GRCC Pn 141 final exam q's
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram
B. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.
What is the best activity for a client w bipolar disorder? A. Ping pong B. Writing C. Chess D. Basketball
B. Solitary activities that require a short attention span, with mild physical exertion are most appropriate. Choose writing, walking, painting to minimize stimulation.
Norm Digoxin
0.8-2.0
The nurse is reviewing the clients record and notes that the health care provider has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. 1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC) count 5. Elevated blood urea nitrogen (BUN) level
1,3,5 Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN and serum creatinine levels start to rise when the glumerular filtration rate falls below 40% to 60%. A decreased RBC count may be noted if erythrompoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease. Thrombocyte cell counts do not indicate decreased renal function.
Norm Mg+
1.3-2.1
Norm Na+
135-148
A client is being admitted with a spinal cord transection at c7. Which of the following assessments take priority upon the client's arrival? Select all that apply. 1.reflexes 2.bladder function 3. blood pressure 4.temperature 5.respirations
3.4.5. The nurse should assess the client for spinal cord shock, which is the immediate response to spinal cord trans-section. Hypotension occurs, and the body loses core temp to environmental temp. the nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should ensure that there is adequate airway and respiration's; there may be respiratory compromise due to intercoastal muscle involvement. Once the client is stable, the nurse should conduct a complete neurological check.
Norm K+
3.5-5
Norm Albumin
3.8-5.0
Norm pCO2
35-45
Which intervention is the most critical for a client with myxedema coma? 1. Administering an oral dose of levothyroxine (Synthroid) 2. Warming the client with a warming blanket 3. Measuring and recording accurate intake and output 4. Maintaining a patent airway
4. Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn't be used because it may cause vasodilation and shock. Gradual warming with blankets is appropriate. Thyroid replacement is administered I.V., not orally. Although recording intake and output is important, these interventions aren't critical at this time.
Norm Glucose
60-110
Norm BUN
7-18
pH
7.35-7.45
Norm Ca+
8.5-10.5
Norm pO2
80-90
Norm Cl-
97-108
Normal BNP
<100
Norm GFR
>60
A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?* Select all that apply A. "I've noticed that I've gain 6 lbs in one week." B. "While I sleep I have to prop myself up with a pillow so I can breathe." C. "I haven't noticed any swelling in my feet or hands lately". D "I have such an increased appetite"
A and B Exacerbation will include weight gain, orthopnea. An increased appetite or no swelling is not signs of exacerbation
Nausea and vomiting is an expected side effect of chemotherapeutic drug use. Which of the following drug should be administered to a client on chemotherapy to prevent nausea and vomiting? A Metochlopramide (Metozol) B Succimer (Chemet) C Anastrazole (Arimidex) D Busulfan (Myleran)
A. Metochlopramide (Metozol) - antiemetic. Succimer (Chemet) - chelating agent for lead poisoning. Anastrazole (Arimidex) - hormone regulator. Busulfan (Myleran) - alkylating agent
A client taking a chemotherapeutic agent understands the effects of therapy by stating: A "I will avoid eating hot and spicy foods." B "I should stay in my room all the time." C "I should limit my fluid intake to about 500 ml per day." D "I should notify the physician immediately if a urine color change is observed."
A. The client should prevent hot and spicy food because of the stomatitis side effect. The client should avoid people with infection but should not isolate himself in his room all the time. Fluid intake should be increased. Urine color change is normal.
A 45 year old male client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that the leg ulcers of this nature are caused by: A .Decrease arterial blood flow secondary to vasoconstriction B. decrease arterial blood flow leading to hyperemia C. Atherosclerotic obstruction of the arteries D. Trauma to the lower extremities
A. Correct response Decrease arterial blood flow secondary to vasoconstriction Rational Decrease arterial blood flow is a result to vasospasm. the etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved.
A pt w Parkinson's is being treated with carbidopa-levidopa. What is a s/e? A. Difficulty performing voluntary movement B. Inc b/p C. Inc. HR D. Itchiness
A. Dyskinesia Other s/e are: N/v, diarrhea, hypotension, bradycardia, confusion, hallucination
Which of the following substance abuse has a genetic link? A. Alcoholic B. Barbiturates C. Heroin D. Marijuana
A. Several chromosomes have been linked to an increased vulnerability to alcohol abuse. As high as 40-60% of first degree relatives of alcohol abusers may become dependant.
