some cancers (e.g., leukemia) are cured by nonsurgical therapies such as radiation and chemotherapy.
Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? A Diabetic ketoacidosis B Thyroid crisis C Hypoglycemia D Tetany
B Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness.
A female client who was found unconscious at home is brought to the hospital by a rescue squaD. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A introducing ice water into the external auditory canal. B touching the cornea with a wisp of cotton. C turning the client's head suddenly while holding the eyelids open. D shining a bright light into the pupil
C
A patient is admitted with complaints of palpations, excessive sweating, and unable to tolerate heat. In addition, the patient voices concern about how her appearance has changed over the past year. The patient presents with protruding eyeballs and pretibial myxedema on the legs and feet. Which of the following is the likely cause of the patient's signs and symptoms?* A. Thyroiditis B. Deficiency of iodine consumption C. Grave's Disease D. Hypothyroidism
C
A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition?* A. Tapazole B. PTU (Propylthiouracil) C. Levoxyrothin/ Synthroid D. Inderal
C
An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: A Thyroid storm. B Cretinism. C Myxedema coma. D Hashimoto's thyroiditis
C
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A prevent respiratory alkalosis. B lower arterial pH. C promote carbon dioxide elimination. D maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
C
The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer? A Janice, a 45 y.o. with a 25-year history of ulcerative colitis B George, a 50 y.o. whose father died of colon cancer C Herman, a 60 y.o. who follows a low-fat, high-fiber diet D Sissy, a 72 y.o. with a history of breast cancer
C
Which of the following signs and symptoms of increased ICP after head trauma would appear first? A Bradycardia B Large amounts of very dilute urine C Restlessness and confusion D Widened pulse pressure
C
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A Give him a barbiturate. B Place him on mechanical ventilation. C Perform a lumbar puncture. D Elevate the head of his bed.
C The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? A An interval when the client's speech is garbled. B An interval when the client is alert but can't recall recent events. C An interval when the client is oriented but then becomes somnolent. D An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
C A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.
Neoplasm can be classified as either benign or malignant. The following are characteristics of malignant tumor apart from: A Metastasis B Infiltrates surrounding tissues Encapsulated Poorly differentiated cells
C Benign: grows slowly, localized, encapsulated, well differentiated cells, no metastasis, not harmful to host. Malignant: Grows rapidly, infiltrates surrounding tissues, not encapsulated, poorly differentiated, metastasis present, always harmful
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? A Give the client a warming blanket B Administer low-dose barbiturate C Encourage the client to hyperventilate D Restrict fluids
C Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm
Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient? A Serum creatinine and BUN B Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) C Serum amylase and lipase D Cardiac enzymes
C Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis
When instructing the female client diagnosed with hyperparathyroidism about diet, nurse Gina should stress the importance of which of the following? A Restricting fluids B Restricting sodium C Forcing fluids D Restricting potassium
C The client should be encouraged to force fluids to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.
Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes: A Continuous peritoneal lavage B Regular diet with increased fat C Nutritional support with TPN D Insertion of a T tube to drain the pancrea
C With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.
A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy? A Urine output of 400 ml in 8 hours B Serum potassium level of 3.6 mEq/L C Blood pressure of 120/64 to 130/72 mm Hg Dry oral mucous membranes and cracked lips
Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous membranes, cracked lips, decreased urine output (less than 40 ml/hour), abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A Widening pulse pressure B Decrease in the pulse rate C Dilated, fixed pupil D Decrease in LOC
D
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A Is clear and tests negative for glucose B Is grossly bloody in appearance and has a pH of 6 C Clumps together on the dressing and has a pH of 7 D Separates into concentric rings and test positive of glucose
D
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? A Disturbed sensory perception (visual) B Self-care deficient: Dressing/grooming C Impaired verbal communication D Risk for injury
D
A patient has an extremely high T3 and T4 level. Which of the following signs and symptoms DO NOT present with this condition?* A. Weight loss B. Intolerance to heat C. Smooth skin D. Hair loss
D
A patient is 6 hours post-opt from a thyroidectomy. The surgical site is clean, dry and intact with no excessive swelling noted. What position is best for this patient to be in?* A. Fowler's B. Prone C. Trendelenburg D. Semi-Fowler's
D
A patient reports they do not eat enough iodine in their diet. What condition are they most susceptible to?* A. Pheochromocytoma B. Hyperthyroidism C. Thyroid Storm D. Hypothyroidism
D
Chemotherapy is one of the therapeutic modalities for cancer. This treatment is contraindicated to which of the following conditions? A Recent surgery Pregnancy C Bone marrow depression All of the above
D Chemotherapy is contraindicated in cases of infection (chemotherapeutic agents are immunosuppressive), recent surgery (chemotherapeutic agent may retard the healing process), impaired renal and hepatic function (drugs are nephrotoxic and hepatotoxic), recent radiation therapy (immunosuppressive treatment), pregnancy (drugs can cause congenital defects) and bone marrow depression (chemo. Agents may aggravate the condition).
