Med Surg II: Exam 2

A very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term? a. Choledochostomy b. Choledochoduodenostomy c. Cholecystostomy d. Cholecystectomy

a. Choledochostomy

The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve? a. 4 in. b. 2 in. c. 5 in. d. 3 in.

b. 2 in.

The nurse knows that the serum amylase concentration returns to normal within which time frame? a. 36 hours b. 48 hours c. 12 hours d. 24 hours

b. 48 hours

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse? a. "You should not use herbal supplements in conjunction with medical treatment." b. "You can use milk thistle instead of the medications you have been prescribed." c. "Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated." d. "Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your primary care provider."

c. "Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated."

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? a. Give acetaminophen per orders. b. Assess for weight loss. c. Document signs and symptoms of inflammation. d. Administer corticosteroids as ordered

d. Administer corticosteroids as ordered

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? a. Beriberi b. Hypoprothrombinemia c. Night blindness d. Scurvy

d. Scurvy

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to a. control shivering. b. control fever. c. reduce cellular metabolic demand. d. dehydrate the brain and reduce cerebral edema

d. dehydrate the brain and reduce cerebral edema

The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a. fluid. b. semi mushy. c. mushy. d. solid.

d. solid.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? a. Assisting the client to turn, cough, and deep breathe every 2 hours b. Performing range-of-motion (ROM) leg exercises hourly while the client is awake c. Teaching the client to choose low-fat foods from the menu d. Assisting the client to ambulate the evening of the operative day

a. Assisting the client to turn, cough, and deep breathe every 2 hours

Which positions is used to help reduce intracranial pressure (ICP)? a. Avoiding flexion of the neck with use of a cervical collar b. Keeping the head flat, avoiding the use of a pillow c. Extreme hip flexion, with the hip supported by pillows d. Rotating the neck to the far right with neck support

a. Avoiding flexion of the neck with use of a cervical collar

A nurse is teaching a client about the types of chronic liver disease. The teaching is determined to be effective when the client correctly identifies which type of cirrhosis as being caused by scar tissue surrounding portal areas? a. Post-necrotic cirrhosis b. Alcoholic cirrhosis c. Compensated cirrhosis d. Biliary cirrhosis

b. Alcoholic cirrhosis

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately? a. Diarrhea or constipation b. Change in mental status c. Fatigue and weight loss d. Anorexia and dyspepsia

b. Change in mental status

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. a. Elevating the head of the bed to 90 degrees b. Frequent oral care c. Administering prescribed antipyretics d. Encouraging deep breathing and coughing every 2 hours e. Maintaining aseptic technique with an intraventricular catheter

b. Frequent oral care c. Administering prescribed antipyretics e. Maintaining aseptic technique with an intraventricular catheter

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? a. Portal hypertension b. Hepatic encephalopathy c. Asterixis d. Cirrhosis

b. Hepatic encephalopathy

Which is the most common cause of esophageal varices? a. Ascites b. Portal hypertension c. Asterixis d. Jaundice

b. Portal hypertension

Which anticholinergic agent is used to control tremor and rigidity in Parkinson disease? a. Benztropine Mesylate b. Amantadine c. Levodopa d. Bromocriptine mesylate

a. Benztropine Mesylate

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply. a. "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." b. "It can assess for ecchymosis in the body." c. "It can evaluate the presence and location of ductal stones and aid in stone removal." d. "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." e. "It is used in the diagnostic evaluation of acute pancreatitis."

a. "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." c. "It can evaluate the presence and location of ductal stones and aid in stone removal." d. "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts."

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply. a. Administer plasma b. Administer electrolytes c. Assist the client to a semi-Fowler position d. Administer a low-fat diet e. Administer pain-relieving medication

a. Administer plasma b. Administer electrolytes c. Assist the client to a semi-Fowler position e. Administer pain-relieving medication