A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dl and a serum creatnine level of 2.2 mg/dl has a total 2-hour urine output of 25 ml. The nurse understands that the client is at risk for which? 1. Hypovolemia 2. Acute kidney injury 3. Glumerulonephritis 4. Urinary tract infection
Answer 2 Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vassopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis
Neoplasm can be classified as either benign or malignant. The following are characteristics of malignant tumor apart from: A Metastasis B Infiltrates surrounding tissues C Encapsulated D Poorly differentiated cells
C. Explanation: Benign: grows slowly, localized, encapsulated, well differentiated cells, no metastasis, not harmful to host. Malignant: Grows rapidly, infiltrates surrounding tissues, not encapsulated, poorly differentiated, metastasis present, always harmful
A client is being discharged after undergoing a thyroidectomy. Which dischange instructions are appropriate for this client. Select all that apply. a. "Report signs and symptoms" b. "Take thyroid replacement medication as ordered." c. "Watch for changes in body changing, such as lethargy, restlessness, sensitive to cold, and dry skin, and report changes to the physician." d. "Recognize the signs of dehydration." e. "Carry injectable dexamethasone at all times."
B and C. After the removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy, restlessness, cold sensitivity, and dry skin, which may indicate the need for a higher dosage of medication. The thyroid gland doesn't regulate glucose levels; therefore, signs and symptoms of hypoglycemia aren't relevant for this client. Dehydration is seen in diabetes insipidus. Injectable dexamethasone isn't needed for this client.
Which ability should the nurse expect from a client in the mild stage of dementia of the Alzheimer's type? A Remembering the daily schedule B Recalling past events C Coping the anxiety D Solving problems of daily living
B- Recent memory loss is the characteristic sign of cognitive difficulty in early Alzheimer's disease. The ability to recall past events is usually retained until the later stages of this disorder. Remembering daily schedules, coping with anxiety, and solving problems of daily living are areas that would pose difficulty in the early phase of Alzheimer's disease.
A client is diagnosed with breast cancer. The tumor size is up to 5 cm with axillary and neck lymph node involvement. The client is in what stage of breast cancer? A Stage I B Stage II C Stage III D Stage IV
B. Stage I - tumor size up to 2 cm. Stage II - tumor size up to 5 cm with axillary and neck lymph node involvement. Stage III - tumor size is more than 5 cm with axillary and neck lymph node involvement. Stage IV - metastasis to distant organs (liver, lungs, bone and brain).
A client is diagnosed with progressive prostate cancer. The nurse expects which drug is given? A Anstrazole (arimidex) B Estramustine (Emcyt) C Pclitaxel (Taxol) D Irinotecan (Camptosar)
B. Anstrazole (arimidex)- treatment of advanced breast cancer in post menopausal women following tamoxifen therapy. Estramustine (Emcyt) - palliative treatment of metastatic and progressive prostate cancer. Pclitaxel (Taxol) - treatment of ovarian cancer, breast cancer and AIDS related to Kaposi's sarcoma. Irinotecan (Camptosar)- treatment of metastatic colon or rectal cancer after treatment with 5-FU.
The arterial blood gasses of a patient with severe chronic obstructive pulmonary disease (COPD) are: pH 7.34 PaO2 80 mm Hg PaCO2 47 mm Hg HCO3 28mEq. Based on these findings, what is the priority action of the nurse? a. Administer oxygen 4 L/minute via mask. b. No action is required at this time. c. Administer an IV corticosteroid. d. Perform vigorous suctioning.
B. This patient has mild respiratory acidosis which can be normal for a patient with COPD. No action is needed. A patient may only be mildly hypoxic in the early stages of COPD, but as the disease progresses, increasing hypoxia stimulates hyperventilation and respiratory alkalosis. In later stages, chronic CO2 retention and respiratory acidosis occurs. Also remember that the administration of oxygen to a patient with COPD can cause respiratory depression
A 25 year old patient is inquiring about the methods or ways to detect cancer earlier. The nurse least likely identify this method by stating: A Annual chest x-ray. B Annual Pap smear for sexually active women only. C Annual digital rectal examination for persons over age 40. D Yearly physical and blood examination
B. Early detection of cancer is promoted by annual oral examination, monthly BSE from age 20 Annual chest x-ray, yearly digital rectal examination for persons over age 40, annual Pap smear from age 40 and annual physical and blood examination. Letter B is wrong because it says Pap smear should be done yearly for sexually active women. All women should have an annual pap smear by age 40 and up whether sexually active or not.
A client w hypothyroidism would report which s/s A. Inc appetite and wt loss B. Puffiness of the hands and face C. Nervousness and tremor D. Thyroid swelling
B. Hashimotos/myxedema causes facial puffiness, extremity edema, and weight gain
A pt has UC. Which assessment causes most concern? A. Oral temp 99.0 B. Rebound tenderness C. Bloody diarrhea D. Borborygmi
B. Rebound tenderness is a sign of peritonitis and could be due to a ruptured colon A and B should be expected D doesn't apply
A nurse is giving a bed bath to a pt w open lesions caused by kaposi sarcoma. What should the nurse incorporate during bathing? A. Gloves B. Gown and gloves C. Gown, gloves and mask D. Gown and gloves for bed change and gloves only for the bath.
B. Spoiled items from wound drainage/incontinence/diarrhea require gown and gloves. Masks are used during droplet/airborne precautions
When teaching patient why spironolactone (Aldactone) and furosemide (Laxis) are prescribed together, the nurse bases teaching on the knowledge that: A. Moderate doses of two different types of diuretics are more effective then a larger dose of one type. B. This combination promotes diuresis but decreases the risk of hypokalemia. C. This combination prevents dehydration and hypovolemia D. Using two drugs increase osmolality of plasma and the glomerular filtration rate.
B. This combination promotes diuresis but decreases the risk of hypokalemia. Rational spironolactone (Aldactone) is a potassium sparing diuretic, furosemide (Laxix) is a potassium losing diuretic. Giving these together minimizes electrolyte imbalance.
A patient arrives at the emergency department with slurred speech, right facial droop, and right arm weakness. Which of these actions will the nurse anticipate as the priority. a. Transfer the patient to the neurological care unit b. Prepare the patient for a computerized tomography (CT) scan of the head c. Call the speech pathologist to the emergency department d. Prepare to administer a thrombolytic medication
B. Time is brain ...treatment is of utmost concern but before administering TPA ... A CT of the head must be done
A patient who has been receiving antiretroviral therapy (ART) to manage infection with human immunodeficiency virus (HIV) has an undetectable viral load. How would the healthcare provider interpret this information? a. More tests are needed to determine the effectiveness of ART b. HIV has been eliminated from the client's blood c. ART has been effective in reducing viral load d. ART can be discontinued in 3 months
C ART therapy is used to decrease the viral load as well as increase the CD4 cells
A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A Prepare to administer recombinant tissue plasminogen activator (rt-PA). B Discuss the precipitating factors that caused the symptoms. C Schedule for A STAT computer tomography (CT) scan of the head. D Notify the speech pathologist for an emergency consult.
C. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A Pulse B Respirations C Blood pressure D Temperature
C. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A Current medications. B Complete physical and history. C Time of onset of current stroke. D Upcoming surgical procedures.
C. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.
40 yr hx of smoking 2pks/day Chronic cough w thick sputum Peripheral edema Cyanotic nail beds Are s/s of what condition? A. ARDS B. Asthma C. Chronic obstructive bronchitis D. Emphysema
C. Ards has acute symptoms. Asthma and emphysema do not have a chronic cough or peripheral edema.
A client had undergone radiation therapy (external). The expected side effects include the following apart from: A Hair loss B Ulceration of oral mucous membranes C Constipation D Headache
C. Diarrhea not constipation is the side effect of radiation therapy
A nurse pokes herself w a needle after giving an IM on an AIDS pt. That is the best response by a supervisor to reduce anxiety? A. If you start on meds soon it will dec the severity of the disease B. Workers comp will cover the cost C. Your chances of contacting HIV are low D. Did you use needle safety protocol?
C. The risk is very small.
Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient's teaching plan? A. Rub the skin vigorously with a towel B. Take frequent baths C. Apply alcohol based emollients to the skin D. Keep fingernails short and clean
D . Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient's risk of infection. Keeping fingernails short and clean helps reduce the risk of infection.
What is the best way to check for patency of the arteriovenous fistula for hemodialysis? A Pinch the fistula and note the speed of filling on release B Use a needle and syringe to aspirate blood from the fistula C Check for capillary refill of the nail beds on that extremity D. Palpate the fistula throughout its length to assess for a thrill
D- The vibration or thrill felt during palpation ensures that the fistula has the desired turbulent blood flow. Pinching the fistula could cause damage. Aspirating blood is a needless invasive procedure.
A client has a severe single episode of depression. What nursing consideration r/t imbalanced nutrition- poor intake is most appropriate? A. Explain the importance of good nutritional intake B. Take wt. 3x / wk. before breakfast. C. Report concern to a psychiatrist and schedule a consult w a nutritionist D. Consult a nutritionist, offer the client several meals per day, schedule interaction during meals
D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake.
N On a clinic visit a client who has a relative with cancer, is asking about the warning signs that may relate to cancer. The nurse correctly identifies the warning signs of cancer by responding: A "If a sore healing took a month or more to heal, cancer should be suspected." B "Presence of dry cough is one of the warning signs of cancer." C "A lump located only in the breast area may suggest the presence of cancer." D "Sudden weight loss of unexplained etiology can be a warning sign of cancer."
D. Unexplained sudden weight loss is a warning signal of cancer. Letter A is wrong because the sore in cancer does not heal. Nagging cough not dry cough and hoarseness of voice is a sign of cancer. Presence of lump is not limited to the breast only; it can grow elsewhere that is why letter C is wrong.
Pcp recommends a family member of a client with a substance abuse problem use a support group. Why?
