Final Med-Surg

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

ANS: A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient's status.

Which intervention would the nurse plan for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/mL during chemotherapy? a. Test all stools for occult blood. b. Encourage fluids to 3000 mL/day. c. Provide oral hygiene every 2 hours. d. Check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? a. Antithyroid medications may take months for full effect. b. Restriction of iodine intake will help reduce thyroid activity. c. Exercise is contraindicated to avoid increasing metabolic rate. d. Surgery will eventually be required to remove the thyroid gland.

ANS: A Medications used to block the synthesis of thyroid hormones may take 2 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot eat adequate calories.

ANS: A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk.

Which action will the nurse include in the plan of care for a patient with right arm lymphedema? a. Avoid isometric exercise on the right arm. b. Assist with application of a compression sleeve. c. Keep the right arm at or below the level of the heart. d. Check blood pressure (BP) on both right and left arms.

ANS: B A compression sleeve assists in improving lymphatic flow toward the heart. Isometric exercises may be prescribed for lymphedema. BPs should only be done on the patient's left arm. The arm should not be placed in a dependent position.

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I can participate in fitness activities except swimming." b. "I must keep the stoma covered with an occlusive dressing." c. "I need to have smoke and carbon monoxide detectors installed." d. "I will wear a Medic-Alert bracelet to identify me as a neck breather."

ANS: B An occlusive dressing will completely block the patient's airway. The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

Which information would the nurse include when teaching a patient who has an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of RA exacerbation. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Which infection reported in the health history of a female patient will the nurse identify as a risk factor for infertility? a. Treponema pallidum b. Neisseria gonorrhoeae c. Condyloma acuminatum d. Herpes simplex virus type 2

ANS: B Complications of gonorrhea include scarring of the fallopian tubes, which can lead to tubal pregnancies and infertility. Syphilis, genital warts, and genital herpes do not lead to problems with conceiving, although transmission to the fetus (syphilis) or newborn (genital warts or genital herpes) is a concern.

Which information about a patient who is scheduled for an oral glucose tolerance test would the nurse consider in interpreting the test results? a. The patient reports having occasional orthostatic dizziness. b. The patient takes oral corticosteroids for rheumatoid arthritis. c. The patient has had a 10-pound weight gain in the last month. d. The patient drank several glasses of water an hour previously.

ANS: B Corticosteroids can affect blood glucose results. The other information will not affect the glucose test results.

Which information will the nurse prioritize in planning preoperative education for a patient undergoing a Roux-en-Y gastric bypass? a. Explaining the nasogastric (NG) tube to the patient b. Teaching the patient coughing and breathing techniques c. Discussing necessary postoperative modifications in lifestyle d. Demonstrating passive range-of-motion exercises for the legs

ANS: B Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.

Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "Avoid eating between meals to reduce acid secretion." d. "Vigorous exercise may increase the incidence of reflux."

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

Which recommendation would the nurse provide to a patient with myasthenia gravis (MG)? a. Anticipate the need for weekly plasmapheresis treatments. b. Complete physically demanding activities early in the day. c. Protect the extremities from injury due to poor sensory perception. d. Perform frequent weight-bearing exercise to prevent muscle atrophy

ANS: B Muscles are generally strongest in the morning, and muscle weakness is prominent by the end of the day, so activities involving muscle activity should be scheduled early. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG. Muscle atrophy does not occur because although muscles are weak, they are still used.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which findings on the nursing assessment would indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

ANS: B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

A nurse is caring for a patient with a goiter and possible hyperthyroidism. Which action by the nurse has the potential for patient harm? a. The nurse checks the blood pressure in both arms. b. The nurse palpates the neck to assess thyroid size. c. The nurse orders saline eye drops to lubricate the patient's bulging eyes. d. The nurse lowers the thermostat to decrease the temperature in the room.

ANS: B Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the nurse are appropriate when caring for a patient with an enlarged thyroid.

Which topic would the nurse plan to teach a 26-yr-old patient who has been treated for pelvic inflammatory disease? a. Use of hormone therapy (HT) b. Potential complication of infertility c. Irregularities in the menstrual cycle d. Changes in secondary sex characteristics

ANS: B Pelvic inflammatory disease may cause scarring of the fallopian tubes and result in difficulty in fertilization or implantation of the fertilized egg. Because ovarian function is not affected, the patient will not require HT, have irregular menstrual cycles, or experience changes in secondary sex characteristics.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.

A patient with newly diagnosed lung cancer tells the nurse, "I don't thinks I'm going to live to see my next birthday." Which initial response would the nurse provide? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"

ANS: B The nurse's initial response would be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

During the physical examination, the nurse cannot feel the patient's thyroid gland. Which action would the nurse take? a. Palpate the patient's neck more deeply. b. Document that the thyroid was nonpalpable. c. Notify the health care provider immediately. d. Teach the patient about thyroid hormone testing.

ANS: B The thyroid is usually nonpalpable. The nurse would simply document the finding. Deep palpation of the neck is not appropriate; do not press too hard or massage an enlarged thyroid gland as this can cause a sudden release of thyroid hormone into an already overloaded system. There is no need to notify the health care provider immediately about a normal finding. There is no indication for thyroid-stimulating hormone (TSH) testing unless there is evidence of thyroid dysfunction.

Which patient statement indicates that teaching about radiation therapy of the larynx was effective? a. "I should not use any lotions on my neck." b. "I will need to carry a water bottle with me." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean my mouth."

ANS: B Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse would be consistent with a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2°F (38.4°C)

ANS: B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes simplex? (Select all that apply.) a. Infected areas should be kept moist to speed healing. b. Sitz baths may be used to relieve discomfort caused by the lesions. c. Consistent use of antiviral medications can cure genital herpes infection. d. Recurrent genital herpes episodes usually are shorter than the first episode. e. The virus can infect sexual partners even when you do not have symptoms.

ANS: B, D, E Patients are taught that shedding of the virus and infection of sexual partners can occur even in asymptomatic periods, recurrent episodes resolve more quickly, and sitz baths can be used to relieve pain caused by the lesions. Antiviral medications decrease the number of outbreaks but do not cure herpes simplex infections. Infected areas may be kept dry if this decreases pain and itching.

When a male patient returns to the clinic for follow-up after treatment for gonococcal urethritis, a purulent urethral discharge is still present. Which question will the nurse ask to identify a possible cause of recurrent infection? a. "Did you take the prescribed antibiotic for a week?" b. "Did you drink at least 3 quarts of fluids every day?" c. "Were your sexual partners treated with antibiotics?" d. "Do you wash your hands after using the bathroom?"

ANS: C A common reason for recurrence of symptoms is reinfection because infected partners have not been simultaneously treated. Because gonorrhea is treated with one dose of antibiotic, antibiotic therapy for a week is not needed. An adequate fluid intake is important, but a low fluid intake is not a likely cause for failed treatment. Poor hygiene may cause complications such as ocular trachoma but will not cause a failure of treatment.

Which action would the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Teach the patient to use cool water when bathing. c. Encourage the patient to take a nap in the afternoon. d. Suggest exercise with light weights several times daily.

ANS: C Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a physical therapist usually develops a therapeutic exercise program that includes exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

Which statement made by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be needed? a. "I am so thirsty that I drink all day long." b. "I get up several times at night to urinate." c. "I feel a lump in my throat when I swallow." d. "I notice my breasts are always tender lately."

ANS: C An enlarged thyroid gland can cause problems swallowing or a change in neck size. Nocturia is associated with diseases such as diabetes, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.

2. A patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), which assessment would the nurse plan to make more frequently than is routine? a. Apical pulse b. Bowel sounds c. Breath sounds d. Abdominal girth

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine

Which assessment would the nurse identify as most important regarding a patient who has myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action would the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

Which question from the nurse during a patient interview would provide focused information about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"

ANS: C Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.

