Evolve Med-Surg EAQ 1

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." Controlling the diabetes decreases the risk of infection; this is the best prevention.

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? No further action is required. Additional tests are necessary. Repeating the skin test is indicated. Results are positive, including infection.

Additional tests are necessary.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? Any rectal cancer in the family. All foods eaten in the past 24 hours. Any recent extreme emotional stress. An upper respiratory infection in the past 10 days.

All foods eaten in the past 24 hours.

A client reports an absence of menstruation to the nurse. Which condition does the nurse suspect? Gonorrhea Amenorrhea Dysmenorrhea Ectopic pregnancy

Amenorrhea

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? Hemorrhage Hypovolemic shock Gastrointestinal atony Autonomic hyperreflexia

Autonomic hyperreflexia. Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency.

Which part of the respiratory system is referred to as Angle of Louis? Hilum. Carina. Alveoli. Epiglottis.

Carina. Located at the level of the manubriosternal junction, the carina is also referred to as the Angle of Louis.

Which is a primary glomerular disease? Diabetic glomerulopathy. Chronic glomerulonephritis. Hemolytic-uremic syndrome. Systemic lupus erythematosus (SLE).

Chronic glomerulonephritis. Diabetic glomerulopathy, hemolytic-uremic syndrome, and systemic lupus erythematosus (SLE) are secondary glomerular diseases.

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.

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

Which drug can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide

Demeclocycline. Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

Which age-related effects on the immune system are seen in the older client? Increased autoantibodies. Increased expression of IL-2 receptors. Increased delayed hypersensitivity reaction. Increased primary and secondary antibody responses.

Increased autoantibodies.

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. 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.

A client injures an amphiarthrodial joint. Which joint did the client injure? Knee joint Pelvic joint Elbow joint Cranial joint

Pelvic joint

Which hormone is crucial in maintaining the implanted egg at its site? Inhibin. Estrogen Progesterone Testosterone

Progesterone. Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

Which retrograde procedure involves the examination of the ureters and the renal pelvises? Cystogram. Pyelogram. Urethrogram. Voiding cystourethrogram.

Pyelogram. A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.

What is a clinical manifestation of hypernatremia in burns? Fatigue Seizures Paresthesias Cardiac dysrhythmias

Seizures. Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? Decrease in urine output Increase in pulse strength Shrinkage of the tumor on scanning Increase in the quantity of white blood cells (WBCs)

Shrinkage of the tumor on scanning

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.

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

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 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.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

Weight gain. The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

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)

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. 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.

Which type of immunity is acquired through the transfer of colostrum from the mother to the child? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity

Natural passive immunity. Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change

No prescription change. The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure).

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. The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted.

Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling's ulcer

Paralytic ileus Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

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

Which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence

Presence of nonintact skin