Support groups emphasize the importance of changing ones own behavior rather than changing the behavior of the user.
When planning care for a patient diagnosed with Alzheimer disease (AD), which of these interventions is most therapeutic? a. Encouraging both verbal and nonverbal communication b. Giving the patient several directions at a time to improve memory c. Speaking in a loud, clear voice when talking to the patient d. Providing immediate feedback by correcting errors in the patient's speech
a As the ability to communicate verbally declines, nonverbal communication may become more prominent. Encouraging both can facilitate communication and decrease frustration.
When caring for a patient during an acute panic attack, which of the following actions by the healthcare provider is most appropriate? a. Offer the patient reassurance of safety and security b. Ask open-ended questions to encourage communication c. Explore common phobias associated with panic attacks d. Use distraction techniques to change the patient's focus
a During the panic attack, the patient's focus is on the distressing physical symptoms caused by the anxiety. Distraction techniques, open-ended questioning, or exploration of phobias will not be helpful during an acute attack. Because the patient may experience a feeling of impending doom and fears for his or her life, reassurance of safety and security is the best initial intervention for this patient
A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review? a. Serum potassium b. Serum troponin c. Serum sodium d. Blood urea nitrogen (BUN)
a Furosemide may cause hypokalemia, which increases the risk of digoxin toxicity.
The children of a patient diagnosed with Alzheimer disease (AD) tell the healthcare provider, "Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings." How should the healthcare provider document the patient's behavior? a. Sundowning b. Depression c. Psychosis d. Delirium
a This patient is experiencing sundowning or sundowner syndrome, a phenomenon prevalent in patients diagnosed with dementia. Sundowning may be associated with impaired circadian rhythms, environmental or social factors, and impaired cognition.
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? a. Vision loss b. Dementia c. Muscle atrophy d. Clonus
a Vision loss and eye pain (optic neuritis) are early symptoms of MS. Dementia is uncommon and found only in severely affected patients. Clonus (rhythmic contractions when a muscle is stretched) is a sign of nerve damage which may be seen as MS progresses. Muscle atrophy is also a later sign of MS which is caused by disuse of a muscle group.
When assessing a patient with chronic heart failure, the healthcare provider would expect to identify which of these clinical manifestations? a. Inspiratory crackles b. Asymmetrical chest expansion c. Expiratory wheezing d. Subcutaneous crepitus
a When there is decreased pumping ability of the heart fluid backs up into the pulmonary system. Inspiratory crackles are caused when air collides with fluid in the lungs.
A patient diagnosed with dementia often becomes agitated and has angry outbursts. Which of the following interventions will the healthcare provider implement when caring for this patient? Select all that apply. a. Utilize distraction when agitation occurs b. Ignore the patient when agitation occurs c. Ensure the safety of the patient and staff d. Discuss the patient's behaviors in a rational manner e. Assist the patient to get involved in unit activities f. Move the patient to a quiet environment
a, c, f Safety for all of the patients on the unit and for the staff is always the priority. Moving the patient to a quiet environment is aimed at decreasing stimulation. Distracting the patient at the first sign of agitation may also be helpful. Ignoring the patient can allow the agitation to escalate.
Which of the following, if assessed in a patient, will the healthcare provider identify as a risk factor for the development of delirium? Select all that apply. a. Infections b. Decreased physical activity c. Decreased social interactions d. Administration of opioids e. Sleep deprivation f. Organ failure
a, d, e, f Sleep deprivation (common in hospitalized patients), organ failure, infections, and numerous drugs can put a patient at risk for delirium. Decreased social interaction can exacerbate delirium but will not cause delirium. Here's handy mnemonic to remember general risk factors for delirium: D = Dementia E = Electrolyte disorders L = Liver, lung, heart, kidney, brain I = Infection R = Rx (medications) I = Injury, pain, stress, U = Unfamiliar environment M = Metabolic
A patient who has tested positive for the human immunodeficiency virus (HIV) arrives at the clinic with a report of fever, nonproductive cough, and fatigue. The patient's CD4 count is 184 cells/mcL. How should the healthcare provider interpret these findings? a. The patient is diagnosed with acquired immunodeficiency syndrome (AIDS). b. The patient is now in the latent stages of HIV infection c. These findings provide evidence that the patient has seroconverted. d. This is an expected finding because the patient has tested positive for HIV
a.
A patient who has been prescribed the antiparkinsonian medication carbidopa/levodopa, asks the healthcare provider, "Why am I getting these two medications?" How should the healthcare provider respond? a. "The carbidopa prevents the breakdown of the levodopa." b. "The levodopa turns the carbidopa into dopamine when it reaches the brain." c. "You will experience fewer side effects when you take both medications together." d. "This drug combination is composed of two types of the same medication."
a. Carbidopa prevents the breakdown (decarboxylation) of levodopa in the intestine and peripheral tissues do more levodopa can travel to the brain, cross the blood brain barrier, where it is converted into.
A patient with a diagnosis of lung cancer is receiving chemotherapy and reports nausea and loss of appetite resulting in decreased food intake. What should the healthcare provider recommend to promote adequate nutrition? Advise the patient to: a. Eat small meals throughout the day. b. Eat only when feeling hungry. c. Eat only favorite foods to increase appetite. d. Eat large meals but less frequently throughout the day.
a. Encouraging the patient to small meals frequently throughout the day can help avoid nutritional deficiencies and improve quality of life.
A clinician is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? a. "It is important for you to seek medical attention immediately if you experience these symptoms again because they could mean that you are having a stroke." b. "Because TIAs don't cause permanent damage, I do not need to worry if I have another one." c. "TIAs are usually caused by large bleeds in the brain that resolve on their own." d. "Transient ischemic attacks (TIAs) are often caused by small bleeds in the brain that resolve on their own."
a. It is important to teach patients to seek medical attention immediately if they develop TIA again as TIAs often progress to stroke.
Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? a. Withholding all oral intake as ordered to decrease pancreatic secretions b. Administering Morphine as ordered to relieve pain c. Limiting IV fluids as ordered to reduce cardiac workload d. Keep the client supine to increase comfort
a. The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it's treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.
Hyperthyroidism is caused by increased levels of thyroxine in the plasma blood. A client with this endocrine dysfunction experiences: a. Heat intolerance and systolic hypertension b. Weight gain and heat intolerance c. Diastolic hypertension and widened pulse pressure d. Anorexia and hyperexcitability
a. An increased metabolic rate in a client with hyperthyroidism caused by excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss-not gain- occurs because of the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat intolerance and widened pulse pressure can occur but systolic hypertension and diastolic hypertension don't. clients with hyperthyroidism experience an increase in appetite.
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause: a. Hyperglycemia b. Air embolism c. Constipation d. Dumping Syndrome
a. Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome
When reviewing the medical record of a patient diagnosed with Alzheimer disease (AD), the healthcare provider notes the patient is aphasic. Which behavior supports this finding? a. Difficultly with motor function b. Unable to speak c. Unable to recognize objects d. Difficulty swallowing
b "-phasia" refers to speech. A patient who is aphasic is unable to speak.
The healthcare provider is reviewing the International Normalized Ratio (INR) results of a patient with a history of embolic stroke. Which of the following indicates a therapeutic value for this patient? Please choose from one of the following options. a. 1.5 b. 2.5 c. 4.1 d. 0.5
b A general rule of thumb is for INR to be between 2.0 and 3.0 in someone who is receiving anticoagulation therapy. The other values would indicate increased risk of embolism, clot, or bleeding.
A patient diagnosed with dementia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? a. Inhibition of acetylcholinesterase improves the patient's motor function b. Acetylcholine is needed for memory and problem solving c. Decreased levels of acetylcholine will help decrease the patient's anxiety d. Acetylcholine increases norepinephrine activity and decreases depression
b Acetylcholinesterase inhibitors prevent the breakdown of acetylcholine in the brain. Acetylcholine is involved in cognitive functions like memory and problem solving, increased levels of acetylcholine will improve these functions.
The healthcare provider is teaching a student about Parkinson disease (PD). Which of these statements best describes the brain abnormality characteristic of the disease? a. Central nervous system neurons become demyelinated b. Neurons in the substantia nigra begin to degenerate c. Amyloid plaques are deposited in the brain d. There is a progressive breakdown of the blood-brain barrier
b As neurons in the substantia nigra begin to degenerate, they produce less dopamine, creating a deficiency of this neurotransmitter.
A patient who has a diagnosis of chronic bronchitis is experiencing an acute exacerbation and is progressing to respiratory failure. When assessing the patient, which of these will be expected? a. Weak, thready pulse b. Altered level of consciousness c. Hypotension d. Bradycardia
b As oxygen delivery to the brain decreases, the patient will experience restlessness and confusion.
When caring for a patient diagnosed with ischemic stroke, which of these is the priority interventions when administering tissue plasminogen activator therapy (tPA)? a. Assess patient's motor function to compare to baseline b. Assess patient for recent history of bleeding or trauma c. Explain the purpose of tPA therapy to the patient and family d. Educate the patient and family on stroke recovery
b Patients must meet certain criteria for tPA therapy. It is important to identify if the patient has recently had any bleeding or trauma to ensure that they are not at risk for hemorrhage as a result of tPA therapy.