Which health history information would the nurse obtain from the patient who has possible testicular cancer? a. Testicular torsion b. Testicular trauma c. Undescended testicles d. Sexually transmitted infection (STI)

ANS: C Cryptorchidism, or undescended testicles, is a risk factor for testicular cancer if it is not corrected before puberty. STI, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient reports 7/10 (0 to 10 scale) abdominal pain. b. The patient is experiencing intermittent waves of nausea. c. The patient has no breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

ANS: C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain would be addressed, but they are not as high priority as the patient's respiratory status. Decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." Which information would be most important for the nurse to provide? a. "Methotrexate is less expensive than some of the newer drugs." b. "It will take 4-6 weeks to see the therapeutic effects of the methotrexate." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

Which assessment data for a patient who has Guillain-Barré syndrome requires the nurse's most immediate action? a. The patient's sacral area skin is reddened. b. The patient reports severe pain in the feet. c. The patient is continuously drooling saliva. d. The patient's blood pressure (BP) is 150/82 mm Hg.

ANS: C Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

A male patient who has a profuse, purulent urethral discharge with painful urination is seen at the clinic. Which information would the nurse obtain as a basis for planning focused care? a. Sexual orientation b. Immunization history c. Recent sexual contacts d. Contraceptive preference

ANS: C Information about sexual contacts is needed to help establish whether the patient has been exposed to a sexually transmitted infection and because sexual contacts also will need treatment. The other information is not pertinent in determining the plan of care for the patient's current symptoms.

A male patient who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. Which information would the nurse explain to the patient? a. Women develop subclinical cases of gonorrhea that are not true gonorrheal infections. b. Women do not develop gonorrhea infections but can serve as carriers to spread the disease to men. c. Women may not be aware they have gonorrhea because they often do not have symptoms of infection. d. When gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs

ANS: C Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease. Women who can transmit the disease have active infections, not subclinical cases or carrier status.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What would the nurse ask the patient about to determine possible risk factors for gastritis? a. The amount of saturated fat in the diet b. A family history of gastric or colon cancer c. Use of nonsteroidal anti-inflammatory drugs d. A history of a large recent weight gain or loss

ANS: C Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

After a patient who has septic shock receives 2 L of IV normal saline, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. Which medication would the nurse anticipate being prescribed? a. Furosemide b. Nitroglycerin c. Norepinephrine d. Sodium nitroprusside

ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action would the nurse take as focused follow-up on this symptom? a. Assess both feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse would stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)

ANS: D Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids.

Which test would the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding would indicate to the nurse that a change in the medication or dosage may be needed? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A patient diagnosed with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for doxycycline. What rationale would the nurse provide to the patient for this combination? a. Treats possible chlamydia infection. b. Prevents reinfection during treatment. c. Treats any coexisting syphilis infection. d. Prevents potential trichomonas infection.

ANS: A Because there is a high incidence of co-infection with gonorrhea and Chlamydia, patients are often treated for both.

Which diagnostic test would the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis? a. Endoscopy b. Angiography c. Barium studies d. Gastric analysis

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

The nurse is coaching a community group for persons who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? a. Walking for 40 minutes 6 or 7 days/week b. Playing soccer for an hour on the weekend c. Running for 10 to 15 minutes 3 times/week d. Lifting weights for 2 hours with friends 1 time/week

ANS: A Exercise should be at least 150 minutes of moderate-intensity aerobic activity (i.e., brisk walking) every week. Muscle-strengthening activities on 2 or more days a week is recommended. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but patients should start with an exercise that is less stressful and can be done for a longer period.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Patients with streptococcal throat infections will also have pain and a fever.

A female patient is diagnosed with Chlamydia during a routine pelvic examination. Which patient statement indicates that the nurse's teaching about the condition has been effective? a. "My partner will need to take antibiotics at the same time I do." b. "Go ahead and give me the antibiotic injection, so I will be cured." c. "I will use condoms during sex until I finish taking all the antibiotics." d. "I do not plan on having children, so treating the infection is not important."

ANS: A Sex partners would be treated simultaneously to prevent reinfection. Chlamydia is treated with oral antibiotics. Abstinence from sexual intercourse is recommended for 7 days after treatment. Condoms would be recommended during all sexual contacts to prevent infection. Chronic pelvic pain, as well as infertility, can result from untreated Chlamydia.