Which of the following describes decerebrate posturing? A Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet C Supination of arms, dorsiflexion of feet D Back arched; rigid extension of all four extremities.
D Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard would suspect which of the following disorders? A Diabetes mellitus B Diabetes insipidus C Hypoparathyroidism D Hyperparathyroidism
D Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
Which nursing diagnosis takes highest priority for a female client with hyperthyroidism? A Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess B Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing C Body image disturbance related to weight gain and edema D Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
D In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A Sternal rub B Pressure on the orbital rim C Squeezing the sternocleidomastoid muscle D Nail bed pressure
D Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail Bed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? A There is no skin breakdown B Her appetite improves C She loses more than 10 lbs D Stools are less fatty and decreased in frequency
D Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance
Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer? A Abdominal CT scan B Abdominal x-ray C Colonoscopy D Fecal occult blood test
D Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps, which can be removed before they become malignant.
During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse should include which statement? A "The head of your bed must remain flat for 24 hours after surgery." B "You should avoid deep breathing and coughing after surgery." C "You won't be able to swallow for the first day or two." D "You must avoid hyperextending your neck after surgery.
D To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing.
A client had undergone radiation therapy (external). The expected side effects include the following apart from: Hair loss B Ulceration of oral mucous membranes Constipation D Headache
Diarrhea not constipation is the side effect of radiation therapy.
Which of the following interventions is the key to increasing the survival rates of clients with lung cancer? A Early bronchoscopy B Early detection C High-dose chemotherapy D Smoking cessation
Early detection of cancer when the cells may be premalignant and potentially curable would be most beneficial. However, a tumor must be 1 cm in diameter before it's detectable on a chest x-ray, so this is difficult. A bronchoscopy may help identify cell type but may not increase survival rate. High-dose chemotherapy has minimal effect on long-term survival. Smoking cessation won't reverse the process but may help prevent further decompensation.
Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by: A breast self-examination. mammography. fine needle aspiration. D chest X-ray.
Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis.
Nurse Oliver should expect a client with hypothyroidism to report which health concerns? A Increased appetite and weight loss B Puffiness of the face and hands C Nervousness and tremors D Thyroid gland swelling
Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).
A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer? Persistent nausea B Rash Indigestion D Chronic ache or pain
Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn't one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.
Nurse Amy is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: A perform breast self-examination annually. have a mammogram annually. C have a hormonal receptor assay annually. D have a physician conduct a clinical examination every 2 years.
The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug A Dysuria B Leg cramps C Tachycardia D Blurred vision
Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.
ina, an oncology nurse educator, is speaking to a women's group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate? Mammography is the most reliable method for detecting breast cancer. B Breast cancer is the leading killer of women of childbearing age. C Breast cancer requires a mastectomy. Men can develop breast cancer.
Men can develop breast cancer, although they seldom do. The most reliable method for detecting breast cancer is monthly self-examination, not mammography. Lung cancer causes more deaths than breast cancer in women of all ages. A mastectomy may not be required if the tumor is small, confined, and in an early stage.
In teaching about cancer prevention to a community group, the nurse stresses promotion of exercise, normal body weight, and low-fat diet because A most people are willing to make these changes to avoid cancer. dietary fat and obesity promote growth of many types of cancer. C people who exercise and eat healthy will make other lifestyle changes. D obesity and lack of exercise cause cancer in susceptible people.
Obesity and dietary fat promote the growth of malignant cells, and decreasing these risk factors can reduce the chance of cancer development. Many people are not willing to make these changes. Good diet and exercise habits are not a guarantee that other healthy lifestyle changes will then occur. Obesity and lack of exercise do not cause cancer, but they promote the growth of altered cells.
Nurse Mary is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination: A at the end of her menstrual cycle. on the same day each month. C on the 1st day of the menstrual cycle. immediately after her menstrual period.
Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the 1st and last days of the cycle, the woman's breasts are still very tender. Postmenopausal women because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination.
A patient who is in her first trimester of pregnancy is diagnosed with hyperthyroidism. Which medication do you suspect the patient will be started on?* A. Propylthiouracil (PTU) B. Radioactive Iodine C. Tapazole D. Synthroid
Propylthiouracil (PTU) is the only anti-thyroid medication that can be used during the 1st trimester of pregnancy.
What should a male client over age 52 do to help ensure early identification of prostate cancer? Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. B Have a transrectal ultrasound every 5 years. C Perform monthly testicular self-examinations, especially after age 50. D Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.
