Health & Illness Exam 2

A nurse is developing a teaching plan for a terminally ill patient and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? A) Most patients reach acceptance by the time of death. B) The stages are applicable to any loss. C) Typically, the stages occur in succession. D) Each patient experiences each of the stages.

B) The stages are applicable to any loss.

The family and child have decided that hospice care best meets their needs during the terminal phase of illness. The nurse recognizes that the parents understand the principles of this care when they state: A) "It will be good to be at home and care for our child." B) "What a relief it will be not to need any more medicines." C) "We are going to miss the support of the hospice team when our child dies." D) "We know that once hospice care starts we will not be able to return to the hospital if the care is difficult."

A) "It will be good to be at home and care for our child."

Diet teaching hyperthyroidism:

-Increased calories -No caffeine -Reduce foods that may cause diarrhea (spicy, high fiber, lactose) -Avoid iodide rich foods

Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? A) dyspnea B) dizziness C) blurred vision D) mental confusion

B) dizziness Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation.

The 5-year old sibling of an infant who has died of SIDS says, "If I wish really hard, maybe the baby will come back." The mother asks the nurse how to handle the child's "wild imagination". What would be the most appropriate response by the nurse? A) "Your child is expressing a wish for another sibling, and that is normal." B) "Your child needs counseling to handle the death more appropriately." C) "Children of this age do not understand the finality of death, and this is a normal response for a 5-year-old." D) "A five-year-old needs an accurate account of why the baby died in order to understand death."

C) "Children of this age do not understand the finality of death, and this is a normal response for a 5-year-old." The 5-year-old child thinks of death as temporary, and engaging in magical thinking is normal for this age group. The child is not hinting about another baby, nor is the child handling the death inappropriately. A child of 5 is not capable of understanding details of the occurrence.

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic acidosis? A) Type B chronic obstructive pulmonary disease (COPD) and pneumonia B) Acute meningococcal meningitis C) A pancreatic fistula that is draining D) Severe hyperaldosteronism

C) A pancreatic fistula that is draining The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss.

A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant? A) jaundice B) passage of meconium C) hypoglycemia D) failure to thrive

C) hypoglycemia

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic alkalosis? A) Type B chronic obstructive pulmonary disease (COPD) and pneumonia B) Acute meningococcal meningitis C) A pancreatic fistula that is draining D) Severe hyperaldosteronism

D) Severe hyperaldosteronism Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

A patient is having her first severe, acute asthma episode. It began 2 hours ago. What blood gas values should the nurse expect to see? A) pH high, PaCO2 high, HCO3- high B) pH low, PaCO2 low, HCO3- low C) pH low, PaCO2 high, HCO3- high D) pH low, PaCO2 high, HCO3- normal

D) pH low, PaCO2 high, HCO3- normal A severe acute asthma episode impairs the excretion of carbonic acid, causing respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3- normal. A high pH occurs with alkalosis, not acidosis. Answers that include abnormal levels of HCO3- are not correct for the 2-hour time frame.

Possible exemplars metabolic alkalosis:

Excessive ingestion of NaHCO3, diuretic therapy, repeated vomiting, mineralocorticoid excess

Possible exemplars respiratory acidosis:

Severe asthma, opioid overdose, bronchitis, pulmonary edema

Possible exemplars respiratory alkalosis:

Acute anxiety attack, hyperventilation, acute pain, head injury

After the death of his wife, a man says, "I can't live without her...she was my whole life." Select the most therapeutic reply by the nurse. A) "Each day will get a little better." B) "Her death is a terrible loss for you." C) "It's important to recognize that she is no longer suffering." D) "Your friends will help you cope with this change in your life."

B) "Her death is a terrible loss for you."

Which diagnosis indicates that the nurse should assess the patient most carefully for development of respiratory alkalosis? A) Type B chronic obstructive pulmonary disease (COPD) and pneumonia B) Acute meningococcal meningitis C) A pancreatic fistula that is draining D) Severe hyperaldosteronism

B) Acute meningococcal meningitis Meningitis can stimulate hyperventilation, which causes respiratory alkalosis.

A man on parole robs a bank in a small town and wounds two police officers during a shoot-out while trying to escape. The robber is fatally shot. The police officers are being hailed as heroes in the news, and the man's previous and current criminal history is prominently featured. The nurse is caring for the bank robber's sibling, who is in the emergency department with emotional problems and suicidal ideation. Which type of grief may the sibling be experiencing, which could be contributing to the current emotional state? A) Anticipatory B) Disenfranchised C) Uncomplicated D) Dysfunctional

B) Disenfranchised

End-of-life care is most synonymous with which of the following types of care? A) Palliative care B) Hospice care C) Supportive care D) Quality of life

B) Hospice care End-of-life care is most synonymous with hospice care. Hospice care uses palliative care for the imminently dying by introducing a team of interdisciplinary health care professionals at the end of a patient's life. The Medicare Hospice Benefit requires that a patient have a prognosis of 6 months or less to be enrolled in this type of care.

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis? (Select all that apply) A) Have you been vomiting today? B) When did your kidneys stop working? C) How long have you had diarrhea? D) What type of antacid did you take? E) Which weight loss diet are you using?

B, C, E Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids.

The nurse is discussing advance directives with a patient. Which statement by the patient indicates good understanding of the purpose of a living will? A) "A living will can keep my children from selling my home when I'm old." B) "A living will can be written as soon as I'm incapacitated and can't think for myself." C) "A living will is a written legal document that states what I want done in health care if I can't tell them myself." D) "A living will is when I appoint someone to make health care decisions for me when I am not able to do so."

C) "A living will is a written legal document that states what I want done in health care if I can't tell them myself."

A 7-year-old is in the end stages of cancer. The parents ask you how they will know when death is imminent. Which of the following physical signs is indicative of approaching death? A) Hunger B) Tachycardia C) Difficulty swallowing D) Increased thirst

C) Difficulty swallowing The child begins to have difficulty swallowing as he or she approaches death. The child's appetite will decrease, and he or she will take only small bites of favorite foods or sips of fluids in the final few days. The pulse rate will slow.

A woman is hospitalized at 32 weeks gestation after a severe hemorrhage from a complete placenta previa. The patient delivers a stillborn infant one week later. Which of the following interventions will the nurse perform to help this family in the grieving process? A) Ask to have the mother moved off the postpartum floor. B) Remove the crib and all baby supplies from the mother's room. C) Facilitate and support the family viewing and holding the infant. D) Refrain from talking about the baby.

C) Facilitate and support the family viewing and holding the infant.

The nurse is caring for a client with type 2 diabetes mellitus. One hour after taking an oral diabetic medication, the client becomes nauseated and vomits. What is the initial action of the nurse? A) Administer another dose of the drug. B) Administer subcutaneous insulin. C) Monitor blood glucose closely, and assess for signs of hypoglycemia. D) Notify the healthcare provider for a prescription for glucose tablets.

C) Monitor blood glucose closely, and assess for signs of hypoglycemia.

The nurse should assess the client with severe diarrhea for which acid-base imbalance? A) respiratory acidosis B) respiratory alkalosis C) metabolic acidosis D) metabolic alkalosis

C) metabolic acidosis A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis.

The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? A) Be sure to aspirate prior to injecting insulin. B) Massage the site after injecting insulin. C) Use a 1-inch needle for the injection. D) Allow the insulin to warm to room temperature before injecting it.

D) Allow the insulin to warm to room temperature before injecting it. Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? A) Serum chloride level of 90 mmol/L B) Serum calcium level of 8 mg/dL C) Serum sodium level of 132 mmol/L D) Serum potassium level of 2.5 mmol/L

D) Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces... A) iodine and thyroid-stimulating hormone (TSH). B) thyrotropin-releasing hormone (TRH) and TSH. C) TSH, triiodothyronine (T3), and calcitonin. D) T3, thyroxine (T4), and calcitonin.

D) T3, thyroxine (T4), and calcitonin.

Possible exemplars metabolic acidosis:

Thyroid storm, DKA, diarrhea, lactic acidosis, starvation ketoacidosis, oliguria, draining fistulas

A nurse assesses a patient with a terminal illness and determines that the patient is in denial about the condition. Which of the following would be most important for the nurse to do when developing the patient's plan of care? A) Accept the patient's denial of the situation. B) Explain to the patient that denial of the situation is unhealthy. C) Seek help from other health care team members to address the patient's denial. D) Correct the patient's misconception about the illness and the treatment goals.

A) Accept the patient's denial of the situation.