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. Nausea, joint pain, and headache are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. Which type of seizure would the nurse suspect? a. Focal-onset b. Atonic c. Absence d. Myoclonic

ANS: A The initial symptoms of a focal-onset seizure involve clinical manifestations that are localized to a particular part of the body or brain; patients may have unusual feelings or sensations. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

Which action would the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Teach the patient how to self-catheterize. b. Encourage decreased evening fluid intake. c. Suggest the use of adult incontinence briefs. d. Assist the patient to the commode every 2 hours.

ANS: A The patient may need to intermittently self-catheterize when urinary retention is not relieved by other means. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will sit down before I put the nitroglycerin under my tongue." b. "I will check my pulse rate before I take any nitroglycerin tablets." c. "I will put the nitroglycerin patch on as soon as I get any chest pain." d. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

ANS: A The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

Two days after an acute myocardial infarction (MI), a patient reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Give PRN acetaminophen (Tylenol). d. Notify the patient's health care provider.

ANS: A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse would be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. Acetaminophen (Tylenol) is not effective for pericarditis pain. An analgesic would not be given before assessment of a new symptom.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

ANS: A The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

Which statement by a patient indicates that the nurse's teaching about primary genital herpes has been effective? a. "I will take the oral acyclovir for the next week." b. "I will use acyclovir ointment to relieve the discomfort." c. "I will need to take all of the medication to cure the infection." d. "I will use condoms for intercourse until the medication is all gone."

ANS: A The treatment regimen for primary genital herpes infections includes acyclovir for 7 to 10 days. The patient is taught to abstain from intercourse until the lesions are gone. Condoms would be used even when the patient is asymptomatic. Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and recurrent.

A 50-yr-old patient is diagnosed with uterine bleeding caused by fibroids. Which information will the nurse include in the patient teaching plan? a. The symptoms may decrease after the patient undergoes menopause. b. The tumor size is likely to increase throughout the patient's lifetime. c. Aspirin or acetaminophen may be used to control mild to moderate pain. d. The patient will need frequent monitoring to detect any malignant changes.

ANS: A Uterine fibroids (leiomyomas) depend on ovarian hormones and will atrophy after menopause, leading to a decrease in symptoms. Aspirin use is discouraged because the antiplatelet effects may lead to heavier uterine bleeding. The size of the tumor will shrink after menopause. Leiomyomas are benign tumors that do not undergo malignant changes.

A patient with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicates the need for immediate action by the nurse? a. Report of chest pain b. Heart rate 102 beats/min c. Pedal pulses 1+ bilaterally d. Blood pressure 103/54 mm Hg

ANS: A The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

The nurse in the outpatient clinic notes that the following patients have not received the human papillomavirus (HPV) vaccine. Which patients would the nurse plan to teach about benefits of the vaccine? (Select all that apply.) a. A 24-yr-old male patient who has a history of genital warts b. A 20-yr-old male patient who has had one male sexual partner c. A 38-yr-old female patient who has never been sexually active d. A 20-yr-old female patient who has a newly diagnosed Chlamydia infection e. A 30-yr-old female patient whose sexual partner has a history of genital warts

ANS: A, B, D, E The CDC recommends that all children, male and female, be vaccinated at age 11 to 12. Vaccination can be started as early as age 9. Routine vaccination is recommended up to age 26. Gardasil 9 is also approved for use in those ages 27 through 45 who may be at risk. There are several types of HPV. Ideally, the vaccines are administered before patients are sexually active, but they offer benefit even to those who already have HPV infection because the vaccines protect against HPV types not already acquired.

A patient is scheduled for a cardiac catheterization with coronary angiography. What information would the nurse provide before the procedure? a. It will be important not to move at all during the procedure. b. A flushed feeling is common when the contrast dye is injected. c. Monitored anesthesia care will be provided during the procedure. d. Arterial pressure monitoring will be needed for 24 hours after the test.

ANS: B A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action would the nurse include in the plan of care? a. Observe for agitation and paranoia. b. Assist with active range of motion (ROM). c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: B ALS causes progressive muscle weakness. Assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. Which intervention would the nurse include in the patient's plan of care? a. Administer oral metoclopramide. b. Instruct the patient not to eat or drink. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate during this acute phase.

Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 30 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.

ANS: B Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Recommend ibuprofen for left upper quadrant pain. b. Schedule immunization with the pneumococcal vaccine. c. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. d. Discourage deep breathing and coughing to reduce risk for splenic rupture.

ANS: B Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal anti-inflammatory drugs (NSAIDs) may increase bleeding risk and would be avoided. The enlarged spleen may decrease respiratory depth, and the patient would be encouraged to take deep breaths.

A 31-yr-old patient who has been diagnosed with human papillomavirus (HPV) infection gives a health history that includes smoking tobacco, taking oral contraceptives, and having been treated twice for vaginal candidiasis. Which topic will the nurse include in patient teaching? a. Use of water-soluble lubricants b. Risk factors for cervical cancer c. Antifungal cream administration d. Possible difficulties with conception

ANS: B Because HPV infection is associated with increased cervical cancer risk, the nurse would emphasize the importance of regular screening for cervical cancer. An HPV infection does not decrease vaginal lubrication, decrease the ability to conceive, or require the use of antifungal creams.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict IV fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Which nursing action would be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Reposition the NG tube if drainage stops. b. Elevate the head of the bed to at least 30 degrees. c. Start oral fluids when the patient has active bowel sounds. d. Notify the doctor for any bloody nasogastric (NG) drainage.

ANS: B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube would not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of famotidine (Pepcid)? a. "Famotidine absorbs the excess gastric acid." b. "Famotidine decreases gastric acid secretion." c. "Famotidine constricts the blood vessels near the ulcer." d. "Famotidine covers the ulcer with a protective material."

ANS: B Famotidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. Famotidine does not constrict the blood vessels, absorb the gastric acid, or cover the ulcer.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks about the purpose of receiving famotidine (Pepcid). Which information would the nurse explain about the action of the medication? a. "It decreases nausea and vomiting." b. "It inhibits development of stress ulcers." c. "It lowers the risk for H. pylori infection." d. "It prevents aspiration of gastric contents."

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates a need for additional teaching about GERD? a. "I quit smoking years ago, but I chew gum." b. "I eat small meals and have a bedtime snack." c. "I take antacids between meals and at bedtime each night." d. "I sleep with the head of the bed elevated on 4-inch blocks."

ANS: B GERD is exacerbated by eating late at night, and the nurse would plan to teach the patient to avoid eating within 3 hours of bedtime. Smoking cessation, taking antacids, and elevating the head of the bed are appropriate actions to control symptoms of GERD.

Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

ANS: B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order would the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen 200 mg twice daily. d. Famotidine (Pepcid) 20 mg daily

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Have you had a recent neck injury?" d. "Are your immunizations up to date?"

ANS: B Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

A patient with Parkinson's disease (PD) has bradykinesia. Which action would the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient use the arms of the chair to help push up to standing. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

ANS: B Pushing down on the arms of the chair and placing the back legs of the chair on small (2-inch) blocks help the individual with PD to stand. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wider base of support, rather than stepping directly forward, will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should avoid nonsteroidal anti-inflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients would avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

Which information should the nurse include in teaching a patient who is scheduled for external beam radiation to the breast? a. The radiation therapy will take a week to complete. b. Careful skin care in the radiated area will be needed. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.

ANS: B Skin care will be needed because of the damage caused to the skin by the radiation. External beam radiation is done over a 5- to 6-week period. Scalp hair loss does not occur with breast radiation therapy. Because the patient does not have radioactive implants, no visitor restrictions are necessary.

How would the nurse suggest that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day? a. A brief routine of isometric exercises b. A warm shower followed by a short rest c. Active range-of-motion (ROM) exercises d. Stretching exercises to relieve joint stiffness

ANS: B Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day when joint stiffness is decreased.

Which information about dietary management would the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause pain." d. "You should avoid eating raw fruits and vegetables."

ANS: B The best information is that each person should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa but chewing well seems to decrease this problem and some patients tolerate these healthy foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little evidence to support their ongoing use.

