Hurst 3

What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.

1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroid crisis. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1. Correct: These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning. 2. Incorrect: The data provided does not lead the nurse to suspect heat stroke. The stem does not tell the temperature the farmer is working in. Heat stroke signs and symptoms include increased sweating, tachypnea and temperature greater than 105.8°F (41.0°C). 3. Incorrect: The data provided does not lead the nurse to suspect anthrax poisoning. The worker has been outside in a field. This is not a risk factor for anthrax exposure. Inhalation anthrax develops when you breathe in anthrax spores. It's the most deadly way to contract the disease, and even with treatment it is often fatal. Initial signs and symptoms of inhalation anthrax include: Flu-like symptoms, such as sore throat, mild fever, fatigue and muscle aches, which may last a few hours or days. Mild chest discomfort, Shortness of breath, Nausea, Coughing up blood, Painful swallowing 4. Incorrect: The data provided does not lead the nurse to suspect gastroenteritis. These signs and symptoms do not go with gastroenteritis. Gastroenteritis signs and symptoms include diarrhea, nausea, vomiting, fever and abdominal cramping.

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? 1. Blood pressure 96/68; HR 98; RR 20 2. WBC 12,000/mm3 (12 x 10^9)/L 3. CVP- 6 mmHg 4. pH- 7.30; pCO2- 44; pO2 -92; HCO3- 20 5. Urinary output of 20 mL/hr

1., & 3. Correct: The systolic BP should be greater than 90. Normal CVP is 2-6 mmHg. 2. Incorrect: Incorrect: WBC is elevated. 4. Incorrect: The client is still in metabolic acidosis, so no improvement. 5. Incorrect: Urinary output should be adequate if treatment is successful. The urinary output should be 30 mL/hr for an adult.

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1., 2., 3., & 4. Correct: Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal. 5. Incorrect: The client may wear jewelry that does not inhibit lymph drainage. They should avoid jewelry that constricts the affected arm.

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1., 2., 3., & 4. Correct: In the hours before death, blood will be shunted to the vital organs and not the periphery. This will make the extremities cool to the touch and mottled in appearance. Both cool extremities and mottling are due to reduced blood flow. Cheyne-Stokes respiration is a respiratory pattern that consists of loud deep inhalations followed by a pause of apnea. Loss of appetite will occur as energy needs decline. The use of moistened clothes around the mouth and lip balm may help with keeping lips moist and comfortable 6. Incorrect: Blood pressure will not increase as death nears. The pumping action of the heart declines when death is occurring which leads to a decrease in cardiac output and blood pressure.

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1., 2., 3., & 4. Correct: Risk factors for developing frostbite include alcohol and drug abuse, dehydration, medical conditions such as diabetes or any condition that results in poor blood flow to the extremities, fatigue and exhaustion. 5. Incorrect: Being at a high altitude reduces the oxygen supply to extremities and places the person at increased risk for developing frostbite.

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1., 2., 4., & 5. Correct: A serving of just one ounce of beef liver contains well over the amount of B12 that the average person needs for the day. Feta cheese contains a good amount of vitamin B12 as well as several other important nutrients such as calcium and vitamin B2. Shrimp contain about 80 percent of the daily value needed of vitamin B12. Tuna either canned or grilled has a lot of vitamin B12. In fact, just one three ounce serving offers an entire day's worth of vitamin B12. 3. Incorrect: Fresh spinach does not have any vitamin B12. 6. Incorrect: Tofu is low-carb, dairy-free, gluten-free, cholesterol-free, and vegan, so it is popular with people who have specialized diets. However, vitamin B12 is not in tofu

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.

4. & 5. Correct: Pushing off with the palms of the hands is using a larger joint and muscles. Using the fingers will cause more joint injury. Use long handled devices such as a hairbrush with an extended handle to decrease stress on joints (in this case the wrist). 1. Incorrect: Larger joints and muscles can take more stress and weight than smaller ones. Using small joints again and again puts more stress on them and may lead to deformity. Try to spread the strain and weight over several joints. This helps you use each part of your body to its best advantage. 2. Incorrect: Do not turn a doorknob clockwise. Turn it counterclockwise to avoid twisting the arm and promoting ulnar deviation. 3. Incorrect: Sit in a chair that has a high, straight back. This will provide more support for the back.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output.

The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

Correct: One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 1. Incorrect: Following a transurethral resection of the prostate (TURP), it is normal for urine to be cherry red in color. Continuous bladder irrigation will keep clots from developing over several days and the deep red color of urine is an expected finding following this procedure. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. Because this client has just returned from surgery, 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma immediately post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected.