MedSurg Final (PrepU Quizzes)

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines" Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery." After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia. Visiting clergy for emotional support is normal after receiving a cancer diagnosis. This action should be encouraged by the nurse. It's appropriate for the client to call the physician if he experiences signs and symptoms of intestinal blockage or obstruction, such as abdominal pain. Because a client with a total gastrectomy will receive enteral feedings or parenteral feedings, he should weigh himself each day and keep a record of the weights.

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions?

"See if rest relieves the chest pain before using the nitroglycerin."

A nurse is preparing a client for a lumbar puncture and informs the client that the needle will be inserted into the subarachnoid space between L3 and L4 or L4 and L5. The client reports that she is worried about damage to her spinal cord. The appropriate response from the nurse is which of the following?

"The spinal cord ends at L1, so puncturing it is not possible." The needle is usually inserted into the subarachnoid space between the 3rd and 4th or 4th and 5th lumbar vertebrae. Because the spinal cord ends at the 1st lumbar vertebra, insertion of the needle below the level of the 3rd lumbar vertebra prevents puncture of the spinal cord.

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level?

115 mEq/L Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30 mL When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube.

A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of:

40 dB in the range of 500 to 2,000 Hz. A general guideline for assessing the patient's need for a hearing aid is a hearing loss exceeding 30 dB in the range of 500 to 2,000 Hz (units of cycles/second).

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

5% DW A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?

50 Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time?

6-8 pm The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.

Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance?

A patient with a minimal urine output of 20 ml/hour

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Alteplase

Which of the following medications is considered a thrombolytic?

Alteplase Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.

A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response?

Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age.

A patient has been diagnosed with a fungal infection causing external otitis. What is the most common fungal infection in the ear?

Aspergillus The most common bacterial pathogens associated with external otitis are Staphylococcus aureus and Pseudomonas species. The most common fungus isolated in both normal and infected ears is Aspergillus

Which of the following assessment results is considered a major risk factor for PAD?

BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

The nurse is caring for an older adult client who is frail in appearance. The client has been diagnosed with glaucoma and will be started on eye drops for the condition. Which medication would cause the nurse to call the health care provider before administering the first dose?

Brimonidine (Alphagan-P) Brimonidine should be used with caution in frail elderly clients because it may cause confusion.

A nurse is assessing a patient receiving tube feedings and suspects dumping syndrome. Which of the following would lead the nurse to suspect this? Select all that apply.

Diaphoresis Tachycardia Diarrhea Dumping syndrome is manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The patient often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator?

Elevated U wave An elevated U wave is specific for hypokalemia. Flat or inverted T waves may also be present. The other tracings are consistent with hyperkalemia.

Hypokalemia can cause which symptom to occur?

Excessive thirst If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia.

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.

A nurse is discussing cardiac hemodynamics with a nursing student and explains the concept of afterload. The student asks what medical conditions might cause increased afterload. The nurse correctly answers which of the following?

Hypertension and aortic valve stenosis Major factors that determine afterload are the diameter and distensibility of the great vessels (aorta and pulmonary artery) and the opening and competence of the semilunar valves (pulmonic and aortic valves). If the client has significant vasoconstriction, hypertension, or a narrowed vavular opening, resistance or afterload increases. Diabetes mellitus and mitral valve stenosis do not directly affect afterload.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

A nurse is caring for a patient receiving parenteral nutrition at home. The patient was discharged from the acute care facility 4 days ago. Which of the following would the nurse include in the patient's plan of care? Select all that apply.

Intake and output monitoring Calorie counts for oral nutrients Daily weights For the patient receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the patient is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the patient's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the patient's ability to maintain muscle tone. Strict bedrest is not appropriate.

The nurse is teaching the client with Meniere's disease about controlling symptoms through diet. Which of the following would the nurse emphasize? Select all that apply.

Limit intake of caffeinated beverages. Maintain hydration. Read labels carefully for sodium content. Avoid foods high in sugar Most clients with Meniere's disease can be successfully treated through nutritional measures, such as adhering to a low-sodium diet to assist in regulating the delicate balance between the endolymph and perilymph in the inner ear. Therefore, the nurse should encourage the client to limit the amount of canned, frozen, and processed foods, substituting fresh fruits, fresh vegetables, and whole grains. Hydration is important, so the client should drink water, milk, and low-sugar fruit juices, avoiding caffeinated fluids because of the diuretic effect of caffeine. Clients also should limit foods high in sugar and read labels carefully to identify foods with hidden salts and sugars.

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply.

Monitor intake and output every shift. Offer a diet with fruit juices and citrus fruits. Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output.

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.

Omeprazole (Prilosec) Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change. Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.

Which of the following are alterations noted in Virchow's triad? Select all that apply

Stasis of blood Vessel wall injury Altered coagulation Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

Symptom onset greater than 3 hours prior to admission Recent intracranial pathology Current anticoagulation therapy Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a client who is anticoagulated (with an INR above 1.7), or a client who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.)

Tachypnea Oliguria Tachycardia Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria, tachycardia (not bradycardia), and tachypnea.

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information?

The possibility of surgery, chemotherapy and radiotherapy Treatment of gastric cancer is usually multimodal, but does not necessitate a colostomy. Weight loss is not a goal during recovery; exercise is not a high priority and may be unrealistic. The prognosis for clients with gastric cancer is generally poor.

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?

Wash the area around the tube with soap and water daily. Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not given to prevent site infection.

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains afterload to the student and then asks the student what nursing interventions might cause decreased afterload. The student correctly answers which of the following?

administration of a vasodilating drug (as ordered by the physician) Afterload is the amount of resistance to the ejection of blood from the ventricles. Anything that decreases this resistance will decrease afterload. Vasodilation will decrease systemic resistance. Antiembolytic stockings and keeping the client's legs elevated will increase resistance.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:

assess lung sounds bilaterally All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

The triage nurse in the ED is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, what is a potential primary cause of the client's heart failure?

atherosclerosis Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure.

The nurse is providing discharge education for the client going home after a cardiac catheterization. Which of the following would be important information to give this client?

avoids tub baths, but shower as desired Guidelines for self-care after hospital discharge following a cardiac catheterization include shower as desired (no tub baths), avoid bending at the waist and lifting heavy objects, the physician will indicate when it is okay to return to work, and notify the physician right away if you have bleeding, new bruising, swelling, or pain at the puncture site.

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. What medication should the nurse anticipate administering to this client? You Selected:

beta-adrenergic blocker Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?

cocaine use Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.

confusion, bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

decrease in glomerular filtration Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.

A patient diagnosed with IBS is advised to eat a diet that is:

diet high in fiber A high-fiber diet is prescribed to control diarrhea and constipation and is recommended for patients with IBS.

The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries?

dobutamine Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. Options A, B, and C would not dilate the coronary arteries.

Which of the following symptoms should the nurse expect to find as an early symptom of chronic heart failure?

fatigue Fatigue is commonly the earliest symptom of chronic heart failure; it is caused by decreased cardiac output and tissue oxygenation. Pedal edema and nocturia are symptoms of heart failure, but they occur later in the course of the condition. An irregular pulse can be a complication of heart failure, but it is not necessarily an early indication of the condition.

what should the nurse recommend to a client with blepharitis?

frequent washing of he face and hair Frequent washing of the face and hair is recommended in a client with blepharitis because seborrhea or excessive oiliness of the skin of the face and scalp is associated with blepharitis. Warm soaks would be included for treatment of a sty. There is no benefit to sleeping with the face parallel to the floor.

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema?

generalized There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca.

The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do?

hang 10% dextrose and water If the parenteral nutrition (PN) solution runs out and no PN is available, the nurse should hang 10% dextrose and water until the PN becomes available.

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

heart failure It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

hyperactive Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma,

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

hypocalcemia Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

hypomagnesemia If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Na+ 134 mEq/L K+ 3.2 mEq/L Cl- 111 mEq/L Mg++ 1.1 mg/dL Ca++ 8.4 mg/dL

hypomagnesemia Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL. Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.

The client has been taking famotidine (Pepcid) at home. The nurse prepares a teaching plan for the client indicating that the medication acts primarily to achieve which of the following?

inhibit gastric acid secretions Famotidine is useful for treating and preventing ulcers and managing gastroesophageal reflux disease. It functions by inhibiting the action of histamine at the H-2 receptor site located in the gastric parietal cells, thus inhibiting gastric acid secretion.

A 35-year-old male client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary provider, what intervention should the nurse prioritize?

insertion of a nasogastric tube Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.

A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of

intestinal malabsorption Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

is not responding to stimuli

A client with a history of hypertension is receiving client education about structures that regulate arterial pressure. Which structure is a component of that process?

kidneys

Which of the following types of diuretic is the first-line treatment for those diagnosed with heart failure (HF)?

loop Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

metabolic acidosis The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

The nurse is providing discharge teaching to a client who had hypophosphatemia during his time in hospital. The client has a diet prescribed that is high in phosphate. What foods should you teach this client to include in his diet? Select all that apply.

milk, poultry, liver If the client experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurse's most appropriate action?

position the client to prone The lumbar puncture headache may be avoided if a small-gauge needle is used and if the client remains prone after the procedure. Acetaminophen is not given as a preventative measure for postlumbar puncture headaches.

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids?

pregnant women at 28 weeks gestation Hemorrhoids commonly affect 50% of clients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.

The nurse is completing a cardiac assessment on a patient. The patient has a blood pressure (BP) reading of 126/80. The nurse would identify this blood pressure reading as which of the following?

prehypertensive A systolic BP of 128 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is Stage I hypertension. A systolic BP of greater than or equal to 160 is classified as Stage 2 hypertension.

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

proton pump inhibitors Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what?

retinal blood vessel damage Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.

A diabetic patient is scheduled for surgery for repair of a detached retina that was caused by proliferative retinopathy. The nurse prepared the patient for surgery, aware that the type of detachment is most likely classified as which of the following?

rhegmatogenous Rhegmatogenous detachment is the most common form of retinal detachment. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the retinal pigment epithelium.

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit?

routine use of quinine for management of leg cramps Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.

Which type of hearing loss is most likely to be caused by frequent ear infections?

sensorineural Sensorineural hearing loss includes such etiologies as atherosclerosis, a tumor of the vestibulocochlear nerve, infections, and drug toxicity. Conductive hearing loss is more commonly caused by obstructions. Tinnitus is a symptom, not a cause of hearing loss.

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose?

slows the progression of the disease Selegiline increases dopaminergic activity and slows the progression of the disease. Carbidopa-levodopa is a dopamine replacement drug. Anticholinergic drugs are used to reduce the symptoms of dyskinesia and other side effects.

A client has impacted cerumen in the left ear. Which of the following would be appropriate to use to help dislodge the cerumen? Select all that apply.

tap water, half strength hydrogen peroxide, mineral oil To remove impacted cerumen, the external auditory ear canal can be irrigated gently with warmed tap water using the lowest effective pressure. Additionally, a few drops of warmed glycerin, mineral oil, or half-strength peroxide can be instilled into the canal for 30 minutes to soften cerumen before its removal. A moistened cotton-tipped applicator should not be used; it can push the cerumen further in the ear, become a foreign body, or cause trauma to the canal. Antibiotic solution is not necessary to remove impacted cerumen.

You are admitting a client with an acoustic neuroma to your unit. What would you include during the assessment of this client?

test for facial sensation The assessment of a client with an acoustic neuroma includes evaluating hearing function, observing the client's facial movements, and testing for facial sensation. The client's urine output, height and weight, and ability to sustain balance, though important, are not as essential as testing for facial sensation.

The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect?

the eighth cranial nerve Ototoxicity describes the detrimental effect of aminoglycosides on the eighth cranial nerve. Signs and symptoms include tinnitus and sensorineural hearing. The other options are not related to the ototoxic effects.

The nurse is assisting the physician with a colonoscopy for a patient with rectal bleeding. The physician requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?

to relax the colonic musculature and reduce spasm Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply.

weakness, tachypnea, lethargy The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride concentration is accompanied by a high sodium concentration and fluid retention.