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. Which topic would the nurse anticipate explaining to the patient? a. Oral corticosteroids b. Dopaminergic drugs c. Magnetic resonance imaging (MRI) d. Electroencephalogram (EEG) testing

ANS: B The clinical diagnosis of Parkinson's is made when tremor, rigidity, akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when dopaminergic drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

Which topic is most important for the nurse to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Avoiding all alcohol use c. Maintaining good nutrition d. Using vitamin B supplements

ANS: B The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not speak to his wife and only responds briefly to the nurse to answer the admission questions. Which action would the nurse take? a. Teach the patient and wife that impotence is unlikely after unilateral orchiectomy. b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. c. Inform the patient's wife that concerns about sexual function are common with this diagnosis. d. Document the patient's lack of communication on the health record and continue preoperative care.

ANS: B The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer teaching about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation.

The nurse provides discharge teaching for a 61-yr-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful? a. "I will need to use my right arm and to rest the left one." b. "I will avoid reaching over the stove with my left hand." c. "I will keep my left arm in a sling until the incision is healed." d. "I will stop the left arm exercises if moving the arm is painful."

ANS: B The patient should avoid any activity that might injure the left arm, such as reaching over a burner. If the left arm exercises are painful, analgesics should be used, and the exercises continued in order to restore strength and range of motion. The left arm should be elevated at or above heart level and should be used to improve range of motion and function.

Which action will the nurse include in the plan of care for a patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

ANS: B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which PRN medication would the nurse expect to be prescribed initially? a. lorazepam (Ativan) b. acetaminophen (Tylenol) c. morphine sulfate (MS Contin) d. butalbital and aspirin (Fiorinal)

ANS: B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be used as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

Which result is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? a. Bilirubin levels b. Ammonia levels c. Potassium levels d. Prothrombin time

ANS: B The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

Which information about testicular self-examination will the nurse plan to include when teaching a young adult who has a family history of testicular cancer? a. Report any lumps or painful areas in the scrotum or testes. b. Testicular self-examination should be done at least weekly. c. The only structure normally felt in the scrotal sac is the testis. d. Call the health care provider if one testis is larger than the other.

ANS: B The value of regular screening is controversial, however, new findings such as lumps or pain in the scrotum or testes should be evaluated by the HCP. The epididymis is also normally palpable in the scrotum. One testis is normally larger. Men at high risk should perform testicular self-examination monthly.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

ANS: B Triptans cause coronary artery vasoconstriction and are contraindicated in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

Which finding would the nurse expect when assessing a patient who is experiencing a cluster headache? a. Nuchal rigidity b. Unilateral ptosis c. Projectile vomiting d. Bilateral facial pain

ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Which action would the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? a. Assess for the presence of chest pain. b. Inquire about urinary tract problems. c. Inspect the skin for rashes or discoloration. d. Ask the patient about any increase in libido.

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Which laboratory value would the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level

ANS: C A low TSH level indicates that the patient's hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3 and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's peripheral pulses are weak. c. The patient reports diffuse chest pressure. d. The patient's heart rate is 110 beats/minute.

ANS: C Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient's diagnosis and should be reported to the health care provider but do not indicate an immediate need for a change in therapy.

A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell count is 1500/mL. d. The erythrocyte sedimentation rate is increased.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding would the nurse report immediately to the health care provider? a. The patient has developed facial acne. b. The patient reports an increased appetite. c. The patient reports burning with urination. d. The patient's fasting blood glucose is 112 mg/dL.

ANS: C Corticosteroid use is associated with an increased risk for infection, so the nurse would report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection, which could lead to urosepsis.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient would avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which initial response would the nurse provide? a. "Are you afraid that it will be very painful?" b. "Did you have bad experiences with surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."

ANS: C More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. Non-small cell lung cancer does not respond well to chemotherapy, but chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery and would not be useful unless the patient describes specific concerns.

Diltiazem is prescribed for a patient newly diagnosed with Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? a. Reduces heart palpitations. b. Prevents coronary artery plaque. c. Decreases coronary artery spasms. d. Increases contractile force of the heart

ANS: C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. Which action is the priority during the first 24 hours after surgery? a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy.

ANS: C The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. The patient may be taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period.

The nurse observes a patient ambulating in the hospital hall. The patient's arms and legs suddenly jerk and the patient falls to the floor. Which action would the nurse take first? a. Give the scheduled divalproex (Depakote). b. Document the timing and description of the seizure. c. Check the environment for sources of potential injury. d. Notify the patient's health care provider about the seizure.

ANS: C The patient who has had a myoclonic seizure and fall is at risk for additional injury from contacting objects in the environment; assuring a safe area is a priority. Documentation of the seizure, notification of the health care provider, and administration of anti seizure medications may also be appropriate actions, but the initial action would be assessment for injury.

After change-of-shift report on the neurology unit, which patient would the nurse assess first? a. Patient with Bell's palsy who has herpes vesicles in front of the ear. b. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes. c. Patient with Guillain-Barré syndrome who is drooling and having difficulty swallowing. d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin.

ANS: C The patient with Guillain-Barré syndrome who has drooling and difficulty swallowing indicates that the nurse would rapidly assess for respiratory distress. The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question would the nurse ask? a. "Have you taken corticosteroids?" b. "Do you have a history of IV drug use?" c. "Do you use any over-the-counter drugs?" d. "Have you recently traveled to another country?"

ANS: C The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause acute liver dysfunction.

A 72-yr-old patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Skin is dry with tenting and poor turgor. b. Patient has not voided for the last 2 hours. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" Which response by the nurse would be the most accurate? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."

ANS: C Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible

The nurse is caring for a patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the provider? a. Bilateral crackles audible at both lung bases b. Redness, irritation, and skin breakdown in skinfolds c. Emesis of bile-colored fluid past the nasogastric (NG) tube d. Use of patient-controlled analgesia (PCA) several times an hour for pain

ANS: C Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the provider to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the provider. Frequent PCA use after bariatric surgery is expected.

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

ANS: D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching? a. Calcium channel blocker b. Selective SA node inhibitor c. Digoxin and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitor

ANS: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. Ivabradine would likely be used for a patient with HF who has symptoms despite optimal doses of other medications.

Which nursing action for a patient with Guillain-Barré syndrome would the nurse identify as appropriate to delegate to experienced assistive personnel (AP)? a. Instilling artificial tears b. Assessing for bladder distention c. Administering bolus enteral nutrition d. Performing range of motion to extremities

ANS: D Assisting a patient with movement is included in AP education and scope of practice. Administration of enteral nutrition, administration of ordered medications, and assessment are skills requiring more education and expanded scope of practice, and the RN should perform these skills.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away with a nitroglycerin tablet."

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

Which suggestion would the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living? a. Strengthen small hand muscles by wringing out sponges or washcloths. b. Protect the knee joints by sleeping with a small pillow under both knees. c. Stand rather than sit when performing daily household and yard chores. d. Limit the number of exercise repetitions during periods of acute inflammation.

ANS: D Patients are advised to avoid repetitious movements and exercises during periods of acute inflammation. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position; sleeping with a pillow behind the knees would decrease the ability of the knee to extend.

Which information would the nurse include when teaching a young women's community service group about breast self-examination (BSE)? a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. Annual mammograms should be scheduled in addition to BSE. d. Performing BSE after the menstrual period is more comfortable.

ANS: D Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. Research has shown that BSE has no effect on reducing deaths from breast cancer. However, you still need to teach women the importance of knowing how their breasts look and feel and to report breast changes (e.g., nipple discharge, a lump) to their HCP. BSE would be done monthly. Annual mammograms are not routinely scheduled for women younger than age 40 years.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. Which medication schedule would the nurse teach the patient? a. Sucralfate at bedtime and antacids before each meal b. Sucralfate and antacids together 0 minutes before meals c. Antacids 30 minutes before each dose of sucralfate is taken d. Antacids after meals and sucralfate 30 minutes before meals

ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic would the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but would not be a concern after treatment.

A patient with Cushing syndrome is admitted for an adrenalectomy. Which information would likely help the patient cope with a disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery

ANS: D The most reassuring and accurate communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome minimize the patient's concerns. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices