Exam 3 medsurg

Which disease exhibits Lhermitte's sign as a clinical manifestation? 1 Multiple sclerosis 2 Myesthenia gravis 3 Lou Gehrig's disease 4 Huntington's disease

1 Lhermitte's sign is a transient sensory symptom manifested in the patients with multiple sclerosis. It is described as an electric shock radiating down the spine or into the limbs with flexion of the neck. Myasthenia gravis does not manifest as sensory loss. Lou Gehrig's disease, or amyotrophic lateral sclerosis, is a degenerative disorder of motor neurons and does not exhibit characteristics related to sensory loss. Huntington's disease is characterized by motor, cognitive, and psychiatric disorders, but there is no sensory loss.

After giving 6 oz. of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dL. Which nursing intervention would be the most appropriate in this situation? 1 Giving an additional 15 g of carbohydrate 2 Administering 5 percent to 10 percent dextrose infusion 3 Giving 25 to 50 mL of 50 percent glucose intravenously 4 Administering 1 mg intramuscular (IM) glucagon

1 A patient with a blood glucose level less than 70 mg/dL should be given 15 g of carbohydrates (5 to 6 oz. of fruit juice) initially. If the glucose is still less than 70 mg/dL and the patient is stable and conscious, then an additional 15 g of carbohydrates should be given. Dextrose (5 percent to 10 percent) is added to the fluid regimen in patients who are on treatment for diabetic ketoacidosis if the blood glucose level approaches 250 mg/dL. Administering 25 to 50 mL of 50% glucose intravenously and 1 mg IM glucagon is indicated for an unconscious patient or if the symptoms of hypoglycemia are worsening.

The nurse is performing discharge education for a patient who was admitted for acute hypothyroidism. The patient is undergoing thyroid hormone therapy for the first time. What statement by the patient to the nurse confirms that discharge teaching was effective? 1 "I should take my levothyroxine every morning before eating my breakfast." 2 "I should only follow up with my doctor if I start having shortness of breath." 3 "I should keep the air conditioning a few degrees colder to help me with sweating." 4 "I should limit the amount of fiber I am eating to help keep me from getting constipated."

1 A patient with a new diagnosis of hypothyroidism should be taught how to manage hypothyroidism, including taking the thyroid hormone in the morning before food. Patients with hypothyroidism need to be taught about the importance of regular follow-up care, not just when they are having abnormal symptoms. Patents with hypothyroidism should be taught to keep the environment warm and comfortable because of cold intolerance. Patients with hypothyroidism should increase the amount of fiber in their diet to prevent constipation; they should not limit the amount of fiber.

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? 1 Headache and rising blood pressure 2 Irregular respirations and shortness of breath 3 Decreased level of consciousness or hallucinations 4 Abdominal distention and absence of bowel sounds

1 Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

The nurse plans care for a patient who has a fractured femur. During the 48 to 72 hours after the fracture the nurse should monitor the patient for the development of what? 1 Fat emboli 2 Renal calculi 3 Muscle atrophy 4 Bone demineralization

1 Pressure on the bone marrow or an increase in catecholamines (related to stress) can mobilize fatty acids and the development of fat globules in the bloodstream. These fat globules travel to the lung and become lodged, causing the pulmonary symptoms. Renal calculi, muscle atrophy, and bone demineralization are potential complications of immobility; however, they would develop much later than 72 hours after the fracture.

Which is a priority nonoperative treatment following a spinal cord injury? 1 Stabilization 2 Spinal fusion 3 Cervical traction 4 Pain management

1 Stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. Pain management is important, but it is a lower priority than stabilization. Spinal fusion is a surgical procedure. Cervical traction is a closed reduction with skeletal traction and is used for early realignment (reduction) of the injury; the patient should be stabilized before a care plan is implemented.

A patient was just diagnosed with Huntington's disease. The patient's adult child is upset about the diagnosis. How can the nurse best help the patient's child? 1 Provide emotional and psychologic support. 2 Encourage him or her to get diagnostic genetic testing done. 3 Tell him the cognitive deterioration will be treated with counseling. 4 Tell him the chorea and psychiatric disorders can be treated with haloperidol (Haldol)

1 The patient's child will first need emotional and psychologic support. He or she should be taught about diagnostic genetic testing for him- or herself but should decide with a genetic counselor if and when he or she wants this done. The treatment plan for the father will be determined depending on the father's needs.

When performing a physical assessment on a patient with amyotrophic lateral sclerosis, which manifestations is the nurse likely to find? Select all that apply. 1 Limb weakness 2 Difficulty swallowing 3 Difficulty articulating words 4 Twisting movements of the face 5 Involuntary movements of the body

1,2,3 Amyotrophic lateral sclerosis is a rare, progressive neurologic disorder characterized by loss of motor neurons. The disease is characterized by limb weakness, difficulty in articulating words (dysarthria), and difficulty in swallowing (dysphagia). The symptoms are due to denervation of the muscles and lack of stimulation and use. Twisting movements of the face and involuntary movements of the body do not occur in amyotrophic lateral sclerosis.

A nurse is taking care of a patient with a cast on the right leg maintained in external traction. However, during the routine examination, the nurse finds that the patient has compartment syndrome. What measures should a nurse take in the management of this patient? Select all that apply. 1 Cut the cast in half. 2 Reduce external traction weight. 3 Remove or loosen any bandage. 4 Apply cold compresses to the leg. 5 Elevate the affected limb above heart level.

1,2,3 If the patient has compartment syndrome, the cast should be split in half. If there are any bandages, they should be removed or loosened to remove the pressure. A reduction in traction weight may also decrease external circumferential pressures. Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level. The application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

The nurse is caring for a patient with Parkinson's disease. What adjustments should the nurse make in the dietary habits of the patient to prevent malnutrition and constipation? Select all that apply. 1 Cut food into bite-size pieces. 2 Serve hot foods on a warmed plate. 3 Include whole grains and fruits in the diet. 4 Include plenty of food items high in protein. 5 Provide three large meals rather than six small meals.

1,2,3 Patients with Parkinson's disease are predisposed to malnutrition and constipation, owing to inadequate food intake caused by difficulty in chewing and swallowing. To promote adequate nutrition, the nurse should include whole grains and fruits in the diet, which will prevent constipation. The food should be cut into bite size pieces so that chewing and swallowing are easy. Serving hot foods on a warmed plate makes the food more appealing. Food items high in protein should be limited in the diet because they can interfere with the absorption of carbidopa-levodopa, the most common drug used in the treatment of Parkinson's disease. Six small meals, rather than three large meals, would be less exhausting for the patients.

The nurse is caring for the patient with skeletal traction for an extremity fracture. What action(s) by the nurse are most appropriate? Select all that apply. 1 Keep the weights off of the floor. 2 Elevate the end of the bed as needed. 3 Ensure that the weights are secured to the pulleys. 4 Confirm that the forces are pulling in the same direction. 5 Make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg). 6 Apply the traction intermittently as prescribed by the health care provider (HCP).

1,2,5 The weights must be kept off of the floor. The end of the bed may need to be elevated so that the weights are off the floor for traction to be applied. Traction weight ranges from 5 to 45 pounds (2.3 to 20.4 kg). Weight forces have to be in the opposite direction (counter traction). Traction must be applied continuously to be effective and the weights have to move freely through the pulleys.

A patient with a family history of Huntington's disease (HD) who underwent genetic testing has positive results. What can the nurse infer from this finding? Select all that apply. 1 There is no cure for this disease. 2 The patient would not be treated completely with the help of drugs. 3 The patient will develop a progressive, degenerative brain disorder. 4 The onset of disease usually occurs between 30 and 50 years of age. 5 The patient will be a carrier of the mutated gene but will not develop the disease.

1,3,4 Huntington's disease is an autosomal dominant disorder caused by a mutation in the HTT gene located on chromosome 4. Genetic testing, or DNA testing, is useful in diagnosing the disease but is not helpful in predicting the onset of symptoms. There is no cure for the disease. The onset of disease usually occurs between 30 and 50 years of age. Huntington's disease is a progressive, degenerative brain disorder. The symptoms of behavioral problems and movement disorder can be controlled with drugs. Negative test results would indicate that the person does not carry the mutated gene and will not develop the disease.

A patient with a family history of Huntington's disease (HD) who underwent genetic testing has positive results. What can the nurse infer from this finding? Select all that apply. 1 There is no cure for this disease. 2 The patient would not be treated completely with the help of drugs. 3 The patient will develop a progressive, degenerative brain disorder. 4 The onset of disease usually occurs between 30 and 50 years of age. 5 The patient will be a carrier of the mutated gene but will not develop the disease.

1,3,4 Huntington's disease is an autosomal dominant disorder caused by a mutation in the HTT gene located on chromosome 4. Genetic testing, or DNA testing, is useful in diagnosing the disease but is not helpful in predicting the onset of symptoms. There is no cure for the disease. The onset of disease usually occurs between 30 and 50 years of age. Huntington's disease is a progressive, degenerative brain disorder. The symptoms of behavioral problems and movement disorder can be controlled with drugs. Negative test results would indicate that the person does not carry the mutated gene and will not develop the disease.

A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient? Select all that apply. 1 Anemia 2 Leukemia 3 Leukopenia 4 Polycythemia vera 5 Thrombocytopenia

1,3,5 Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia, leukopenia, and thrombocytopenia are probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia is also due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Leukemia and polycythemia vera are not caused by cirrhosis.

The nurse is planning discharge teaching for a patient with myasthenia gravis. What instructions should the nurse include in the plan? Select all that apply. 1 Plan activities with periods of rest. 2 Practice hobbies such as playing golf. 3 Include liquid rather than solid foods in the diet. 4 Eat a balanced diet that can be easily chewed and swallowed. 5 Schedule drugs so that the peak effect of the drug is at mealtime.

1,4,5 The discharge teaching should focus on the neurologic deficits and their effect on daily living. Teach the patient about a balanced diet that can easily be chewed and swallowed. Help the patient plan activities of daily living to avoid fatigue. Scheduling doses of drugs so that peak action is reached at mealtime may make eating less difficult. Semisolid foods may be easier to eat than solids or liquids. Arrange diversional activities that require little physical effort and match the patient's interests. Playing golf may be too exhausting.

Bisphosphonates have been recommended for a patient with osteoporosis. What patient education is important for the nurse to include? Select all that apply. 1 Take them with a full glass of water. 2 Drink only sips of water with the pill. 3 Take them with a full meal at dinner. 4 Take them 30 minutes before food or medications. 5 Remain upright for at least 30 minutes after taking a dose. 6 Take them first thing in the morning on an empty stomach.

1,4,5 Bisphosphonates should be taken with a full glass of water at least 30 minutes before meals and other medications, and the patient should remain upright for at least 30 minutes after the dose. It is not recommended to take on an empty stomach, with a full meal, or with sips of water.

A patient with a T3-level spinal cord injury has been discharged from the hospital with an indwelling catheter for neurogenic bladder. The nurse is teaching the patient regarding the care for indwelling catheters. What instructions should the nurse give regarding home care for indwelling catheters? Select all that apply. 1 Cleanse the catheter regularly. 2 Always keep the urine bag above the waist. 3 Limit water intake to less than a liter a day. 4 Check for the presence of any folds or kinks in the catheter tube. 5 Check for signs of urinary tract infection (fever, change in odor or color of urine).

1,4,5 Indwelling catheters should be cleaned regularly, and the method of cleaning should be taught properly by the nurse to the patient to avoid any infections. The patency of the catheter tube should always be checked to prevent any accumulation of urine in the bladder. Long-term use of an indwelling catheter may be associated with urinary tract infection. Signs and symptoms of these conditions should be explained to the patient. The urine bag should always be placed below the level of the bladder to ensure proper drainage. Patients with indwelling catheters need to have an adequate fluid intake (at least 3 to 4 L/day).v

The nurse is managing the care of a patient with a seizure disorder who was admitted for status epilepticus. Which long-acting antiseizure medications would be effective for a patient with status epilepticus? Select all that apply. 1 Phenytoin 2 Diazepam 3 Lorazepam 4 Lamotrigine 5 Phenobarbital

1,4,5 Phenytoin, lamotrigine, and phenobarbital are the drugs with a long half-life that are used in treating status epilepticus. Diazepam and lorazepam are the rapid-acting drugs used in the treatment of status epilepticus. They have a short half-life.

Which assessment findings are associated with complications of cirrhosis of the liver? Select all that apply. 1 Pedal edema 2 Productive cough 3 Mental status changes 4 Black, tarry stools 5 Chest pain with diaphoresi

3,4 Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can present as blood in vomitus or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbance, and lethargy. Cirrhosis doesn't typically cause chest pain, diaphoresis, or productive cough.

