diabetes
The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? The scar is firm and inelastic on palpation. Fibrin strands form a scaffold or framework. White blood cells migrate into the wound. Epithelial cells are grown over the granulation tissue bed.
The scar is firm and inelastic on palpation. Rationale The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.
A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective? "I should massage my feet and legs with oil or lotion." "I should apply heat intermittently to my feet and legs." "I should eat foods high in protein and carbohydrate kilocalories." "I should control my blood glucose with diet, exercise, and medication."
"I should control my blood glucose with diet, exercise, and medication." Rationale Controlling the diabetes decreases the risk of infection; this is the best prevention. Oil or lotion that is not completely absorbed may provide a warm, moist environment for bacterial growth. Coexisting neuropathy may result in injury from heat application. Protein, carbohydrates, and fats must be in an appropriate balance; high carbohydrate intake can provide too many calories.
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins."
"The cause is incompetent valves of superficial veins." Rationale Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? "Your primary healthcare provider must have forgotten to prescribe it." "Your condition is not severe enough to have physical therapy approved." "Your joints are still inflamed, and physical therapy can be harmful." "Physical therapy is not helpful for persons who suffer from RA."
"Your joints are still inflamed, and physical therapy can be harmful." Rationale Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.
The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? 68 mg/dL (3.8 mmol/L) 78 mg/dL (4.3 mmol/L) 88 mg/dL (4.9 mmol/L) 98 mg/dL (5.4 mmol/L)
68 mg/dL (3.8 mmol/L) Rationale Normal blood glucose level for an adult is 72-108 mg/dL (4-6 mmol/L). Clients who have blood glucose levels below 72 mg/dL (4 mmol/L) may experience hypoglycemia; 78 mg/dL (4.3 mmol/L), 88 mg/dL (4.9 mmol/L), and 98 mg/dL (5.4 mmol/L) are normal blood glucose levels.
A client reports an absence of menstruation to the nurse. Which condition does the nurse suspect? Gonorrhea Amenorrhea Dysmenorrhea Ectopic pregnancy
Amenorrhea Rationale An absence of menstruation indicates amenorrhea. Gonorrhea is a sexually transmitted disease. Dysmenorrhea is with painful menstruation associated with abdominal cramps. The formation of a fetus outside the uterus, such as a Fallopian tube, indicates ectopic pregnancy.
A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? Tympany Borborygmi Abdominal bruit Pleural friction rub
Borborygmi Rationale Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.
The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? Apples Broccoli Cherries Cauliflower
Broccoli Rationale Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.
A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? Client pushes the airway out. Client has snoring respirations. Client's respirations are 16 breaths per minute and unlabored. Client's systolic blood pressure drops from 130 to 90 mm Hg.
Client's systolic blood pressure drops from 130 to 90 mm Hg. Rationale A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.
What could be the possible cause of a scald injury? Contact with grease Contact with hot liquids or steam Contact with alkali in oven cleaners Contact with open flame in house fires
Contact with hot liquids or steam Rationale Scalding injuries usually result from contact with hot liquids or steam. Contact with grease and the alkali in oven cleaners may cause chemical injuries. An open flame in house fires may cause thermal injuries.
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? Cranial nerve I Cranial nerve X Cranial nerve V Cranial nerve VIII
Cranial nerve I Rationale Cranial nerve I, also known as the olfactory nerve, originates at the olfactory bulb and assists with the perception of smell. Damage to this nerve may cause a decrease in olfactory acuity. Cranial nerve X, also known as the vagus nerve, has both sensory and motor functions. Cranial nerve V, also known as the trigeminal nerve, has both sensory and motor functions. Cranial nerve VIII, also known as the vestibulocochlear nerve, assists with sensory functions such as auditory acuity.
Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes? Radiography Renal arteriography Electromyography (EMG) Cystometrography (CMG)
Cystometrography (CMG) Rationale Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes. Radiography is a diagnostic test for clients with disorders of kidney and urinary system to screen for the presence of two kidneys, to measure kidney size, and to detect gross obstruction in kidneys or urinary tract. Renal arteriography is a diagnostic study used to determine renal blood vessel size and abnormalities. Electromyography (EMG) is an urodynamic study used to test the strength of perineal muscles in voiding.
A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? Hemorrhage Gastroparesis Pulmonary embolism Tension pneumothorax
Hemorrhage Rationale In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? Hypokalemia and hyponatremia Hyperkalemia and hyponatremia Hypokalemia and hypernatremia Hyperkalemia and hypernatremia
Hyperkalemia and hyponatremia Rationale Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.
A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? Ketoacidosis Somogyi phenomenon Hypoglycemic reaction Hyperosmolar nonketotic coma
Ketoacidosis Rationale Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? Listen to the client's fears Encourage the client to socialize Grant the client's request about visitors Darken the client's room by pulling the drapes
Listen to the client's fears Rationale Voicing fears often reduces the associated anxiety. Socialization, when feelings need exploration, is not therapeutic. Although the client's request about visitors should be granted, simply accepting the client's wishes is not by itself therapeutic. Darkening the client's room avoids the problem and is not therapeutic.
Which diagnostic test may be used to distinguish vascular from nonvascular structures? Chest X-ray Pulmonary angiogram Computed tomography Magnetic resonance imaging
Magnetic resonance imaging Rationale Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.
Which structure is a component of the auditory ossicles? Malleus Vestibule Tympanic membrane External acoustic meatus
Malleus Rationale The malleus along with the incus and stapes constitutes the auditory ossicles. The vestibule is present in the inner ear and is an organ of balance. The tympanic membrane (eardrum) is a part of the middle ear. The external acoustic meatus is a component of the external ear.
The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? Notify the primary healthcare provider immediately Apply a warm, moist compress to the incision site Increase the intravenous fluid rate by 20 mL/hr Monitor vital signs more frequently
Notify the primary healthcare provider immediately Rationale The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.
A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. Oliguria Lethargy Irritability Hypotension Slurred speech
Oliguria Irritability Hypotension Rationale Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.
A client injures an amphiarthrodial joint. Which joint did the client injure? Knee joint Pelvic joint Elbow joint Cranial joint
Pelvic joint Rationale Amphiarthrodial joints are those that permit slight movements. The pelvic joint is an example of amphiarthrodial joint. Knee and elbow joints are the examples of diarthrodial joints, which are freely movable. A cranial joint is an example of a synarthrodial joint, which is immovable.
Which is the definition of photophobia? Double vision Foreign body sensation Persistent abnormal intolerance to light Gradual or sudden inability to see clearly
Persistent abnormal intolerance to light Rationale Photophobia is a persistent abnormal intolerance to light. Diplopia is double vision. Foreign body sensation results in pain. A gradual or sudden inability to see clearly is called blurred vision.
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism
Plasma proteins moving out of the intravascular compartment Rationale The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? Irrigate the T-tube as necessary Protect the abdominal skin from bile drainage Have the client wear a binder when out of bed Empty the T-tube drainage bag every two hours
Protect the abdominal skin from bile drainage Rationale The enzymatic activity of bile can cause excoriation and skin breakdown; the skin should be protected. A T-tube is not irrigated. A binder will not protect the skin, although it may support abdominal musculature. Drainage is emptied when the bag is full or at routine intervals (usually every 8 to 12 hours).
Why is Phalen's test performed in a client? To diagnose atrophy To diagnose bone tumor To detect rotator cuff injuries To detect carpal tunnel syndrome
To detect carpal tunnel syndrome Rationale Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.
A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? To decrease insulin sensitivity To stimulate glucagon production To improve the cellular uptake of glucose To reduce metabolic requirements for glucose
To improve the cellular uptake of glucose Rationale Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.