A patient diagnosed with general anxiety disorder (GAD) reports ongoing nausea and abdominal bloating. A physical examination fails to confirm a medical illness to explain these symptoms. The healthcare provider suspects these findings are a result of which of the following? a. Derealization b. Somatization c. Dysthymia d. Dissociation
b Somatization is a means of coping with psychosocial distress by developing physical symptoms (soma = body). Dysthymia is a persistent depressive disorder that may occur together with anxiety and somatization. Derealization is a sense of detachment from reality. Dissociation is impaired awareness of one's body, self, or environment, and may include derealization.
The healthcare provider is caring for a patient with emphysema. Which one of the following is an expected assessment finding for this patient? a. Decreased total lung capacity b. Increased anterior-posterior diameter of the chest c. A productive cough d. Inspiratory stridor
b. A productive cough is a common finding in patients with chronic bronchitis. Stridor is associated with an obstruction of the upper airway. Total lung capacity is often increased in obstructive lung diseases like emphysema. Emphysema causes air to become trapped in the lungs. The lungs become hyperinflated and the rib cage stays partially expanded, increasing the anterior-posterior diameter of the chest. This is called a barrel chest.
When evaluating the arterial blood gases (ABGs) of a patient with a 202020 year history of chronic bronchitis, which of these would the healthcare provider expect? a. Metabolic acidosis, uncompensated b. Respiratory acidosis, compensated c. Respiratory alkalosis, uncompensated d. Metabolic alkalosis, compensated
b. Chronic bronchitis diminishes airflow during expiration. Diminished expiratory airflow traps carbon dioxide in the lungs.Increased carbon dioxide lowers the arterial pH. The kidneys respond to acidosis by conserving bicarbonate, keeping the pH in a low-normal range, resulting in a state of compensated respiratory acidosis.
A patient is recovering from an acute exacerbation of emphysema . Which of the following is important for the healthcare provider to include in discharge teaching? Please choose from one of the following options. a. "Use your home pulse oximeter to maintain an oxygen saturation of 100\%100%100, percent." b. "Be sure to get an influenza vaccination every year." c. "Try not to cough too forcefully to avoid further lung damage." d. "Try to smoke no more than 111 pack of cigarettes per day."
b. Oxygen therapy should be titrated to the lowest effective dose. Maintaining an oxygen saturation of 100\%100%100, percent may suppress this patient's hypoxic drive. Huff coughing is an effective coughing technique that helps clear the airway forceful exhalation. For patients with COPD, the most common cause of an acute exacerbation is infection from bacteria or viruses. An annual influenza vaccination is one way to decrease the frequency of exacerbations.
The healthcare provider is teaching a patient who has been diagnosed with acquired immunodeficiency syndrome (AIDS) about the need for multi-drug therapy. Which of the following best explains the rationale for using more than one antiretroviral medication to treat AIDS? a. "This combination of medications will eliminate the AIDS virus from your body." b. "This is intended to keep the virus from developing resistance to the medications." c. "You will not be able to transmit the disease while you take this medication combination." d. "You will experience less side effects when you take a combination of medications."
b. Using a combination of medications decreases the patient's viral load and increases CD4 counts, but does not eliminate the virus.\ Even with a lower viral load, the patient is still able to transmit the disease to others. There are occasions when a combination of medications may allow a reduction in dose and therefore a reduction of adverse effects, but it may also result in increased adverse effects. The HIV virus mutates rapidly so resistance to medications is a concern. Emergence of resistance is related to viral load (e.g. the higher the viral load, the more probable it is that a virus will become resistant). By giving a combination of medications, viral load is reduced along with the likelihood of resistance.
When planning care for a patient diagnosed with Parkinson disease (PD), which of these patient outcomes should receive priority in the patient's plan of care? a. Working on a favorite hobby b. Taking a daily walk around the neighborhood c. Toileting and bathing independently d. Taking a vitamin supplement each day
c Being able to perform such tasks as toileting and bathing is important in maintaining some degree of independence and quality of life, so this is the priority outcome.
A patient is diagnosed with an abdominal aortic aneurysm (AAA). Which of the patient's vital signs will be a priority for the healthcare provider to monitor? a. Pulse rate b. Respiratory rate c. Blood pressure d. Core temperature
c Blood pressure should be monitored most closely in this patient. Avoiding hypertension is important because this could promote enlargement and rupture of the aneurysm. Hypotension could signal that rupture has occurred and blood volume has been lost. Respiratory rate and pulse rate may be elevated in early shock secondary to AAA leakage or rupture.
An unconscious patient arrives at the emergency department. Periumbilical (Cullen's sign) and flank ecchymosis (Grey Turner's sign) is noted , and a ruptured abdominal aortic aneurysm (AAA) is suspected. Which of these additional assessment findings will the healthcare provider anticipate? a. Decorticate posturing b. Expiratory wheezes c. Pale, clammy skin d. Pinpoint pupils
c In hypovolemic shock, a patient may present with pale, clammy skin as circulating volume decreases and peripheral vessels constrict in an attempt to shunt available blood to vital organs.
