MS 2

After completing discharge education, a nurse recognizes the need for further teaching when a client, diagnosed with cirrhosis, says:

C. "I know propranolol has been ordered to decrease my blood pressure.

A client recovering from acute pancreatitis that has been NPO asks a nurse when he can begin eating again. Which response by the nurse is most accurate?

C. "When your pain is controlled, and your serum lipase level has decreased

The client's vision is tested with a Snellen chart. The client is standing at 10ft. from the chart and can read the line that can be read 70 ft away by an individual with normal visual acuity. The nurse should document the findings as:

C. 10/70

While conducting a home visit with a client who had a partial resection of the ileum for Crohn's disease 4 weeks previously, a nurse becomes concerned when the client says:

A. "My stools float and seem to have fat in them

A triage nurse, working in an emergency department, receives four admissions. Prioritize the order in which the nurse should assess the clients. 1. An 18-year-old client who thinks he might have a broken ankle 2. A 40-year-old client who is diaphoretic and is feeling chest pressure 3. A 35-year-old client who cut her hand with a knife while preparing food 4. A 60-year-old client who is dyspneic and has swollen lips after being stung by a bee

A. 2, 4, 3, 1

Which of the following interventions is appropriate for a client with retinal detachment except?

A. Allow client to ambulate.

A client was diagnosed with otosclerosis. Which of the following findings would correlate to otosclerosis

A. Pinkish discoloration of the tympanic membrane.

The client is a 49-year-old man with a hiatal hernia, whom you are about to counsel. Health care counseling for the client should include which of the following?

A. Restrict intake of high-carbohydrate foods.

A client who has undergone hypophysectomy has been diagnosed with diabetes insipidus. Which of the following laboratory findings would the nurse expect in the client's medical records?

A. Serum sodium - 160 mEq/L

A nurse is assessing a 16-year-old adolescent in an emergency department who has been admitted because of burns over 25% of the client's body. Upon initial examination, the nurse makes several observations. Which observation should be most concerning to the nurse?

Areas on lower extremities are waxy white

The nurse is conducting a health history on a client with hyperparathyroidism. Which question asked of the client would elicit information about this condition?

B. "Are you experiencing pain in your joints?

A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus. Which teaching point should the nurse emphasize?

B. Exercise for 30 minutes daily, preferably after a meal.

A clinic nurse is teaching a client who has been diagnosed with hypothyroidism. Which instructions should NOT be included by the nurse regarding the use of levothyroxine sodium?

B. Report adverse effects of the medication, including weight gain, cold intolerance, and alopecia

The nurse keeps the environment warmer for older adults because they are more sensitive to cold because of the age-related changes in their:

B. subcutaneous tissue.

A client taking thyroid replacement hormone was involved in an automobile accident and was hospitalized for a femur fracture. A week after being hospitalized, a nurse notes that the client is becoming increasingly lethargic. Vital signs show a decreased blood pressure, respiratory rate, temperature, and pulse. In which order should the actions be taken by the nurse? 1. Warm the client 2. Administer intravenous fluids 3. Assist in ventilatory support 4. Administer the prescribed thyroxine

C. 3, 2, 1, 4

11. A nurse is planning care for four clients. Prioritize the order in which the nurse should plan to attend to the clients. 1. A 13-year-old client waiting to be admitted from the emergency department after receiving stitches for facial lacerations from a dog bite 2. A 9-year-old client whose mother is present to receive teaching about wound care for her child's left leg skin graft in anticipation of discharge tomorrow 3. A 5-year-old client with an infected leg wound who is scheduled for a dressing change now 4. A 2-year-old client whose temperature has risen to 39.9°C

C. 4, 3, 1, 2

A nurse is assessing a client diagnosed with acute diverticulitis. Which finding should make the nurse suspect that the client has an intestinal perforation?

C. Absent bowel sounds

A client has developed syndrome of inappropriate antidiuretic hormone secondary to a pituitary tumor. The client's symptoms include thirst, weight gain, and fatigue. The client's serum sodium is 120 mEq/L. Which physician order should the nurse anticipate when treating SIADH?

C. Administration of vasopressin antagonist

A client who has had a vehicular accident was sent to the ER. The client has hyphema. Which of the following interventions is appropriate for the client except

C. Allow the client to read and watch television for a long period of time

An adolescent is admitted with a diagnosis of suspected Addison's disease. Which assessment manifestations should the nurse expect to find if Addison's disease is the correct diagnosis?

C. Gradual onset of salt craving decreased pubic and axillary hair, and irritability

A nurse's assessment of a client diagnosed with Cushing's syndrome includes the following findings: 4+ pitting leg edema, blood glucose 140 mg/dL, irregular heart rate, and ecchymosis on the right arm. Which action should be taken by the nurse first?

C. Notify the physician

A client who is diagnosed with hyperparathyroidism has a calcium level of 11 mg/dL. Which of the following findings would NOT be expected for this client?

C. Positive trousseau's sign

While reviewing a client's medical records, a nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client's medical record?

C. Severe abdominal pain

The nurse is taking care of a client who has been diagnosed with diabetes insipidus. Which of the following interventions is appropriate for the client?

C. Tell the client to avoid caffeinated drinks.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101 °F (38.3 °C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse?

C. Temperature

A client tells a nurse that he has been diagnosed with macular degeneration, "wet type." Based on the nurse's knowledge of this diagnosis, the nurse, examining this client's eyes using an ophthalmoscope, should expect to observe:

C. growth of abnormal blood vessels in the macula

A client is hospitalized for conservative treatment of cirrhosis. As part of the collaborative plan of care, a nurse would anticipate

C. monitoring the client's blood sugar

Which instruction about insulin administration should a nurse give to a client?

D. "Always follow the same order when drawing the different insulins into the syringe."

The client is a 49-year-old man with a hiatal hernia, whom you are about to counsel. Which of the following medications is contraindicated to a client with hiatal hernia?

D. Atropine

A client with detached retina was sent to the ER. Which of the following findings would not correlate with retinal detachment?

D. Painful loss of a portion of the visual field.

A client with close-angle glaucoma was sent to the ER. Which of the following findings would not correlate to close-angle glaucoma?

D. Painless and increased IOP

Nurse reports to a health-care provider that a client has decreased peripheral vision. An ophthalmologist consult is ordered, and the client is diagnosed with chronic open-angle glaucoma. The client cries when told the diagnosis. Which of the following is the priority nursing diagnosis

D. Sensory/perceptual alterations (visual) related to decreased peripheral vision.

The client found out that the symptoms of diabetes were caused by high levels of blood glucose, he decided to break the habit of eating carbohydrates. With this, the nurse would be aware that the client might develop what complication?

D. acidosis

A client diagnosed with pancreatitis, is concerned about pain control. A nurse explains to the client that the initial plan for controlling the pain of chronic pancreatitis involves the administration of:

D. pancreatic enzymes with H2 blocker medications

A nurse is teaching a client experiencing hyperparathyroidism resulting from a lack of parathyroid hormone (PTH) about foods to consume. Which should be included on a list of appropriate foods for a client experiencing hyperparathyroidism?

Dark green vegetables, soybeans, and tofu

The nurse is taking care of a client who has undergone gastric surgery. Following gastric surgery, which of the following interventions is contraindicated for the client?

Irrigate the NG tube when the client is nauseous.

A nurse is caring for a client who is 6 hours post-open cholecystectomy. The client's T-tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?

Notifying the surgeon about these findings

After Billroth II surgery (gastrojejunostomy), a client experiences weakness, diaphoresis, anxiety, and palpations 2 hours after a high carbohydrate meal. A nurse should interpret that these symptoms indicate the development of:

postprandial hypoglycemia