The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on what knowledge? 1 Decreased peristalsis in the gastrointestinal tract contributes to a buildup of bile salts. 2 Jaundice results from the body's inability to conjugate and excrete bilirubin. 3 A lack of clotting factors promotes the collection of blood under the skin surface. 4 Decreased colloidal oncotic pressure from hypoalbuminemia causes the yellowish skin discoloration.

2 Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin. Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure.

A patient's blood glucose level before breakfast is 324 mg/dL. The nurse reviews the electronic medical record and notes that the patient receives a high dose of insulin each evening at bedtime. The nurse recognizes that the patient's hyperglycemia is most likely due to which problem with insulin therapy? 1 Lipodystrophy 2 Somogyi effect 3 Allergic reaction 4 Dawn phenomeno

2 The Somogyi effect occurs when a patient receives a high dose of evening/bedtime insulin that produces a decline in blood glucose levels during the night. As a result, counter regulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. Lipodystrophy is atrophy or hypertrophy of the subcutaneous tissue. Allergic reactions related to insulin occur as local inflammatory reactions and do not produce hyperglycemia. The dawn phenomenon also is characterized by hyperglycemia that is present on awakening; however, it is caused by growth hormone and cortisol excretion during the early morning hours and is unrelated to the amount of insulin given at nighttime.

After giving 6 oz. of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dL. Which nursing intervention would be the most appropriate in this situation? 1 Giving an additional 15 g of carbohydrate 2 Administering 5 percent to 10 percent dextrose infusion 3 Giving 25 to 50 mL of 50 percent glucose intravenously 4 Administering 1 mg intramuscular (IM) glucago

2 A patient with a blood glucose level less than 70 mg/dL should be given 15 g of carbohydrates (5 to 6 oz. of fruit juice) initially. If the glucose is still less than 70 mg/dL and the patient is stable and conscious, then an additional 15 g of carbohydrates should be given. Dextrose (5 percent to 10 percent) is added to the fluid regimen in patients who are on treatment for diabetic ketoacidosis if the blood glucose level approaches 250 mg/dL. Administering 25 to 50 mL of 50% glucose intravenously and 1 mg IM glucagon is indicated for an unconscious patient or if the symptoms of hypoglycemia are worsening.

What is the clinical manifestation of Addison's disease? 1 Delusions 2 Hypokalemia 3 Hyperglycemia 4 Truncal obesity

2 Addison's disease occurs due to the hypofunction of adrenal cortex. This hypofunction manifests as delusions, which occur due to decreased levels of glucocorticoids. Hypokalemia, hyperglycemia, and truncal obesity are clinical manifestations of Cushing syndrome that occur due to hyperfunction of the adrenal cortex.

Which statement by a patient shows ineffective learning about diabetes management? 1 "I will exercise daily." 2 "I will drink fruit juices daily." 3 "I will walk wearing shoes daily." 4 "I will have yearly influenza vaccination.

2 Having fruit juices daily does not help in diabetes management, because it contains sugars that are easily absorbed. Exercising daily helps to maintain good health. Wearing shoes daily will avoid injuries to feet, which is important, because wound healing is delayed in diabetic patients. Diabetic patients have weakened immune systems and are more prone to flu. Therefore, annual vaccination against influenza is required

A patient is admitted to the hospital after sustaining a C7 spinal cord injury. What is the most important nursing intervention during the acute stage of care? 1 Monitoring vital signs 2 Maintaining a patent airway 3 Maintaining proper body alignment 4 Turning and repositioning the patient every two hours

2 Initial care for a patient with a C7 spinal cord injury is focused on establishing and maintaining a patent airway and supporting ventilation. Even though the injury is located at C7, spinal edema may extend to the C4 level and cause paralysis of the diaphragm. Therefore the effects and extent of edema are unpredictable, initially necessitating close monitoring of respiratory status. Monitoring the vital signs and maintaining proper body alignment are important nursing interventions but are not as high a priority as maintaining a patent airway. Turning and repositioning the patient every two hours depends on the stability of the spinal cord injury and the status of spinal precautions. A patient with a spinal cord injury may require a specialty bed or device.

The patient received regular insulin eight units subcutaneously (SQ) at 0900. The nurse plans to monitor this patient for signs of hypoglycemia during which time? 1 1000 and 1100 2 1100 and 1400 3 1200 and 1300 4 1300 and 1500

2 Regular insulin exerts peak action in two to five hours, placing the patient at greatest risk for hypoglycemia between 1100 and 1400. At this time, the nurse should offer the patient a snack. 1000 and 1100, 1200 and 1300, and 1300 and 1500 are not consistent with peak action of insulin administered at 0900.

A patient is at risk of bone fracture from osteoporosis. Which high-impact activity should the nurse inform the patient to avoid because it may cause bone fracture? 1 Walking 2 Running 3 Dancing 4 Swimming

2 Running places too much repetitive stress on the bones and may cause bone fractures in a patient with osteoporosis. Swimming, walking, and dancing are low-impact activities that place less stress on the bones.

A nurse is caring for a patient with diabetes mellitus who is in an inpatient unit. The primary health care provider has ordered regular insulin. The nurse is preparing the medication for subcutaneous injection. What is the most effective site for subcutaneous injection of insulin? 1 Thigh 2 Abdomen 3 Upper arm 4 Right buttock

2 The abdomen is the preferred injection site; it provides the fastest subcutaneous absorption. The thigh, upper arm, and buttock are other sites that may be used for subcutaneous injection, but the abdomen is the best site.

The patient is brought to the emergency department following a car accident and is wearing medical identification that says the patient has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient? 1 Low-sodium diet 2 Increased glucocorticoid replacement 3 Suppression of pituitary adrenocorticotropic hormone (ACTH) synthesis 4 Elimination of mineralocorticoid replaceme

2 The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's also may need a high-sodium diet. Suppression of pituitary ACTH synthesis is done for Cushing's syndrome. Elimination of mineralocortic

The nurse teaches a student nurse about traction. Which statement made by the student nurse reflects effective learning? 1 "Traction prevents active and passive exercise." 2 "Traction provides immobilization to the joint or body part." 3 "Traction decreases the joint space before a major joint reconstruction." 4 "A Buck's traction boot is a type of skeletal traction."