A patient is receiving care after being diagnosed with generalized anxiety disorder (GAD). Which of these statements made by the patient indicate to the healthcare provider that the patient is beginning to show signs of improvement? a. "As long as I take my medication, I can deal with anxiety." b. "Situations that cause anxiety can always be avoided." c. "I can tell when I'm beginning to experience anxiety." d. "Now I know that my anxiety is caused by a lack of sleep."
c Recognizing when symptoms of anxiety occur is an initial goal for the patient. Once anxiety is recognized, the patient can employ coping skills to manage the anxiety. Mediations can be helpful in managing GAD, but should be used in conjunction with cognitive-behavioral therapies.
The health care provider is assessing a patient who is recovering from a stroke. Which of these problems should receive priority for this patient?. a, Impaired mobility b. Risk for altered coping c. Risk for aspiration d. Impaired communication
c Risk for aspiration should always be considered as early as possible because some patients might have difficulty clearing their own salivary secretions. Aspiration of saliva and or other liquids can lead to pneumonia, which can be a fatal complication of stroke.
The healthcare provider is assessing a patient who has a been diagnosed with an abdominal aortic aneurysm (AAA). Which assessment finding is an indication that the aneurysm is expanding? a. Hoarseness and cough b. Dysphasia c. A report of lower back pain d. Anginal pain
c Symptoms of an AAA are the result of compression of abdominal structures, so back and abdominal pain are often reported. Anginal pain may be a symptom of compromised cardiac perfusion secondary to a thoracic aortic aneurysm.
A patient has been admitted to the cardiac unit with a diagnosis of right ventricular failure. Which of the following assessment findings would the healthcare provider expect to observe? is most likely to be observed by the healthcare provider? a. Fatigue and hemoptysis b. Bradycardia and circumoral cyanosis c. Peripheral edema and jugular vein distension d. Dyspnea and pulmonary crackles
c The right ventricle receives blood from the right atrium. If right ventricular pumping is impaired, blood will back up through the right atrium and into the venous system.
During an exacerbation of IBD a pt receives TPN and liquids. What is the priority of the pt. a. Monitor urine specific gravity every shift b. Infuse the solution in a large peripheral vein c. Monitor the patient's blood glucose per protocol d. Change the administration set every 72 hours
c. TPN may cause hyperglycemia so blood glucose is monitored.
A patient who has a history of chronic bronchitis is admitted to the medical unit. The healthcare provider notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient? a. Hypercapnia b. Insensible water loss c. Chronic hypoxia d. Decreased fluid intake
c. This patient's primary problem is hypoventilation of the alveoli secondary to airway obstruction. The kidneys respond to chronic hypoxia by releasing erythropoietin, stimulating red blood cell production, and elevating the red blood cell count.
A patient who is human immunodeficiency positive (HIV) positive is receiving a nucleoside reverse transcriptase inhibitor (NRTI). Which of these clinical findings would indicate the patient is experiencing an adverse effect of this medication? a. Increased blood glucose b. Weight gain c. Decreased hemoglobin d. Metabolic Alkalosis
c. NRTIs are Nukes...nukes destroy cell structure which results in bone marrow depression. This leads to anemia
The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? a.. position the client on the left side. b.Control the environment by turning the lights off and decreasing stimulation for the client. c. Check the client's bladder for distention. d.Administer pain medication.
c. The client is experiencing autonomic dysreflexia, which is a medical emergency. The nurse should immediately evaluate the client for bladder distention and be prepared to cath the client.
A male client with HIV infection becomes depressed and tells the nurse; "I have nothing worth living for now." Which of the following statements would be the best response by the nurse? - a. You are a young person and have a great deal to live for - b. You should not be too depressed; we are close to finding a cure for AIDS - c. You are right; it is very depressing to have HIV - d. Tell me moire about how you are feeling about being HIV positive
d
In educating a client about HIV, the nurse should take into account the fact that the most effective method known to control the spread of HIV infection is: - - a. premarital serologic screening - b prophylactic treatment of exposed people - c. laboratory screening of pregnant women - d. ongoing sex education about preventative behaviors
d
The healthcare provider is assessing a patient with a diagnosis of chronic bronchitis. Which of these physical findings represents the effects of air trapping in this patient? a. The sternum is prominently protruding from the chest. b. Asymmetrical expansion of the thorax is noted during inspiration. c. There are indentations in the intercostal spaces during inspiration. d. The width of the chest is equal to the depth of the chest.
d Air trapping over time causes a "barrel chest," where the anterior-posterior is ususally 2:1 is now 1:1
When obtaining a health history of a patient admitted with a diagnosis of heart failure, which statement made by the patient supports the diagnosis of heart failure? a. "I often feel pain in my lower legs when I take my walk." b. "I sometimes feel pain in the middle of my chest during exercise." c. "I get hot and break out in a sweat during the night." d. "I get out of breath when I go up a flight of stairs."
d Decreased pumping ability of the heart results in decreased cardiac output and pulmonary congestion, causing shortness of breath.
A patient who is diagnosed with Parkinson disease (PD) states, "I can't tie my shoelaces anymore." The healthcare provider recognizes that this patient's problem is due to a deficiency in which of these neurotransmitters? Please choose from one of the following options. a. Norepinephrine b. Seratonin c. Glutamate d. Dopamine
d Dopamine helps our brains control movement and coordination. The cells in the brain that make dopamine slowly die in patients who have PD, making it increasingly difficult to control muscles for movement, including fine motor movement needed to tie one's shoelaces.
A patient is being assessed for possible heart failure. Which of these laboratory results will provide support this diagnosis? a. Decreased C-reactive protein b. Increased creatine kinase c. Decreased serum sodium d. Increased brain natriuretic peptide (BNP)
d Heart failure is associated with increased cardiac filling pressures and stretch of the myocardium. The actions of the renin-angiotensin system is increased in heart failure. Increased fluid volume causes an increased stretch of the myocardium, causing the cells to release BNP. BNP is a peptide that opposes the actions of the renin-angiotensin system.
A patient diagnosed with mild heart failure is prescribed hydrochlorothiazide (Microzide). The healthcare provider should determine the teaching about the medication has been successful if the patient makes which of these statements? a. "I should not worry if I experience a dry cough when taking this medication." b. "I might experience swelling in my legs when taking this medication." c. "This medication might cause me to have a decrease in my appetite." d. "It is important for me to change positions slowly because I might become dizzy."
d Hydrochlorothiazide inhibits sodium reabsorption, causing sodium and water (along with potassium and hydrogen ions) to be excreted. The diuretic effect and decrease in fluid volume may cause orthostatic (postural) hypotension. Position changes should be made slowly to prevent falls.
When assessing a patient diagnosed with multiple sclerosis (MS), which of the following would require immediate action by the healthcare provider? a. Fatigue and depression b. Paresthesia and tremor c. Nystagmus and diplopia d. Dysphagia and congested cough
d These are all signs and symptoms of MS, but some can be more serious than others. Select the clinical manifestations of MS that may result in a serious secondary problem for the patient. Dysphagia puts the patient at risk for aspiration pneumonia, and the congested cough is an indication that aspiration has already occurred.
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 mls from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a. Creatinine b. Urobilinogen c. Chloride d. Albumin
d. Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.
A patient with a history of ischemic stroke is receiving warfarin therapy. Which of the following statements indicates the patient has a correct understanding of warfarin therapy? a. "The warfarin will help reverse the effects of my stroke so I can have a chance at full recovery." b. "I should increase my daily intake of leafy green veggies." c. "My activated partial thromoplastin time (aPTT) will need to be checked regularly from now on." d. "I need to check with my provider before taking over-the-counter medications"
d. As many medications can interact with warfarin, it is important to teach patients to check with their providers before taking any medication. The other statements are incorrect.
The healthcare provider is teaching a patient with emphysema pursed-lip breathing. Pursed lip breathing helps patients with emphysema because it: a. Creates negative pressure in the airways. b. Helps the patient achieve maximum inhalation. c. Increases the respiratory rate and oxygenation. d. Helps keep the small airways open and prevents air trapping.
d. Decreased elastic recoil results in airway collapse during expiration. Air becomes trapped in the lungs and it's difficult to exhale.
A patient who has a diagnosis of chronic bronchitis is receiving albuterol (Proventil) via nebulizer to treat an acute exacerbation. Which assessment noted by the healthcare provider is an indication the patient is experiencing an side effect of this medication? a Sedation b. Urinary incontinence c. Hypoglycemia d. Tachycardia
d. Systemic effects of the medication are minimized but not eliminated when administered by inhalation. Albuterol is a selective beta-222 agonist which can lose selectivity at high doses. Albuterol may also stimulate beta-111 receptors in the heart, causing tachycardia.
A patient whose lung cancer has metastasized to the bone reports lethargy, nausea, and vomiting. The healthcare provider monitor suspects the patient is experiencing hypercalcemia. Which of the following assessments associated with hypercalcemia would confirm the healthcare provider's suspicion? a. Presence of Chvostek sign b. Serum calcium level 10mg/dL c. Abdominal cramps and diarrhea d. Decreased deep tendon reflexes
d. The serum calcium level is within normal limits. Chvostek sign is a facial spasm associated with hypocalcemia. Increased calcium ions have a depressive effect on the central and peripheral nervous system. Smooth muscle in the gastrointestinal tract slows (leading to constipation) and skeletal muscle becomes hypotonic (leading to decreased deep tendon reflexes).