The client is 12-hours-post-lumbar laminectomy. Which nursing intervention should be implemented? a. Assess ability to void and log roll client every two (2) hours b. Medicate with IV steroids and keep the bed in a Trendelenburg position c. Place sandbags on each side of the head and give laxative medications. d. Administer IV anticoagulants and place the client on oxygen at eight (8) L/min

a. Assess ability to void and log roll client every two (2) hours

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? a. Bile-stained vomiting b. Weight loss c. Warm, dry skin d. Hypertension

a. Bile-stained vomiting

Which is the most common presenting symptom of colon cancer? a. Change in bowel habits b. Weight loss c. Fatigue d. Anorexia

a. Change in bowel habits

Which is the earliest sign of increasing intracranial pressure? a. Change in level of consciousness b. Headache c. Vomiting d. Posturing

a. Change in level of consciousness

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? a. Change in the client's handwriting and/or cognitive performance b. Anorexia for more than 3 days c. Constipation for more than 2 days d. Weight loss of 2 pounds in 3 days

a. Change in the client's handwriting and/or cognitive performance

Which term most precisely refers to the incision of the common bile duct for removal of stones? a. Choledocholithotomy b. Choledochoduodenostomy c. Choledochotomy d. Cholecystostomy

a. Choledocholithotomy

Steve has moderate to late-stage Parkinson's disease and is admitted to the medical unit where you are a nurse. Steve has a new diagnosis with new-onset orthostatic hypotension and occasional dysphagia. According to his wife, he needs assistance with ADLs only on days when his rigidity is worse and walks short distances in the house using a walker. Which of the following actions would the nurse take? Select all that apply a. Consult with the speech-language pathologist for a swallowing evaluation b. Remind the client and wife to call for nursing staff to help the client out of bed c. Obtain a prescription for a different antihypertensive medication d. Place the client on the hospital's fall precautions protocol. e. Refer the client for physical and occupational therapy evaluations. f. Place the client on a liquid diet to prevent choking. g. Remind the nursing staff to place the client in a sitting position during meals. h. Perform frequent orthostatic blood pressure checks.

a. Consult with the speech-language pathologist for a swallowing evaluation b. Remind the client and wife to call for nursing staff to help the client out of bed d. Place the client on the hospital's fall precautions protocol. e. Refer the client for physical and occupational therapy evaluations. g. Remind the nursing staff to place the client in a sitting position during meals. h. Perform frequent orthostatic blood pressure checks.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client? a. "This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation." b. "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." c. "This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated." d. "This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use."

b. "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort."

A client with end-stage liver disease is scheduled to undergo a liver transplant. The client tells the nurse, "I am worried that my body will reject the liver." Which statement is the nurse's best response to the client? a. "You would not be scheduled for a transplant if there was a concern about rejection." b. "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." c. "The problem of rejection is not as common in liver transplants as in other organ transplants." d. "It is easier to get a good tissue match with liver transplants than with other types of transplants."

b. "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs."

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy? a. Placing the client in the semi-Fowler position immediately after surgery b. Assessing the color of the sclera every shift c. Clamping the T-tube immediately after surgery d. Placing the client on NPO (nothing by mouth) status for 2 days after surgery

b. Assessing the color of the sclera every shift

Which is a clinical manifestation of cholelithiasis? a. Nonpalpable abdominal mass b. Clay-colored stools c. Epigastric distress before a meal d. Abdominal pain in the upper left quadrant

b. Clay-colored stools

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? a. Apply barrier powder b. Dry skin thoroughly after washing c. Apply triamcinolone acetonide spray d. Dust with nystatin powder

b. Dry skin thoroughly after washing

A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir? a. At least once every 2 days b. Every 4 to 6 hours c. Three or four times daily d. At least once a day

b. Every 4 to 6 hours

A client with a cervical disc herniation in the acute phase reports of numbness and tingling in the arms. What are the priority interventions for the nurse to perform? Select all that apply. a. Encourage exercises to strengthen the legs b. Have the client wear a cervical collar daily c. Assist the client in isometric exercises of the arms d. Provide NSAID therapy e. Encourage weight lifting to strengthen arms

b. Have the client wear a cervical collar daily d. Provide NSAID therapy

A client with chronic hepatitis C is experiencing nausea, anorexia and fatigue. The client reports drinking 1-2 glasses of wine with dinner, that he takes St.John's wort for "a bit of depression" and takes acetaminophen for frequent headaches. What actions will the nurse take? Select all that apply. a. Instruct the client that the wine with meals can be beneficial for cardiovascular health. b. Instruct the client to confer with the primary care provider prior to taking over the counter medications. c. Instruct the client to eat small, frequent meals. d. Encourage the client to obtain sufficient rest. e. Reassure the client that taking acetaminophen every 4 hours is ok.

b. Instruct the client to confer with the primary care provider prior to taking over the counter medications. c. Instruct the client to eat small, frequent meals. d. Encourage the client to obtain sufficient rest.

Which enzyme aids in the digestion of fats? a. Trypsin b. Lipase c. Secretin d. Amylase

b. Lipase

A client is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and reports of vague upper and midabdominal pain that increases in intensity at night. The client' health history indicates alcoholism, smoking of a pack of cigarettes daily, and diabetes for the past 20 years. Upon examination the nurse finds swelling in the feet and abdominal ascites. Based on the clinical manifestations, which condition is the most likely diagnosis? a. Cholecystitis b. Pancreatic carcinoma c. Acute pancreatitis with edema d. Pancreatic pseudocysts

b. Pancreatic carcinoma

Teaching about home management after a laparoscopic cholecystectomy will include: a. Keep the bandages on the incision sites for 1 week. b. Report bile colored drainage at the incision site c. Use over-the-counter antiemetics if nausea/vomiting occurs d. Measure and empty the bile bag every day

b. Report bile colored drainage at the incision site

A client with a neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Administering prescribed antipyretics b. Restricting fluid intake and hydration c. Hyperoxygenation before and after tracheal suctioning d. Maintaining adequate hydration

b. Restricting fluid intake and hydration

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis? a. Calcification of the pancreatic duct, leading to its blockage b. Self-digestion of the pancreas by its own proteolytic enzymes c. Fibrosis and atrophy of the pancreatic gland d. Use of loop diuretics to increase the incidence of pancreatitis

b. Self-digestion of the pancreas by its own proteolytic enzymes

Which is the most common report by clients with pancreatitis? a. Increased and painful urination b. Severe, radiating abdominal pain c. Tarry, black stools and dark urine d. Increased appetite and weight gain

b. Severe, radiating abdominal pain

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? a. Assist the client regarding the correct diet or to minimize food intake b. Suggest fluid intake of at least 2 L/day c. Instruct the client to keep a record of food intake d. Instruct the client to avoid prune or apple juice

b. Suggest fluid intake of at least 2 L/day

The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, "Why not try chemotherapy first? It has helped with my other tumors." The nurse's response is based on which scientific rationale? a. Chemotherapy is only used as a last resort in caring for clients with brain tumors. b. The blood-brain barrier prevents medications from reaching the brain. c. Radiation therapy will have fewer side effects than chemotherapy. d. Metastatic tumors become resistant to chemotherapy, and it becomes useless

b. The blood-brain barrier prevents medications from reaching the brain.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? a. Insert oral airway b. Turn the client to the side c. Place a cooling blanket on the client d. Administer mannitol

b. Turn the client to the side

Which medication classification should be avoided in the treatment of brain tumors? a. Osmotic diuretics b. Anticonvulsants c. Anticoagulants d. Corticosteroids

c. Anticoagulants

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? a. The pupils are dilated and fixed. b. Cerebral perfusion pressure (CPP) is 21 mm Hg. c. Increased ICP is 12 mm Hg. d. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP).

c. Increased ICP is 12 mm Hg.

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program? a. The lifetime risk of developing colorectal cancer is 1 in 10. b. The incidence of colorectal cancer decreases with age. c. It is the third most common cancer in the United States. d. Colorectal cancer has no hereditary component.

c. It is the third most common cancer in the United States.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? a. Maintaining fluid volume b. Controlling bleeding c. Maintaining the airway d. Relieving the client's anxiety

c. Maintaining the airway

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? a. Apply soft wrist restraints b. Raise all four side rails on the bed c. Pad the side rails on the bed d. Prevent visitors, so as not to agitate the client

c. Pad the side rails on the bed

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? a. Serum bilirubin b. Serum potassium c. Serum amylase d. Serum calcium

c. Serum amylase

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? a. Provide oxygen or anticonvulsants, whichever is available b. Place a cooling blanket beneath the client c. Turn the client to the side during a seizure and do not restrain movements d. Suction the client's mouth and pharynx

c. Turn the client to the side during a seizure and do not restrain movements

After A.R. is treated with lorazepam and levetiracetam for their seizure, they are very lethargic. As the nurse, you assess that A.R. opens their eyes to verbal stimulation, answers yes/no questions, then falls back to sleep. BP 140/80, HR 88, RR 16, Temp 36.5 C, O2 sat 96% on RA. What is the best response by the nurse? a. Place oxygen at 2 LPM b. Call the provider immediately to request flumazenil c. Place the HOB flat to promote better sleep d. Document this assessment and continue routine hourly checks

d. Document this assessment and continue routine hourly checks

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? a. The CPP is within normal limits. b. The CPP reading is inaccurate. c. The CPP is high. d. The CPP is low.

d. The CPP is low.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? a. Warm moist skin b. Hypotension c. Polyuria d. Bradycardia

b. Hypotension

The nurse is caring for a 78 year old male who underwent pituitary removal using a transsphenoidal approach. Which statement made by the patient indicates a need for further education? a. I will not use a straw for drinking fluids. b. I know that urinating every hour is normal after this surgery c. I will avoid blowing my nose. d. I will avoid brushing my teeth until the incision heals.

b. I know that urinating every hour is normal after this surgery

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered a. low. b. within normal limits. c. high. d. inaccurate

a. low.

Which value indicates a normal intracranial pressure (ICP)? a. 5 mm Hg b. 27 mm Hg c. 17 mm Hg d. 20 mm Hg

a. 5 mm Hg

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply. a. Agitation b. Insomnia c. Alterations in mood d. Report of headache e. Decreased deep tendon reflexes

a. Agitation b. Insomnia c. Alterations in mood

What is the most common type of brain neoplasm? a. Neuroma b. Glioma c. Angioma d. Meningioma

b. Glioma

Cerebral edema peaks at which time point after intracranial surgery? a. 12 hours b. 48 hours c. 24 hours d. 72 hours

c. 24 hours

The nurse teaches the client that corticosteroids will be used to treat his brain tumor to a. prevent extension of the tumor. b. identify the precise location of the tumor. c. reduce cerebral edema. d. facilitate regeneration of neurons.

c. reduce cerebral edema.

Which drug is considered a stimulant laxative? a. Magnesium hydroxide b. Psyllium hydrophilic mucilloid c. Mineral oil d. Bisacodyl

d. Bisacodyl

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? a. Antianxiety b. Diuretics c. Anticonvulsants d. Corticosteroids

c. Anticonvulsants

The nurse is admitting a client to the med-sure unit who is suspected of having acute pancreatitis. Which of the following provider orders does the nurse anticipate? Select all that apply. a. Low-fat diet b. 0.9% NS at 125 ml/hr c. Avoid acetaminophen d. Serum lipase e. Serum glucose f. Hydromorphone 0.5 mg IV— Q 3 hrs PRN g. Famotidine 20 mg IV BID h. Administer pancreatic enzymes with meals

b. 0.9% NS at 125 ml/hr d. Serum lipase e. Serum glucose f. Hydromorphone 0.5 mg IV— Q 3 hrs PRN g. Famotidine 20 mg IV BID

A client is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation? a. To control blood pressure b. To increase the client's pain threshold c. To control muscle spasms d. To diagnose the cause of abdominal pain

b. To increase the client's pain threshold

A rapid, jerky, involuntary, and purposeless movement of the extremities or facial muscles is a. Paresthesia b. Akathisia c. Dyskinesia d. Chorea

d. Chorea

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? a. 1 month b. 7 months c. 4 months d. Over 1 year

b. 7 months

A client has undergone a liver biopsy. Which post-procedure position is appropriate? a. On the right side b. On the left side c. High Fowler d. Trendelenburg

a. On the right side

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu? a. Pancakes with butter and honey, and orange juice b. Omelet with green peppers, onions, mushrooms, and cheese with milk c. Ham and cheese sandwich, baked beans, potatoes, and coffee d. Baked chicken with sweet potato french fries, cornbread, and tea

a. Pancakes with butter and honey, and orange juice

Which disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells? a. Parkinson disease b. Multiple sclerosis c. Huntington disease d. Creutzfeldt-Jakob disease

a. Parkinson disease

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss? a. Skipping meals out of fear of painful attacks b. Ingesting a low-fat diet to prevent abdominal pain c. Malabsorption d. Vomiting after heavy meals

a. Skipping meals out of fear of painful attacks

Which term is used to describe edema of the optic nerve? a. Scotoma b. Papilledema c. Angioneurotic edema d. Lymphedema

b. Papilledema

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? a. Nitroglycerin b. Cimetidine c. Vasopressin d. Spironolactone

c. Vasopressin

What is the most common cause of small-bowel obstruction? a. Hernias b. Volvulus c. Adhesions d. Neoplasms

c. Adhesions

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? a. Provide ventriculostomy care. b. Inspect the ICP monitor to ensure it is working properly. c. Administer acetaminophen per orders. d. Assess for signs and symptoms of infection

c. Administer acetaminophen per orders.

Which is a late sign of increased intracranial pressure (ICP)? a. Headache b. Irritability c. Altered respiratory patterns d. Slow speech

c. Altered respiratory patterns

he nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? a. Use pressure-relieving pads or a similar type of mattress b. Perform the Heimlich maneuver c. Apply warm or cool cloths to the forehead or back of the neck d. Maintain hydration by drinking eight glasses of fluid a day

c. Apply warm or cool cloths to the forehead or back of the neck

The nurse determines which nursing intervention would best assist the client with a brain tumor who may be at increased risk for aspiration? a. Monitoring vital signs b. Assistance with self-care c. Frequent reorientation d. Evaluation of gag reflex and ability to swallow

d. Evaluation of gag reflex and ability to swallow

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis? a. Increased appetite and weight gain b. Increased and painful urination c. Tarry, black stools, and dark urine d. Severe, radiating abdominal pain

d. Severe, radiating abdominal pain

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? a. Urine output of 100 mL/hr b. Capillary refill of 2 seconds c. Cool, dry skin d. Shivering

d. Shivering

Which position should be used for a client undergoing a paracentesis? a. Upright at the edge of the bed b. Prone c. Trendelenburg d. Supine

d. Supine

The client diagnosed with a brain tumor has diminished gag response. Which intervention should the nurse implement? a. Make the client NPO indefinitely b. Position the client in low Fowler's position for all meals c. Encourage the client to consume only liquids d. Teach the client to direct food and fluid toward the unaffected side

d. Teach the client to direct food and fluid toward the unaffected side

Which condition indicates an overdose of lactulose? a. Hypoactive bowel sounds b. Constipation c. Fecal impaction d. Watery diarrhea

d. Watery diarrhea

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? a. High Fowler b. On the left side c. Trendelenburg d. On the right side

d. On the right side

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? a. Shock b. Tetany c. MODS d. Pancreatic necrosis

d. Pancreatic necrosis

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? a. Frequent vomiting, leading to loss of fluid volume b. Dry mouth, which makes the client thirsty c. High glucose concentration in the blood d. Acetone in the urine

a. Frequent vomiting, leading to loss of fluid volume

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a. Herniation b. Monro-Kellie hypothesis c. Cushing response d. Autoregulation

a. Herniation

Which is a gerontological consideration associated with the pancreas? a. Increased amount of fibrous material b. Increased rate of pancreatic secretion c. Increased bicarbonate output d. Increased calcium absorption

a. Increased amount of fibrous material

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? a. Ineffective cerebral tissue perfusion b. Fluid volume deficit c. Risk for infection d. Risk for injury

a. Ineffective cerebral tissue perfusion

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? a. Vasopressin b. Spironolactone c. Nitroglycerin d. Cimetidine

a. Vasopressin

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a client's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The client is placed in he high Fowler position and a blood pressure cuff is secured around the arm in preparation for which procedure? a. Abdominal ultrasound b. Dialysis c. Liver biopsy d. Paracentesis

d. Paracentesis

The nurse teaches the client with which disorder that the disease is due to decreased levels of dopamine in the basal ganglia of the brain? a. Creutzfeldt-Jakob disease b. Huntington disease c. Multiple sclerosis d. Parkinson disease

d. Parkinson disease

The digestion of carbohydrates is aided by a. lipase. b. trypsin. c. secretin. d. amylase.

d. amylase.

What is the only known risk factor for brain tumors? a. Head trauma b. Ionizing radiation c. Use of hair dyes d. Cellular telephones

b. Ionizing radiation

Which term described the passage of a hollow instrument into a cavity to withdraw fluid? a. paracentesis b. asterixis c. ascites d. dialysis

a. paracentesis

A nurse applies an ostomy appliance to a client who is recovering from ileostomy surgery. Which intervention should the nurse utilize to prevent leakage from the appliance? a. Ask the client to remain inactive for 5 minutes. b. Press the adhesive faceplate from the stomal edge inward c. Ensure that there are no holes in the pouch d. Ensure that no air is trapped in the pouch

a. Ask the client to remain inactive for 5 minutes.

Which foods should be avoided following acute gallbladder inflammation? a. Coffee b. Cooked fruits c. Mashed potatoes d. Cheese

d. Cheese

Which category of laxatives draws water into the intestines by osmosis? a. Bulk-forming agents (e.g., psyllium) b. Fecal softeners (e.g., docusate) c. Stimulants (e.g., bisacodyl) d. Saline agents (e.g., magnesium hydroxide)

d. Saline agents (e.g., magnesium hydroxide)

Which nursing assessment is most important in a client diagnosed with ascites? a. Assessment of the oral cavity for foul-smelling breath b. Auscultation of abdomen c. Daily measurement of weight and abdominal girth d. Palpation of abdomen for a fluid shift

c. Daily measurement of weight and abdominal girth

Which activity should be avoided in clients with increased intracranial pressure (ICP)? a. Enemas b. Suctioning c. Position changes d. Minimal environmental stimuli

a. Enemas

Which dietary modification is used for a client diagnosed with acute pancreatitis? a. Low-carbohydrate diet b. High-fat diet c. Elimination of coffee d. High-protein diet

c. Elimination of coffee

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? a. Bilirubin b. Albumin c. Hemoglobin d. Temperature

b. Albumin

Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? a. Biliary cirrhosis b. Alcoholic cirrhosis c. Compensated cirrhosis d. Post-necrotic cirrhosis

b. Alcoholic cirrhosis

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as a. decerebrate. b. decorticate. c. flaccid. d. normal.

a. decerebrate.

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a. Decerebrate b. Decorticate c. Normal d. Flaccid

b. Decorticate

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? a. Assistance with self-care b. Frequent reorientation c. Evaluation of gag reflex and ability to swallow d. Monitoring vital signs

c. Evaluation of gag reflex and ability to swallow

The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening? a. History of skin cancer b. Age younger than 40 years c. Low-fat, low-protein, high-fiber diet d. Familial polyposis

d. Familial polyposis

What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply. a. foul-smelling breath b. stretch marks c. rapid weight gain d. increased abdominal girth e. visible distended veins

b. stretch marks c. rapid weight gain d. increased abdominal girth e. visible distended veins

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the a. supine position with the head slightly elevated. b. dorsal recumbent position. c. Trendelenburg position. d. prone position with the head turned to the unaffected side

a. supine position with the head slightly elevated.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. a. Exercise in a dark room. b. Maintain a headache diary. c. Keep a food diary. d. Use St. John's Wort. e. Sleep no more than 5 hours at a time.

b. Maintain a headache diary. c. Keep a food diary.

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? a. Electroencephalography (EEG) b. Angiography c. Magnetic resonance imaging (MRI) d. Radioisotope liver scan

d. Radioisotope liver scan

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Administering prescribed antipyretics b. Hyperoxygenation before and after tracheal suctioning c. Maintaining adequate hydration d. Restricting fluid intake and hydration

d. Restricting fluid intake and hydration

A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome? a. Reducing the spread of the disease b. Minimizing social isolation c. Identifying the source of exposure to hepatitis d. Establishing a stable home environment

b. Minimizing social isolation

A client has undergone a cervical discectomy. The nurse determines which interventions are essential to teach the client? Select all that apply. a. Keep staples or sutures clean and dry b. Avoid twisting or flexing the neck c. Do not remove dressing until the next visit d. Call health care provider if the area is red or irritated e. Cover incision with dry dressing f. Sit as much as possible; standing can cause pain

a. Keep staples or sutures clean and dry b. Avoid twisting or flexing the neck c. Do not remove dressing until the next visit d. Call health care provider if the area is red or irritated e. Cover incision with dry dressing

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply. a. Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort b. Altered nutrition, more than body requirements, related to decreased activity and bed rest c. Risk for injury related to altered clotting mechanisms d. Disturbed body image related to changes in appearance, sexual dysfunction, and role function e. Urinary incontinence related to general debility and muscle wasting

a. Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort c. Risk for injury related to altered clotting mechanisms d. Disturbed body image related to changes in appearance, sexual dysfunction, and role function

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern? a. The client's hands flap back and forth when the arms are extended. b. The client has gained 2 kg from the previous day. c. The skin on the client's abdomen has multiple spider-shaped blood vessels. d. The client reports nausea and anorexia.

a. The client's hands flap back and forth when the arms are extended.

The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem? a. arrange for a low air loss bed b. reposition the client every 4h c. restrict dietary protein intake d. perform passage ROM exercises 4x/day

a. arrange for a low air loss bed

The initial sign of increasing intracranial pressure (ICP) includes a. decreased level of consciousness. b. sore throat. c. herniation. d. vomiting.

a. decreased level of consciousness.

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because a. shivering in hypothermia can increase ICP. b. hypothermia can cause death. c. hypothermia is indicative of severe meningitis. d. hypothermia is indicative of malaria.

a. shivering in hypothermia can increase ICP.

Steve, a 71-year-old male client with moderate to late-stage Parkinson's disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. On admission, the nurse notes the following findings: Which of the following assessment findings require follow-up by the nurse? a. Lives at home with his wife who cares for him b. Needs assistance with ADLs on days when his rigidity is worse c. Walks short distances in the house using a walker d. Is alert and oriented x3 e. Has resting tremors in both arms and hands, but the right hand is worse than the left (Steve is right-handed) f. Chokes at times when he eats g. Has fallen twice in the past week because of dizziness when he stands from a sitting or lying position h. Temperature= 36.7C (98F) i. Pulse = 76 BPM/Regular j. Blood Pressure= 100/64 mm Hg (in supine position) k.o States he is not in pain

b. Needs assistance with ADLs on days when his rigidity is worse c. Walks short distances in the house using a walker e. Has resting tremors in both arms and hands, but the right hand is worse than the left (Steve is right-handed) f. Chokes at times when he eats g. Has fallen twice in the past week because of dizziness when he stands from a sitting or lying position j. Blood Pressure= 100/64 mm Hg (in supine position)

A client with a herniated lumbar disc has asked about nonsurgical strategies to help with mobility. What strategies will the nurse teach the client? Select all that apply. a. Hydrotherapy b. Physical therapy c. Positive feedback and attitude d. Nonsteroidal anti-inflammatory medications e. Weight reduction f. Muscle relaxants

b. Physical therapy d. Nonsteroidal anti-inflammatory medications e. Weight reduction f. Muscle relaxants

The nurse is caring for a male client admitted with hepatic encephalopathy. The client is drowsy and confused; moves all extremities spontaneously. His abdomen is distended, active bowel sounds; client has a poor appetite. Bilateral LE edema is present. Lactulose has been prescribed for the encephalopathy. The client's spouse asks how you will know if the treatment is working. What is the nurse's best response? a. "There will be less lower extremity swelling present." b. "His abdomen will become less distended." c. "He will become more oriented and less confused." d. "The protein levels in his blood will increase."

c. "He will become more oriented and less confused."

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? a. Over 1 year b. 1 to 4 months c. 6 to 12 months d. 4 to 6 months

c. 6 to 12 months

The nurse is providing education to a group of nurses about the prevention of Hep A. Which of the following topics with the nurse emphasize? a. Safe needle practices b. Admin of immune globulin after exposure c. Adequate hand hygiene d. Cap needles after use

c. Adequate hand hygiene

The client is 1h post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? a. Instruct the client to cough forcefully b. Encourage early ambulation c. Assess for return of a gag reflex d. Administer held medications

c. Assess for return of a gag reflex

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? a. Ask if the client can walk. b. Ask the client if there is pain on ambulation. c. Have the client lie on the back and lift the leg, keeping it straight. d. Ask if the client has had a bowel movement.

c. Have the client lie on the back and lift the leg, keeping it straight.

Which medication is the most effective agent in the treatment of Parkinson disease? a. Amantadine b. Benztropine c. Levodopa d. Bromocriptine mesylate

c. Levodopa

Which category of laxatives draws water into the intestines by osmosis? a. Stimulants (e.g., bisacodyl) b. Fecal softeners (e.g., docusate) c. Bulk-forming agents (e.g., psyllium) d. Saline agents (e.g., magnesium hydroxide)

d. Saline agents (e.g., magnesium hydroxide)

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? a. To prevent the occurrence of fibrosis b. To drain the pancreatic bed c. To avoid inflammation of the pancreas d. To aid opening up of pancreatic duct

c. To avoid inflammation of the pancreas

Which is an age-related change of the hepatobiliary system? a. Increased drug clearance capability b. Enlarged liver c. Decreased blood flow d. Decreased prevalence of gallstones

c. decreased blood flow

The nurse identifies which type of jaundice in an adult experiencing a transfusion rxn? a. nonobstructive b. obstructive c. hemolytic d. hepatocellular

c. hemolytic

Corticosteroids are used in the management of brain tumors to a. identify precise location of the tumor. b. prevent extension of the tumor. c. reduce cerebral edema. d. facilitate regeneration of neurons.

c. reduce cerebral edema.

The Monro-Kellie hypothesis explains a. nonresponse of the brain to the environment. b. the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. c. the dynamic equilibrium of cranial contents. d. why the client is awake but lacks consciousness, without cognitive or affective mental function.

c. the dynamic equilibrium of cranial contents.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment? a. "The tube provides relief from nausea and vomiting." b. "The tube helps control fluid and electrolyte imbalance." c. "The tube allows toxins to be removed." d. "The tube allows the gastrointestinal tract to rest."

d. "The tube allows the gastrointestinal tract to rest."

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a. Assess vital signs. b. Assess pupils. c. Assess Glasgow Coma Scale. d. Assess for a patent airway.

d. Assess for a patent airway.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? a. Increases in the rate of pancreatic secretion b. Development of local complications c. Increases in the bicarbonate output by the kidneys d. Decreases in the physiologic function of major organs

d. Decreases in the physiologic function of major organs

Which type of jaundice is the result of increased destruction of red blood cells? a. Hepatocellular b. Obstructive c. Nonobstructive d. Hemolytic

d. Hemolytic

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a. Obstructive b. Hepatocellular c. Nonobstructive d. Hemolytic

d. Hemolytic

Which of the following is the most common complaint(s) of patients with pancreatitis? a. Tarry black stools and dark urine b. Increased and painful urination c. Increased appetite and weight gain d. Severe radiating abdominal pain

d. Severe radiating abdominal pain

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? a. Achieving adequate fluid and electrolyte balance b. Developing no acute complications from the pancreatitis c. Maintaining satisfactory pain control d. Maintaining normal respiratory function

d. Maintaining normal respiratory function

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? a. Monitor for reports of nausea and vomiting b. Measure abdominal girth every shift c. Auscultate the abdomen for bowel sounds every 4 hours d. Measure blood glucose concentration every 4 to 6 hours

d. Measure blood glucose concentration every 4 to 6 hours

What symptoms may be suggestive of an intestinal obstruction in a pt with an ileostomy? a. Continuous flow of liquid stools and belching b. Hypervolemia and hyperkalemia c. Muscle spasms and numbness of the extremities d. Nausea and abdominal distention

d. Nausea and abdominal distention

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? a. Angiography b. Electroencephalography c. Magnetic resonance imaging d. Radioisotope liver scan

d. Radioisotope liver scan

The nurse is preparing a community education program about the prevention of Hep B. Which information will be incorporated into the teaching plan? a. Hep B is relatively uncommon among college students b. Frequent ingestion of ETOH can predispose an individual to the development of Hep B c. Good personal hygiene habits are most effective at preventing the spread of Hep B d. The use of a barrier method is advised for sexual intercourse

d. The use of a barrier method is advised for sexual intercourse

Which method is used to help reduce intracranial pressure? a. Extreme hip flexion, with the hip supported by pillows b. Keeping the head of bed flat c. Rotating the neck to the far right with neck support d. Using a cervical collar

d. Using a cervical collar