2 Traction is the application of a pulling force to an injured or diseased part of the body or an extremity. Traction is used to immobilize a joint or part of the body in order to promote joint stabilization and prevent soft tissue damage. Traction promotes active and passive exercise. It does not prevent it. This minimizes muscle spasms, which may further complicate the injury. Traction helps to increase, not decrease, space in the joint before major joint reconstruction. A Buck's traction boot is s type of skin traction that is used preoperatively in a patient with a hip fracture awaiting surgery. It helps to reduce muscle spasm.

Which treatment is useful in decreasing the serum ketone level in patients with diabetic ketoacidosis? 1 Electrolytes 2 Insulin therapy 3 Sodium bicarbonate 4 Intravenous (IV) fluids

2 When the body cannot utilize glucose for energy, it burns fat for energy, resulting in the production of ketones. Insulin therapy is useful for reducing the serum ketone levels. Electrolytes are given to correct the electrolyte imbalance. Sodium bicarbonate is given to treat metabolic acidosis. IV fluids are indicated for correction of dehydration.

What nursing interventions would be applied first for the patient with acute exacerbation of multiple sclerosis? Select all that apply. 1 Assisting the patient with the grieving process 2 Preventing the complication of pressure ulcers 3 Preventing the complication of urinary tract infections 4 Teaching the patient to build a general resistance to illness 5 Teaching the patient to maintain a good balance between exercise and rest

2,3, A patient experiencing an acute exacerbation of multiple sclerosis may be immobile and confined to bed. The first nursing interventions in this phase are aimed at preventing major complications associated with immobility. Pressure ulcers may occur due to the immobility of the patient while confined to the bed. Immediate care should be taken to prevent this. Urinary tract infections are also common due to the stagnation of urine. Assisting the patient with the grieving process is an important intervention during the diagnostic phase of multiple sclerosis. It is not applicable to a patient with an acute exacerbation of the disease. Teaching the patient to build general resistance to illness is a general intervention for a patient suffering from multiple sclerosis. Teaching the patient to maintain a good balance between exercise and rest is a general intervention for a patient with multiple sclerosis. It is not applicable for patients who are immobile.

A patient with spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient states to the nurse, "I can't believe this is happening to me." Which nursing actions are appropriate for this patient? Select all that apply. 1 Show sympathy towards the patient. 2 Encourage the patient to set daily goals. 3 Encourage the patient to participate in care. 4 Explain the injury using written teaching material. 5 Teach the patient what to expect during the rehabilitation period.

2,3,5 Appropriate nursing actions include encouraging the patient to participate in care, allowing the patient to make daily goals, and teaching the patient what to expect during the rehabilitation process. Although the nurse should empathize with the patient, sympathy is not a therapeutic action. The use of written material may not be the best way to teach this patient at this time.

A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply. 1 Tachycardia 2 Bradycardia 3 Hypotension 4 Hypertension 5 Peripheral vasodilation 6 Peripheral vasoconstriction

2,3,5 A spinal cord injury above T-6 leads to dysfunction of the sympathetic nervous system, which may result in neurogenic shock, indicated by peripheral vasodilation, bradycardia, and hypotension. Tachycardia, hypertension, and peripheral vasoconstriction typically only occur if the sympathetic system is intact.

A patient diagnosed with myasthenia gravis reports difficulty in swallowing, chewing, eye movement, and facial mobility. Which drugs are most suitable for the patient? Select all that apply. 1 Tramadol 2 Prednisone 3 Azathioprine 4 Chlorzoxazone 5 Pyridostigmine

2,3,5 Difficulty in swallowing, chewing, eye movement, and facial mobility are the symptoms of myasthenia gravis. The most common drug therapies for this condition include anticholinesterase drugs, corticosteroids, and immunosuppressants. Corticosteroids, especially prednisone, are used to suppress the immune responses that are the main reason for such symptoms. Azathioprine is an immunomodulator used for immune suppression. Pyridostigmine is an example of an anticholinesterase that prolongs the action of acetylcholine at the neuromuscular junction. Tramadol is an opioid analgesic; it is contraindicated for patients with myasthenia gravis. Chlorzoxazone is an example of a muscle relaxant; it is contraindicated for patients with myasthenia gravis.

Which clinical manifestations does the nurse expect in a hospitalized patient diagnosed with Graves' disease? Select all that apply. 1 Anemia 2 Dysrhythmia 3 Systolic murmurs 4 Distant heart sounds 5 Systolic hypertension

2,3,5 Graves' disease is a term used to describe hyperthyroidism. Clinical manifestations associated with this disease process include tachycardia, dysrhythmia, systolic murmurs, and systolic hypertension. Hypothyroidism is associated with anemia and distant heart sounds.

A patient with spinal cord injury has begun to get stress ulcers. What nursing interventions should be performed for this patient? Select all that apply. 1 Withhold antacids. 2 Check stools for blood. 3 Motivate the patient and provide a stress-free environment. 4 Obtain prescriptions for increased dosage of corticosteroids. 5 Administer proton pump inhibitors for prophylaxis as prescribed.

2,3,5 In spinal cord injuries, stress ulcers are an important complication resulting from the physiologic response to severe trauma, the psychologic stress associated with the injury, and treatment with high-dose corticosteroids. The stress ulcers usually appear between 6 to 14 days after injury. Stool and gastric contents should be daily checked for presence of blood. Prophylactic treatment with histamine (H2)-receptor blockers like ranitidine or proton pump inhibitors like pantoprazole helps in decreasing the secretion of HCl acid and prevents ulcers during the initial phase. Antacids should be given along with corticosteroids to prevent development of stress ulcers.

A patient is suspected of having cervical cord injury following a motor vehicle accident. Which nursing interventions are appropriate for this patient to stabilize the cervical spine? Select all that apply. 1 Avoid "logrolling" of the patient. 2 Ensure that the patient's body is correctly aligned. 3 Use a sternal-occipital-mandibular immobilizer brace. 4 Use a soft cervical collar to stabilize the cervical spine. 5 Use a firm backboard to prevent any spinal movement.

2,3,5 Proper immobilization of the neck involves the maintenance of a neutral position. This can be obtained by use of a hard cervical collar and a backboard to stabilize the neck to prevent lateral rotation of the cervical spine. The nurse should ensure that the body is always correctly aligned. The patient can also use a sternal-occipital-mandibular immobilizer brace. A soft collar is not sufficient to immobilize the cervical spine. When turning the patient, the patient's body should be moved as a unit (i.e., "logrolling") to prevent movement of the spine.

The nurse is caring for a patient after thyroidectomy. What are the nursing interventions for this patient? Select all that apply. 1 Place the patient in Fowler's position. 2 Monitor vital signs and calcium levels. 3 Check for muscular twitching or tingling in the toes. 4 Assess the patient for hemorrhage every six hours. 5 Assess the patient for irregular breathing or neck swelling.

2,3,5 The nurse should monitor the patient's vital signs and calcium levels. The patient should be assessed for muscular twitching or tingling in the toes, which are signs of tetany secondary to hypoparathyroidism. The nurse should assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings. The patient should be placed in semi-Fowler's position and the head should be supported with pillows.

A patient with spinal cord injury has to be catheterized. Which nursing interventions will help to prevent urinary tract infection (UTI)? Select all that apply. 1 Empty the urine bag whenever it is 25 percent filled. 2 Ensure regular and complete drainage of the bladder. 3 Start intermittent catheterization once the patient is stabilized. 4 Maintain the urine drainage bag above the level of the bladder. 5 Cleanse the patient's genitalia using antiseptic before placing the catheter.

2,3,5 UTIs are a common problem in patients with spinal cord injuries. The best method for preventing UTIs is regular and complete bladder drainage. After the patient is stabilized, the best means of managing long-term urinary function should be assessed. Usually the patient is started on an intermittent catheterization program. The other common yet important intervention that a nurse could utilize is to use aseptic methods while inserting the catheter, like cleaning the genitalia using antiseptic. The urine bag should be drained every eight hours or when filled about two thirds. When catheterized for a long period, the urine bag should be kept below the level of the bladder; this will prevent backflow of urine and guard against infections.

A patient with a T1-level spinal cord injury is soon to be discharged from the hospital. The nurse has to plan the home care for neurogenic bowel management. What should the nurse include in the care plan? Select all that apply. 1 Teach the Valsalva maneuver. 2 Explain the use of stool softeners. 3 Advise the patient to eat a high-fiber diet. 4 Advise the patient to limit fluids in the diet. 5 Teach the patient how to use suppositories for evacuation. 6 Teach the patient to perform digital stimulation of the rectum.

2,3,5,6 Careful management of bowel evacuation is necessary in the patient with spinal cord injury (SCI) because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

Which discharge instructions would a nurse give to a patient with a cast? Select all that apply. 1 Use talcum powder under the cast as needed. 2 Keep the extremity elevated as much as possible. 3 Take pain medications only when the pain is unbearable. 4 Report a fever or a foul odor coming from beneath the cast. 5 Report itching under the cast that could indicate an infection. 6 Keep the extremity in a dependent position as much as possible.

2,4, A fever or a foul odor coming from beneath the cast may indicate an infection and requires immediate attention. The extremity should be elevated as much as possible to prevent edema. No product such as talcum powder, cornstarch, or lotion should be put down a cast to relieve itching, because this may increase the risk of infection. If pain is present, the patient should take pain medication before reaching an unbearable level. Itching under the cast is normal and does not need to be reported to the primary health care provider, but the patient must be advised to avoid scratching, because breaks in the skin under the cast can easily become infected. Keeping the extremity elevated, not dependent, decreases edema.

The nurse is performing a physical examination on a patient with Parkinson's disease. What manifestations of Parkinson's disease is the nurse likely to find? Select all that apply. 1 Nystagmus 2 Drooling of saliva 3 Patchy blindness 4 Decreased arm swing 5 Shuffling, propulsive gait

2,4,5 The patient may manifest drooling of saliva; shuffling, propulsive gait; and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia. Patchy blindness and nystagmus are not found in Parkinson's disease.

A patient is diagnosed with adrenocortical insufficiency. Which laboratory findings would be consistent with this diagnosis? Select all that apply. 1 Serum sodium: 140 mEq/L 2 Serum potassium: 6.5 mEq/L 3 Blood glucose levels: 80 mg/dL 4 Blood urea nitrogen (BUN): 30 mg/dL 5 Electrocardiogram (ECG): Peaked T waves

2,4,5 Adrenocortical insufficiency leads to hyperkalemia and the resulting peaked T waves in an electrocardiogram (ECG), as well as an elevated blood urea nitrogen (BUN) level. Normal serum electrolyte ranges include sodium from 135 to 145 mEq/L, potassium from 3.5 to 5 mEq/L, glucose from 70 to 99 mg/dL, and blood urea nitrogen from 6 to 20 mg/dL. A serum potassium level of 6.5 mEq/L shows hyperkalemia, which promotes peaked T waves in an ECG. A blood urea nitrogen level of 30 mg/dL shows an increased level.

A nurse is caring for a patient who underwent subtotal thyroidectomy because of the overproduction and release of thyroid hormone. Postoperative nursing interventions are important to prevent complications after surgery. Which nursing interventions should the nurse implement for safe, effective care? Select all that apply. 1 Monitor vital signs and potassium levels. 2 Control postoperative pain by administering medication. 3 Place the patient supine and support the head with pillows. 4 Assess for signs of tetany secondary to hypoparathyroidism. 5 Assess the patient every two hours for signs of bleeding or tracheal compression.

2,4,5 Nursing interventions after a thyroidectomy are important to prevent complications, such as airway obstruction. These interventions include controlling pain with medication; assessing for signs of tetany (i.e., tingling in toes, fingers, and around the mouth, Trousseau sign, and Chvostek sign); and assessing the patient every two hours for signs of bleeding and tracheal compression. Monitoring vital signs is important, but monitoring potassium levels is not; the calcium levels should be monitored. The patient should be placed in a semi-Fowler's position, not supine, with the head supported with pillows.

A nurse is caring for a patient admitted for hyperthyroidism. What laboratory results will the nurse expect to see in the electronic chart to confirm hyperthyroidism? Select all that apply. 1 Elevated TSH level 2 Undetectable TSH level 3 Low free thyroxine (free T4) level 4 Elevated free thyroxine (free T4) level 5 Low thyroid-stimulating hormone (TSH) level

2,4,5 The primary laboratory findings to confirm the diagnosis of hyperthyroidism are low or undetectable TSH levels and elevated free thyroxine levels. Low free thyroxine levels and elevated TSH levels are found with hypothyroidism.

A patient has been admitted with T2-level spinal cord injury and has abnormal cardiovascular signs and symptoms. Which drugs should the nurse administer to stabilize the condition of this patient? Select all that apply. 1 Digoxin 2 Atropine 3 Metoclopramide 4 Vasodilator drugs 5 Vasopressor drugs

2,5, Due to the spinal cord injury at the T2 level, the patient may have abnormal cardiac signs and symptoms like bradycardia, peripheral vasodilation, and hypotension. Atropine should be administered to increase the heart rate and prevent hypoxemia. Hypotension should be treated by administering IV fluids or vasopressor drugs. Vasodilators would accentuate the peripheral pooling of blood, thereby worsening the condition. Digoxin is used to treat arrhythmias like ventricular tachycardia, and they act by reducing the heart rate. The patient has bradycardia, so digoxin administration would worsen the condition. Metoclopramide is not given for cardiac condition; it is used to treat delayed gastric emptying.

A patient with a history of epilepsy is in the postanesthesia recovery unit (PACU) after surgery under local anesthesia. The patient has a tonic-clonic seizure that lasts two minutes. Which action should the nurse take while the patient is having the seizure? 1 Restrain the patient to prevent injury. 2 Reorient the patient to place and time. 3 Ensure the patient has a patent airway. 4 Administer 50 grams of dextrose intravenously.

3 During a tonic-clonic seizure, the patient becomes unconscious, has generalized stiffening (tonic phase), and then jerking (clonic phase). The most important nursing intervention is to maintain the patient's open airway. Suctioning equipment should be available. The patient should not be restrained but protected from injury. Intravenous dextrose is not indicated, because the patient is not noted to be hypoglycemic. Reorientation is not done with the patient unconscious during the seizure.

Which clinical manifestation is a classic finding in Graves' disease? 1 Gingivitis 2 Cretinism 3 Exophthalmos 4 Muscular dystrophy

3 Exophthalmos is the protrusion of eyeballs from the orbits; it results from increased fat deposits and fluid in orbital tissues. It is a classic clinical manifestation in Graves' disease. Gingivitis, cretinism, and muscular dystrophy are not classic clinical manifestations associated with Graves' disease.

A nurse is reviewing the laboratory findings of a diabetic patient. What condition does the nurse suspect? BG 260 PH 6.8 serum bicarbonate 12 meq ketone bodies moderate to large 1 Diabetic retinopathy 2 Diabetic neuropathy 3 Diabetic ketoacidosis 4 Diabetic nephropath

3 Laboratory findings of blood glucose level greater than 250 mEq/L, arterial blood pH less than 7.30, serum bicarbonate level less than 16 mEq/L, and the presence of moderate to large ketone bodies in the urine or serum indicate diabetic ketoacidosis. Diabetic retinopathy is microvascular damage to the retina; it may not be associated with these manifestations. Diabetic neuropathy is nerve damage due to diabetes mellitus. Diabetic nephropathy is damage to nephrons due to hyperglycemia.

A patient diagnosed with osteoporosis has a daily diet that includes 1 cup of skim milk, 1 cup of soft-serve ice-cream, 1 cup of cooked spinach, 1 cup of almonds, 8 oz. of yogurt, and 1 egg. What should the nurse record as the patient's calcium intake? 1 400 mg/day 2 1080 mg/day 3 1521 mg/day 4 2000 mg/day

3 Osteoporosis can be prevented and treated by maintaining a recommended calcium intake. For postmenopausal women who are not receiving supplemental estrogen, 1500 mg/day is recommended. The diet plan includes 1 cup skim milk = 302 mg, 1 cup soft-serve ice cream = 272 mg, 1 cup cooked spinach = 200 mg, 1 cup almonds = 415 mg, 8 oz. yogurt = 304 mg, 1 egg = 28 mg. Therefore the total calcium intake of this patient is 1521 mg/day.

What is the nursing action of highest priority to be taken with a patient who experiences a generalized tonic-clonic seizure? 1 Restraining the arms and legs 2 Controlling head movements 3 Protecting the head and extremities 4 Inserting a tongue blade between the teeth

3 Staying with the patient to provide protection of the head and extremities is the most important nursing care activity for a patient experiencing a generalized tonic/clonic seizure. Attempting to restrain or control the jerking movement of the head and extremities during a seizure may cause further injury and even fracture bones. Body parts should not be restrained or controlled. Use of a tongue blade is not acceptable in current practice because it is difficult to insert once the seizure begins and the patient may bite through the tongue blade and aspirate.

A nurse is providing discharge teaching to a patient with a new diagnosis of type I diabetes mellitus who will need to give self-injections of insulin at home. What statement by the patient indicates to the nurse that the discharge teaching was effective? 1 "I can use my lower forearm for insulin injections." 2 "If my intermediate-acting insulin looks cloudy, I should discard the bottle." 3 "I need to rotate sites of injection to allow for better absorption of the insulin." 4 "I should push the plunger all the way down and then remove the needle as soon as possible."

3 Teaching the patient to rotate the injection within and between sites is important to allow for better insulin absorption. The lower forearm is not an injection site for subcutaneous insulin administration. The abdomen, arm, thigh, and buttock are the preferred sites. Intermediate-acting insulin is normally cloudy, and the patient should gently roll the bottle between the palms of hands to mix the insulin. The patient should push the plunger all the way down and leave the needle in place for 5 seconds to ensure that all of the insulin has been injected before removing the needle.

A patient hospitalized with diabetes mellitus has become shaky, anxious, and diaphoretic. Which action should the nurse implement first? 1 Administer a 15 g snack. 2 Notify the health care provider. 3 Check the blood glucose level. 4 Administer the prescribed insulin dose.

3 The blood glucose level should be checked with the first signs of hypoglycemia because it can be reversed easily, but can be life threatening if not treated. In the hospital setting, it is convenient to check the blood glucose. A 15 g snack should be provided after the blood glucose has been determined to be low. The health care provider should be notified after the blood glucose level is known. The patient is exhibiting signs of decreased blood glucose. Administration of insulin will lower further the blood glucose.

Which measure is a priority for a nurse to include in the plan of care for a patient who has multiple sclerosis? 1 Referring the patient for genetic counseling 2 Teaching the patient about medications used during acute exacerbations 3 Assisting the patient in identifying the factors that precipitate exacerbations 4 Instructing the patient in the proper technique for self-administration of an enema

3 The cause of multiple sclerosis is unknown, although fatigue, stress, or events such as pregnancy or acute illness can bring on an exacerbation. Identifying and avoiding such activities or factors may prevent exacerbations. Multiple sclerosis does not have a genetic link. Teaching the patient about medications and the proper technique for the self-administration of an enema is important but not as high of a priority as preventing exacerbations of the disease and complications.

The nurse is discussing a healthy eating plan for a patient with diabetes. Which should the nurse include in the teaching about diabetes and diet? 1 Avoid nonnutritive sweeteners. 2 Consume a high-protein diet for weight loss. 3 If ingesting alcohol, also consume carbohydrates. 4 Include 50-60 g/day of dietary fiber.

3 The nurse should inform the patient to eat carbohydrates when drinking alcohol to reduce the risk for alcohol-induced hypoglycemia. Nutritive and nonnutritive sweeteners may be included in a healthy meal plan in moderation. The amount of daily protein in the diet for people with diabetes should be 15% to 20% of the total calories consumed. High-protein diets are not recommended as a weight loss method for people with diabetes. There is no evidence that a person with diabetes should consume more fiber than an individual who does not have diabetes. The current recommendation for the general population is 25 to 30 g/day.

A patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? 1 Provide multivitamins with each meal. 2 Provide a diet that is low in complex carbohydrates and high in protein. 3 Provide small, frequent meals throughout the day that are easy to chew and swallow. 4 Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

3 Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low-carbohydrate diet is not indicated.

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? 1 Cardiac output 2 Blood pressure 3 Abdominal girth 4 Intake and output

3 Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the health care provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continue to be monitored to account for the paracentesis fluid, but these are not as informative as abdominal girth.

A patient with a spinal cord injury (SCI) at the level of the seventh cervical vertebra (C7) has experienced episodes of autonomic dysreflexia. What signs and symptoms occur with this condition? Select all that apply. 1 Involuntary stool 2 Severe drop in blood pressure 3 Sudden onset of severe headache 4 Sweating above the level of the SCI 5 Flushed face and chest above the level of the SCI

3,4,5 Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system, but caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the face and sweating above the site of the SCI. The rapid rise in blood pressure gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

A patient with multiple sclerosis is under treatment with β-interferon. What patient teaching would be appropriate for this patient? Select all that apply. 1 Do not drink grape juice. 2 Monitor vital signs regularly. 3 Rotate injection sites with each dose. 4 Know that flu-like symptoms are common. 5 Wear sunscreen while exposed to sunlight.

3,4,5 Patients on β-Interferon should wear sunscreen when exposed to sunlight because the drug may cause photosensitivity. The injection site should be rotated with each dose to prevent lipodystrophy. The nurse should let the patient know that flu-like symptoms are common with β-interferon. The symptoms usually subside on their own; if they do not, they can be treated with nonsteroidal antiinflammatory drugs. The drug does not interact with grape juice; therefore, grape juice can be consumed. Monitoring of vital signs is not a specific teaching related to the drug.

A nurse is caring for a patient with cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply. 1 White patches on skin 2 Deposits of dark pigments 3 Small areas of bleeding into the skin 4 Vascular lesions formed by small blood vessels 5 Small dilated blood vessels with spiderlike branches

3,4,5, Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis.

A nurse is providing education for a patient with a new diagnosis of type I diabetes mellitus. Therapy for the patient will require subcutaneous insulin injections several times per day. When teaching the patient how to administer subcutaneous insulin, what education is the most accurate? 1 "You must use an alcohol swab on the site before self-injection." 2 "If you are planning on going jogging, you should use the thigh injection site to administer insulin." 3 "You should use one site for insulin injections so you get used to the process of administering insulin." 4 "Avoid injecting insulin intramuscularly, because rapid and unpredictable absorption could result in hypoglycemia."

4 Patient education for administration of insulin for diabetes should include teaching the patient to avoid intramuscular injections because of the rapid and unpredictable absorption that could result in hypoglycemia. The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and water is adequate. Patients should be taught to avoid injection sites that will be exercised, because doing so could increase body heat and circulation, increase the rate of insulin absorption, and speeding up the onset of action, resulting in hypoglycemia. Patients should be taught to rotate the injection within and between sites, not to use one site, to allow for better insulin absorption.

The nurse is teaching a patient with type 2 diabetes about exercise as a method to control blood glucose levels. The nurse knows the patient understands when the patient elicits which exercise plan? 1 "I want to go fishing for 30 minutes each day. I will drink fluids and wear sunscreen." 2 "I will go running each day when my blood sugar is too high to bring it back to normal." 3 "I will plan to keep my job as a teacher because I get a lot of exercise every school day." 4 "I will take a brisk 30-minute walk five days per week and do resistance training three times a week."

4 The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity five days per week and resistance training three times a week. Brisk walking is moderate activity. Fishing and teaching are light activity and running is considered vigorous activity.

A nurse is caring for a patient with diabetic ketoacidosis (DKA). The patient is on a continuous short-acting insulin infusion and receiving a continuous infusion of normal saline solution. The nurse understands that insulin causes an intracellular shift of potassium, water, and glucose to move into the intracellular space. The nurse has several things to observe, but what is the highest priority? 1 Urine output 2 Temperature 3 Respiratory rate 4 Cardiac monitoring

4 A patient with DKA is receiving a continuous insulin infusion, which causes potassium to move from the extracellular space to the intracellular space. This shift causes a decrease in the serum potassium level and can cause cardiac dysrhythmias; therefore, cardiac monitoring is the nurse's highest priority. Urine output is important to monitor for patients with DKA, but it is not the highest priority. Temperature is not relevant to monitoring patients with DKA. The respiratory rate is important to monitor, but it is not the highest priori

After admitting a patient with diabetic ketoacidosis (DKA) to the emergency department, which nursing intervention is a priority ? 1 Administer intravenous (IV) insulin 2 Administer oxygen 3 Insert a Foley catheter 4 Establish intravenous (IV) access

4 Because fluid imbalance in a patient with DKA is potentially life threatening, the initial goal of therapy is to establish IV access and begin fluid and electrolyte replacement. Insulin is administered intravenously only after a potassium level is determined, because insulin administration may cause hypokalemia. Administration of oxygen and insertion of a Foley catheter may be necessary in the initial emergency management of DKA, but obtaining IV access must come first.

The health care provider prescribes lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? 1 Relief of constipation 2 Relief of abdominal pain 3 Decreased liver enzymes 4 Decreased ammonia levels

4 Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. Lactulose does not relieve constipation or abdominal pain or decrease liver enzymes.

Which diagnostic study is used to assess soft tissue injury and neurologic changes? 1 Doppler ultrasound 2 Cervical radiography 3 Computed tomographic (CT) scan 4 Magnetic resonance imaging (MR

4 MRI is used to assess soft tissue injury and neurologic changes. A cervical radiograph is used when a CT scan is not readily available. Doppler ultrasound is used to diagnose deep vein thrombosis. A CT scan is used to diagnose the location and degree of injury and the degree of spinal canal compromise.

What is the major complication associated with myasthenic crisis? 1 Speech alteration 2 Difficulty chewing 3 Impaired facial mobility 4 Respiratory insufficiency

4 Myasthenic crisis is the acute exacerbation of myasthenia gravis. This is a life-threatening condition that occurs when the muscles that control breathing and swallowing become too weak to perform their functions. The clinical manifestations of myasthenia gravis include speech alteration due to muscle weakness related to speech. However, this is not a major complication associated with myasthenic crisis. Difficulty in chewing is due to the weakness of muscles related to chewing but is not a major complication associated with myasthenic crisis. Impaired facial mobility and expression are the clinical manifestations of myasthenia gravis due to the weakness of facial muscles but are not a major complication associated with myasthenic crisis.

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? 1 Decrease fluid intake to avoid ascites. 2 Eat foods quickly so they do not get cold and cause distress. 3 Avoid exercise because it may cause bleeding of the varices. 4 Avoid straining during defecation to keep venous pressure low.

4 Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid, and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation.

Which statement by the patient with diabetes mellitus indicates that further education regarding exercise is required? 1 "I should exercise about 30 minutes five days a week." 2 "Because I take insulin daily, I should exercise about one hour after eating a meal." 3 "Exercise will help me to lose weight, which will help my body to better use insulin." 4 "It is especially important that I exercise if my blood sugar is above 250 mg/dL and my urine is positive for ketones."

4 Strenuous activity can be perceived by the body as a stress and cause an increase in blood sugar by the release of counterregulatory hormones when the blood sugar is elevated and ketosis is present. The American Diabetes Association recommends that people with diabetes exercise 30 minutes per day, five days per week. To prevent hypoglycemia, it is important to exercise about an hour after consuming a meal or eat small carbohydrate snacks every 30 minutes during exercise. Weight loss decreases insulin resistance, which can lower blood glucose.

A patient sustained a concussion after a motor vehicle crash and is fully alert when arriving at the emergency department. What does the nurse document that the Glasgow Coma Scale score is? 1. 3 2. 6 3. 8 4. 15

4 The Glasgow Coma Scale is a quick, practical, and standardized system for assessing the level of consciousness in a patient. According to the Glasgow Coma Scale, the score of a fully alert patient will be 15. This includes 4 for spontaneous response of the patient when approached to bedside, 5 for appropriate response during verbal questioning, and 6 for obedience of commands. The lowest possible score according to the Glasgow Coma Scale is 3, which indicates severe coma conditions. A score of 6 or 8 indicates coma.

The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication? 1 Urine retention 2 Increased blood glucose 3 No bowel movement in three days 4 Frequent nosebleeds and bruising

4 The liver produces clotting factors. As cirrhosis becomes more advanced, the production of clotting factors is disrupted and thereby decreased, making the patient more susceptible to bleeding. Increasing frequency and severity of nosebleeds and bruising would indicate a deterioration in liver function. Urine retention, abnormal blood glucose, and constipation are not directly associated with advanced cirrhosis.

A patient with cirrhosis of the liver has ascites and is being prepared for a paracentesis. What instructions should the nurse give the patient? 1 The patient should fast overnight. 2 The patient should not pass urine until the procedure. 3 The patient should not take any fluids before the procedure. 4 The patient should void urine immediately before the paracentesis.

4 The nurse should instruct the patient to void prior to the paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.

In developing a teaching plan for the patient with Addison's disease, what is the nurse's highest priority? 1 Avoiding infection 2 Following a low-salt diet 3 Practicing stress management techniques 4 Managing lifelong corticosteroid replacement

4 The patient with Addison's disease experiences hypofunctioning of the adrenal cortex, resulting in decreased production of glucocorticoids, mineral corticoids, and androgens. Patients with Addison's disease require lifelong glucocorticoid and mineral corticoid replacement therapy to avoid Addisonian crisis. Addisonian crisis is characterized by profound hypotension, dehydration, fever, tachycardia, hyponatremia, and hyperkalemia. Circulatory collapse may occur if the patient is treated inadequately. Although Addisonian crisis often is triggered by illness-related physiologic stress, and although avoiding infection is important, avoiding infection is of lower priority than managing lifelong corticosteroid replacement. Corticosteroid replacement must be increased during times of stress to prevent Addisonian crisis. Patients taking a mineralocorticoid should increase their salt intake. Emotional stress may contribute to the need for increased corticosteroid replacement. Stress management techniques are important. Practicing stress management techniques, however, is of lower priority than managing lifelong corticosteroid replacement.

A patient reports "eye problems". On assessment of this patient, the nurse notes exophthalmos. What other abnormal assessments should the nurse expect to find in this patient? 1 Puffy face, decreased sweating, and dry hair 2 Muscle aches and pains and slow movements 3 Decreased appetite and increased thirst and pallor 4 Systolic hypertension and increased heart rate

4 The patient's symptoms point to Graves' disease, or hyperthyroidism; its symptoms would also include systolic hypertension, increased heart rate, and increased thirst. Puffy face, decreased sweating, dry, coarse hair, muscle aches and pains, slow movements, decreased appetite, and pallor are all manifestations of hypothyroidism.

A patient is prescribed carbamazepine for a new-onset seizure disorder. The nurse is educating the patient about this drug. What teaching comment by the nurse is most accurate? 1 Do not take this medication with grapefruit. 2 This medication is given to treat absence and myloclonic seizures. 3 Don't be concerned if any visual disturbances occur while taking this medication. 4 The goal of this medication is to cure your condition and prevent any more seizures.

5 Grapefruit inhibits the activity of the gastrointestinal enzyme that breaks down this medication so that more of the drug is in the body, and sometimes dangerously high amounts can enter the bloodstream. Carbamazepine is given to treat generalized tonic-clonic and partial seizures. Patients are instructed to report any type of visual abnormalities. Antiseizure drugs do not cure the condition but help to prevent seizures with a minimum of side effects.