Question 23 Explanation: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastases
A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells? Liver B Colon C Reproductive tract White blood cells (WBCs)
Question 27 Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A Bloody drainage from the ears B Frequent swallowing C Guaiac-positive stools D Hematuria
Question A Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? A Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B Emergent; the client is poorly oxygenated. C Normal D Significant; the client has alveolar hypoventilation.
Question A A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? A Count the rate to be sure the ventilations are deep enough to be sufficient B Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. C Call the physician to adjust the ventilator settings. D Check deep tendon reflexes to determine the best motor response .
Question B Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis
A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect: A hair loss. B stomatitis. fatigue. D vomiting.
Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific, not generalized, adverse effects of radiation therapy.
Warning signs and symptoms of lung cancer include persistent cough, bloody sputum, dyspepsia, and which of the other following symptoms? A Dizziness B Generalized weakness C Hypo tension D Recurrent pleural effusion
Recurring episodes of pleural effusions can be caused by the tumor and should be investigated. Dizziness, generalized weakness, and hypotension aren't typically considered warning signals, but may occur in advanced stages of cancer.
Nurse Kent is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make? Testicular cancer is a highly curable type of cancer. B Testicular cancer is very difficult to diagnose. Testicular cancer is the number one cause of cancer deaths in males. D Testicular cancer is more common in older men.
Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men.
Nurse Lucia is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms: yearly after age 40. B after the birth of the first child and every 2 years thereafter. C after the first menstrual period and annually thereafter. D every 3 years between ages 20 and 40 and annually thereafter.
The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are incorrect. It's recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years.
Gio, a community health nurse, is instructing a group of female clients about breast self-examination. The nurse instructs the client to perform the examination: A At the onset of menstruation B Every month during ovulation C Weekly at the same time of day 1 week after menstruation begins
The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.) Alcohol use Physical activity Body weight Colorectal screening Tobacco use Mammography Pap testing sunscreen use
The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
The nurse is instructing the client to perform a testicular self-examination. The nurse tells the client: A To examine the testicles while lying down. The best time for the examination is after a shower C To gently feel the testicle with one finger to feel for a growth That testicular examination should be done at least every 6 months.
The testicular-self examination is recommended monthly after a warm shower or bath when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with the fingers under the scrotum and the thumbs on top, the client should gently roll the testicles, feeling for any lumps. Question 37
The client with a benign lung tumor is treated in which of the following ways? A The tumor is treated with radiation only. B The tumor is treated with chemotherapy only. C The tumor is left alone unless symptoms are present. D The tumor is removed, involving the least possible amount of tissue.
The tumor is removed to prevent further compression of the lung tissue as the tumor grows, which could lead to respiratory decompensation. If for some reason it can't be removed, then radiation or chemotherapy may be used to try to shrink the tumor.
Mr. Miller has been diagnosed with bone cancer. You know this type of cancer is classified as: sarcoma. B lymphoma. C carcinoma. melanoma.
Tumors that originate from bone,muscle, and other connective tissue are called sarcomas.
On a clinic visit a client who has a relative with cancer, is asking about the warning signs that may relate to cancer. The nurse correctly identifies the warning signs of cancer by responding: A "If a sore healing took a month or more to heal, cancer should be suspected." B "Presence of dry cough is one of the warning signs of cancer." C "A lump located only in the breast area may suggest the presence of cancer." "Sudden weight loss of unexplained etiology can be a warning sign of cancer."
Unexplained sudden weight loss is a warning signal of cancer. Letter A is wrong because the sore in cancer does not heal. Nagging cough not dry cough and hoarseness of voice is a sign of cancer. Presence of lump is not limited to the breast only; it can grow elsewhere that is why letter C is wrong.
The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cancer. Which of the following, if identified by the client as a risk factor, indicates a need for further instructions? A Viral factors B Stress Low-fat and high-fiber diets D Exposure to radiation
Viruses may be one of multiple agents acting to initiate carcinogenesis and have been associated with several types of cancer. Increased stress has been associated with causing the growth and proliferation of cancer cells. Two forms of radiation, ultraviolet and ionizing, can lead to cancer. A diet high in fat may be a factor in the development of breast, colon, and prostate cancers. High-fiber diets may reduce the risk of colon cancer.
Nurse April is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: A cancerous lumps. B areas of thickness or fullness. changes from previous self-examinations. D fibrocystic masses.
Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? a Reposition the client to avoid neck flexion B Administer 1 g Mannitol IV as ordered C Increase the ventilator's respiratory rate to 20 breaths/minute D Administer 100 mg of pentobarbital IV as ordered.
a The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.