The patient has severe metabolic alkalosis. Which intervention has the highest priority? A) Raise the side rails on the patient's bed. B) Measure the urine output and skin turgor. C) Teach the family about metabolic alkalosis. D) Administer intravenous NaHCO3 as ordered.

A) Raise the side rails on the patient's bed. Severe metabolic alkalosis causes a decreased level of consciousness; raising the side rails is a safety intervention in that situation.

A 26-week gestation pregnant woman has completed a 1-hour glucose screening test. What action should the nurse take first if the glucose level is 150 mg/dL (8.3 mmol/L)? A) Refer the client for a 3-hour glucose test. B) Teach the client how to administer insulin. C) Document the results as normal. D) Instruct the client on proper diet.

A) Refer the client for a 3-hour glucose test.

Which diagnosis indicates that the nurse should assess the patient most carefully for development of respiratory acidosis? A) Type B chronic obstructive pulmonary disease (COPD) and pneumonia B) Acute meningococcal meningitis C) A pancreatic fistula that is draining D) Severe hyperaldosteronism

A) Type B chronic obstructive pulmonary disease (COPD) and pneumonia Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion.

When assessing a teminally ill patient, the nurse notices that the patient has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include? A) Using a soft toothbrush to vigorously clean the patient's mouth. B) Positioning the patient on their side with their head supported with a pillow. C) Administering a prescribed anticholinergic agent to the patient. D) Performing gentle suctioning of the patient's mouth.

A) Using a soft toothbrush to vigorously clean the patient's mouth. Secretions are more distress to the family than the patient. Gentle mouth care w/ a moistened swab or soft toothbrush maintains integrity of mucous membranes and least invasive. Helpful= positioning on the side w/ head supported with pillows to allow secretions to drain, gently suction oral cavity, administer prescribed anticholingergics sublingual or transdermal. Deeper suctioning = significant discomfort, invasive, rarely benefits bc secretions reaccummulate quickly. Vigorous cleaning during mouth care is not helpful.

A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH? A) increased respiratory rate B) increased urine output C) decreased blood pressure D) increased body temperature

A) increased respiratory rate Critically ill client with sepsis is at risk for decreased perfusion of tissues & organs = lactic acid production = metabolic acidosis. To compensate, the lungs eliminate carbonic acid by blowing off more CO2 via increased RR. Respiratory system compensates for metabolic acidosis, not the renal system. Blood pressure will be low in the client with sepsis, but blood pressure is not a compensatory mechanism for pH imbalances. While body temperature can affect acid base balance, this is not how the body compensates for metabolic acidosis.

A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning? A) irregular heart rate B) abdominal cramping C) respiratory rate of 28 D) excoriated skin around the rectum

A) irregular heart rate Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. The diarrhea would result in skin breakdown. Abdominal cramping would be anticipated. Kussmaul respirations are anticipated as a compensatory response. Irregular heart rate could be a sign of electrolyte imbalances and is most concerning.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? A) tetany B) hemorrhage C) thyroid storm D) laryngeal nerve damage

A) tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: A) are unable to inspire sufficient oxygen. B) are unable to exchange oxygen and carbon dioxide. C) have ineffective cilia from years of smoking. D) are unable to blow off carbon dioxide.

D) are unable to blow off carbon dioxide.

The nurse assesses a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest? A) short attention span and weight loss B) weight loss and flushed skin C) rapid pulse and heat intolerance D) dry skin and constipation

D) dry skin and constipation

A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? A) metabolic acidosis and hyperkalemia B) metabolic acidosis and hypokalemia C) metabolic alkalosis and hyperkalemia D) metabolic alkalosis and hypokalemia

D) metabolic alkalosis and hypokalemia

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? A) Request an order for pain medication and oxygen at 6 L/min. B) Lubricate the patient's lips and allow continued hyperventilation. C) Have the patient breathe into a paper bag to stop hyperventilating. D) Contact the physician immediately regarding this complication.

B) Lubricate the patient's lips and allow continued hyperventilation. Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

Palliative care is best explained in the management of a patient with a symptomatic chronic obstructive pulmonary disease (COPD) by which of the following? A) Hospice nurses must be involved to provide palliative care in a dying COPD patient. B) Palliative care is used when the COPD patient is beginning to die. C) Palliative care is used to help manage the symptoms that often accompany COPD. D) The COPD patient must be enrolled into the Medicare Hospice Benefit to receive palliative care.

C) Palliative care is used to help manage the symptoms that often accompany COPD.