N433

B cell lymphoma

2nd most common malignancy with AIDS- lymphomas usually occur outside the lymph nodes, commonly in the brain, bone marrow, and GI tract

You are caring for a patient with heart failure. You know the overall goals of management for this patient are what? (mark all that apply) A. Improve functional status B. Increase cardiac contractility C. Extend survival D. Decrease pulmonary venous pressure E. Relieve patient symptoms

A, C, E

A client with a total hip replacement is concerned about dislocation of the prosthesis. What can the nurse say to reassure this client? A. "Avoid activities that cause adduction of the hip to prevent dislocation." B. "Use of elevated toilet seats alone will prevent dislocation." C. "Perform bending exercises as often as able to prevent dislocation." D. "Remove the foam abduction pillow as soon as possible postoperatively."

A. "Avoid activities that cause adduction of the hip to prevent dislocation."

Formulas are only a guide for burn care fluid resuscitation. How often must the patient' s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? a. 1 hour b. 2 hours c. 3 hours d. 4 hours

A. 1 hour

The nursing instructor is going over laboratory results for HIV/AIDS patients. The instructor tells the students that upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4+ T- lymphocyte cell count drops below what? A. 200 cells/mm3 of blood B. 3000 cells/mm3 of blood C. 400 cells/mm3 of blood D. 500 cells/mm3 of blood

A. 200 cells/mm3 of blood

The nurse expects the patient diagnosed with polycythemia vera to display which of the following manifestations of the disease? A. Elevated red blood cells and splenomegaly B. Lowered hematocrit and splenomegaly C. Lowered hematocrit and janundice D. Elevated red blood cells and jaundice

A. Elevated red blood cells and splenomegaly

A patient is admitted with sickle cell anemia. The nurse is aware that the care of this patient often requires: A. Chronic transfusions with RBC's B. Platelet transfusions C. Vitamin B 12 replacement D. Phlebotomy

A: Chronic transfusions with RBCs

A 42 year old woman with Meniere disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? A. Dim the lights in the patient's room B. Encourage increased oral fluid intake C. Change the patient's position every 2 hours D. Keep the head of the bed elevated 30 degrees

A: Dim the lights in the patient's room Meniere Disease affects the inner ear and balance

A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is: a. Risk for injury related to decreased sensation. b. Impaired skin integrity related to decreased peripheral circulation. c. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d. Activity intolerance related to imbalance between oxygen supply and demand.

A: Risk for injury related to decreased sensation

The home care nurse visits a patient with chronic heart failure who is taking digoxin (Lanoxin) and furosemide (Lasix). The patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take? A. Perform a dipstick urine test for protein. B. Notify the health care provider immediately. C. Have the patient eat foods high in potassium. D. Ask the patient to record a weight every morning.

Answer B: Notify the health care provider immediately Administration of furosemide increases excretion of potassium and may cause hypokalemia. The risk for digitalis toxicity increases if potassium levels are below normal and digoxin is administered. Signs and symptoms of digitalis toxicity include anorexia, nausea and vomiting, visual disturbances (such as "yellow" vision), and dysrhythmias.

A patient presents to the emergency department complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left sided heart failure. The patient is agitated and coughing up pink tinged, foamy sputum. What should the nurse recognize these signs and symptoms of? A) Right sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

Answer B: decreased perfusion to the brain -> agitation

The nurse is caring for a patient with type 1 diabetes mellitus who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? a.Hypokalemia b. Fluid overload c. Hypoglycemia d. Hyperphosphatemia

Answer: a Rationale: Electrolytes are depleted in diabetic ketoacidosis. Osmotic diuresis occurs with depletion of sodium, potassium, chloride, magnesium, and phosphate levels. A patient with diabetic ketoacidosis will be dehydrated (fluid volume deficit), and blood glucose levels would be elevated (hyperglycemia).

The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? a. The patient is alert and oriented. b. The patient's lung sounds are clear. c. The patient's urinary output decreases. d. The patient's potassium level is 5.7 mEq/L.

Answer: a Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? a. "The medication prevents sodium and water retention after surgery." b. "The drug prevent clots from forming in the legs during your recovery from surgery." c. "This medicine is given to help your body respond to stress after removal of the adrenal glands." d. "This drug stimulates your immune system and promotes wound healing."

Answer: c Rationale: Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure.

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? A. Limit caffeine intake to two cups of coffee per day. B. Do not lie down for 2 hours after eating. C. Follow a low protein diet. D. Take medication with milk to decrease irritation.

B CAFFEINATED BEVERAGES decease pressure in the lower esophageal sphincter and milk increases gastric secretion so these beverages should be avoided

A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply A. Administering an antacid hourly until nausea subsides. B. Monitoring the client's vital signs. C. Notifying the physician of the client's symptoms. D. Initiating oxygen therapy E. Reassessing the client in an hour.

B,C The nausea and dizziness may be indicative of a hemorrhage

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? A. "I will wash my hands often during the day." B. "I will remove my contact lenses at bedtime." (conjunctivitis can be viral or bacterialàshould not be wearing makeup or contacts, buy new makeup) C. "I will not share towels with my family members." D. "I will monitor my family for redness or drainage of their eyes."

B. "I will remove my contact lenses at bedtime." (conjunctivitis can be viral or bacterial à should not be wearing makeup or contacts, buy new makeup)

The most frequent symptom and complication of anemia is: A. Bleeding gums B. Ecchymosis C. Fatigue D. Jaundice

C. Fatigue

A nurse is evaluating the response of a client with anemia to therapy. Which laboratory test result would the nurse review that best reflects bone marrow production of red blood cells? A. Hematocrit B. Hemoglobin C. Serum ferritin D. Reticulocyte

D: Reticulocyte

Wasting syndrome

Profound involuntary weight loss; exceeding 10% of baseline body weight: chronic diarrhea > than 30 days or chronic weakness or intermittent or constant fever without other illness; may lead to organ failure; see progressive tissue wasting

Ischemic stroke account for 80% to 85% of strokes, while hemorrhagic stroke accounts for 15% to 20%.

True CT to determine which stroke it is

Which of the following patients is at a greater risk for the development of blindness? a. A 58-year-old Caucasian female with macular degeneration b. A 28-year-old Caucasian male with astigmatism c. A 58-year-old African American female with hyperopia d. A 28-year-old African American male with myopia

a. A 58-year-old Caucasian female with macular degeneration

A 56 year old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiutetic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n): a. Elevated hematocrit b. Decreased serum sodium c. Low urine specific gravity d. Increased serum chloride

b. decreased serum sodium

A 29 year old woman with systemic lupus erythematosus has been prescribed 2 weeks of high dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? a. "Weigh yourself daily to monitor for weight gain caused by increased appetite." b. "A weight-bearing exercise program will help minimize the risk of osteoporosis." c. "The prednisone dose should be decreased gradually rather than stopped suddenly." d. "Call the health care provider if you experience mood alterations with prednisone."

c. "The prednisone dose should be decreased gradually rather than stopped suddenly."

Kaposi's syndrome

the most common HIV related malignancy; it involves the endothelial layer of blood and lymphatic vessels. May be seen on the skin as skin lesions and may effect multiple organ systems. Appears in more than 90% of HIV patients as immune function deteriorates. These lesions relate to low CD4 counts

A fungal infection present in almost all patients with HIV/AIDS is Kaposi's sarcoma.

False. Candidiasis is the fungal infection.

The clinic nurse is caring for a patient admitted with HIV. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what? A) HIV encephalopathy B) B-cell lymphoma C) Kaposi's syndrome D) Wasting syndrome

A HIV encephalopathy- was called AIDS dementia complex ; research indicates that it is a direct result of HIV infection. HIV has been found in the brain and CSF of those with HIV encephalopathy, the infection is thought to release toxins that interfere with neurotransmitters

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? A. The patient has a temperature of 100.6 (infection, amoxicillin is not working if pt is still symptomatic) B. The patient complains of "popping" in the ear. C. The patient frequently asks the nurse to repeat information D. The patient states that the right ear has a feeling of fullness

A. The patient has a temperature of 100.6 (infection, amoxicillin is not working if pt is still symptomatic)

Since the HIV/AIDS epidemic began professionals have learned much about the virus that causes the disease and the disease process itself. The human immunodeficiency virus (HIV) belongs to a group of viruses known as retroviruses. What patient is at greatest risk of contracting HIV? A. Injecting drug user B. Female homosexual C) Blood transfusion recipient in 1995 D) health care provider

A. injecting drug user

A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these drugs? A. Observe skin turgor B. Auscultate lung sounds C. Measure blood pressure D. Review intake and output

Answer B: auscultate lung sounds -> looking for a reduction in adventitious lung sounds-crackles

A patient with heart failure cannot take ACE inhibitors because of cough. What drugs can be used as an alternative to ACE inhibitors? A) Calcium channel blockers B) Loop diuretics C) Anti-hypertensives D) Angiotensin II receptor blockers

Answer D: Angiotensin II receptor blockers

A patient with type 1 diabetes calls the clinic with complaints of nausea, vomiting, and diarrhea. It is most important that the nurse advise the patient to a. Withhold the regular dose of insulin. b. Drink cool fluids with high glucose content. c. Check the blood glucose level every 2 to 4 hours. d. Use a less strenuous form of exercise than usual until the illness resolves.

Answer: c Rationale: If a person with type 1 diabetes mellitus is ill, he or she should test blood glucose levels at least at 2- to 4-hour intervals to determine the effects of this stressor on the blood glucose level.

The nurse plans a class for patients who have newly diagnosed type 2 diabetes mellitus. Which goals is most appropriate? a. Make all patients responsible for the management of their disease. b. Involve the family and significant others in the care of these patients. c. Enable the patients to become active participants in the management of their disease. d. Provide the patients with as much information as soon as possible to prevent complications.

Answer: c Rationale: The goal of diabetes education is to enable the patient to become the most active participant in his or her own care.

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L). Which statement by the nurse is best? a. "The laboratory test result is positive for type 2 diabetes." b. "You will develop type 2 diabetes within 5 years." c. "The test result is normal, and diabetes is not a problem." d. "You are at increased risk for developing diabetes."

Answer: d Rationale: Impaired fasting glucose (fasting blood glucose level between 100 and 125 mg/dL) and impaired glucose tolerance (2-hour plasma glucose level between 140 and 199 mg/dL) represent an intermediate stage between normal glucose homeostasis and diabetes. This stage is called prediabetes, and patients are at increased risk for the development of type 2 diabetes.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? A. Use of oral opioids for pain control B. Administration of corticosteroid eye drops C. Importance of coughing and deep breathing exercises D. Need for bed rest for the first 1 to 2 days after the surgery

B. Administration of corticosteroid eye drops

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping related to fear of diagnosis of chronic illness B. Deficient knowledge related to unfamiliarity with significant signs and symptoms. C. Constipation related to decreased gastric motility. D. Imbalanced nutrition: Less than body requirements related to gastric bleeding.

B. Peptic Ulcer disease-may be referred as gastric, duodenal or esophageal ulcer, depending on it's location. A peptic ulcer is an excavation (hollowed out area) that forms in in the mucosal wall. It is caused from an erosion of the mucous membrane. May be caused from H pylori. Black tarry stools are a warning of bleeding in peptic ulcer disease

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a. "I should not use heating pads to warm my feet." b. "I should cut back on my walks if it causes pain in my legs." c. "I will examine my feet every day for any sores or red areas." d. "I can quit smoking if I use nicotine gum and a support group."

B: "I should cut back on my walks if it causes pain in my legs."

The patient reports experiencing pain in the left lower leg and foot while walking. This pain is relieved with bed rest. The nurse notes that the left lower leg is slightly edematous and is hairless. What is the patient experiencing? A) coronary artery disease B) Intermittent claudication C) Arterial embolus D) Raynaud's disease

B: Intermittent claudication

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for: A. Strength of the eye muscles B. Both near and distant vision C. Cloudiness in the eye lenses D. Intraocular pressure changes

B: both near and distant vision

You are assessing a patient suspected of having right-sided heart failure. What assessment finding may indicate right- sided heart failure? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

B: distended neck veins with left sided failure you will hear S3 (ken-tuck-y) ventricular gallop

A patient who experienced a thrombotic stroke and has residual hemiparesis of the right side is undergoing rehabilitation. The nurse caring for this client reinforces occupational therapy recommendations by placing items for personal hygiene: A. On the overbed table on the right side B. On the overbed table on the left side. C. One foot away from the bed on the right side D. One foot away from the bed on the left side

B: on the overbed table on the left side

An 82 year old patient who is admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? A. Overenunciate while speaking B. Speak normally but more slowly C. Increase the volume when speaking. D. Use more facial expressions when talking

B: speak normally but more slowly

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? A. Bland Foods. B. High protein foods. C. Any foods that are tolerated. D. Large amounts of milk.

C

The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? A. A client awaiting surgery for a hiatal hernia repair @ 11 AM. B. A client with suspected gastric cancer who is nothing by mouth (NPO) status for tests. C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain. D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.

C,B, D, A

A 35 year old kidney transplant patient comes to the clinic complaining of skin lesions. The diagnosis is Kaposi's sarcoma. As the nurse caring for this patient you know that this is what type of Kaposi's sarcoma? A. Classic B. AIDS-related C. Immunosuppression-related D. Endemic

C. Immunosuppression-related

A client in traction slides down in the bed so that the feet touch the foot of the bed. What should the nurse do to ensure that the pull of traction remains uninterrupted? A. Release weights, pull client up in bed, and then reapply weights. B. Ask physician for a change in the amount of weight ordered. C. Move client up in bed without releasing pull of traction on the extremity. D. Elevate client's feet on a pillow.

C. Move client up in bed without releasing pull of traction on the extremity.

A patient diagnosed with basal cell carcinoma asks the nurse how he got cancer. The nurse tells the patient that the most common cause of basal cell carcinoma is what? A. Immunosuppression B. Radiation exposure C. Sun exposure D. Burns

C. Sun exposure

** Need to know** A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse knows that the primary method of treatment in this type of cancer is what? A. Chemotherapy B. Radiation therapy C. Surgical excision D. Biopsy of sample tissue

C. surgical excision

A 79 year old male is admitted with digital gangrene; he states that he had stubbed his toe going to the bathroom. What is the cause of digital gangrene? A) Venous insufficiency B) CAD C) Arterial insufficiency D) Varicose veins

C: Arterial insufficiency

You are working as a triage nurse in the emergency department managing the care of a patient with HF. In reviewing PMH what is the cause of the patient's heart failure? A) Type 1 diabetes B) Arteriosclerosis C) Atherosclerosis D) Pulmonary congestion

C: Atherosclerosis

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the ulcer is arterial or venous in origin. How would you position a patient who has leg ulcers that are venous in origin? A) Keep the legs flat without the knee gauche raised B) Gauche the knees to about a 45* angle C) Elevate the lower extremities D) Hang the legs over the side of the bed

C: Elevate the lower extremities arterial down, venous up

When assessing a patient with anemia, the nurse notes that the patient has developed peripheral numbness and poor coordination. The patient's family states that the patient appears to be confused at times at home. Neurologic symptoms most often accompany which type of anemia? A. Iron deficiency anemia B. Folic acid deficiency C. Pernicious anemia D. Thalassemia major

C: Pernicious anemia- impaired uptake of vitamin b12 due to the lack of intrinsic factor in the gastric mucosa- megablastomic anemia

What are 7 warning signs of advanced cancer?

CAUTION Change in bowel or bladder habits, a sore throat that does not heal, unusual bleeding or discharge from any orifice, thickening or a lump in the breast or lsquare, indigestion or difficulty with swallowing, obvious change in wart or mole, nagging cough or hoarseness

The primary care provider determines a 55 year old woman who has experienced menopause is at risk for osteoporosis. What other foods other than milk can the nurse suggest to this client to increase her calcium intake? A. Seafood, wheat, corn, green vegetables B. Chicken, green vegetables, sardines, broccoli C. Green vegetables, sardines, salmon with the bone, broccoli D. Eggs, cheese, sardines, fish

D. Eggs, cheese, sardines, fish

A patient is brought to the E.D. from the site of a chemical fire. The patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. He verbalized no pain in the right arm and the skin appears charred. What is the depth of the burn on the patient's right arm? A. Superficial partial-thickness B. Deep partial - thickness C. Full partial -thickness D. Full-thickness

D. Full thickness

When assisting a blind patient in ambulating to the bathroom, the nurse should: A. Take the patient by the arm and lead the patient slowly to the bathroom B. Have the patient place a hand on the nurse's shoulder and guide the patient C. Stay beside the patient and describe any obstacles on the path to the bathroom D. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow

D. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow

A client with a recently applied plaster leg cast complains of unrelieved pain and paresthesia in the affected extremity. The assessment by the nurse reveals diminished pulse, pallor, and increased pain on passive motion. What must the nurse do first? A. Monitor the client for the next hour B. Administer an analgesic for pain C. Administer an anxiolytic D. Notify the physician immediately

D. notify the physician immediately

The nurse notes that a patient, who is a vegetarian, has an abnormal number of megaloblasts. The nurse suspects a deficiency in? A. Iron B. Zinc C. Vitamin C D. Vitamin B12

D: Vitamin B12

A patient is diagnosed with hypoproliferative anemia. The nurse is aware that this type of anemia is due to: A. Lack of production of RBC's B. Loss of RBC's C. Injury to the RBC's in circulation D. Abnormality of RBC's

D: abnormality of RBCs

As a nursing student you are assigned to the cardiac unit for clinical. You are reviewing your assessment data, which one of following would indicate an increase in a patient's risk for heart failure (HF)? A) Lasix 20 mg/day B) potassium level of 5.7 mEq/L C) African-American man D) Age of 65 years or older

D: age of 65 years or older

Polycythemia Vera is characterized by bone marrow overactivity, resulting in the clinical manifestations of: A. Angina B. Claudication C. Thrombophlebitis D. All of the above

D: all of the above

Which of the following food choices made by a client with anemia best indicates that the nurse's instructions about food s high in iron has been successful? A. Oranges and grapefruits B. Spinach and broccoli C. Eggs, milk, and milk products D. liver and muscle meats

D: liver and muscle meats

In reviewing a 55 year old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mmHg. The nurse will plan to assess: A. visual acuity B. pupil reaction C. Color perception D. Peripheral vision (Glaucoma only have central vision)

D: peripheral vision

What is agnosia? a. Failure to recognize familiar objects perceived by the senses. b. Inability to express oneself or to understand language. c. Inability to perform previously learned purposeful motor acts on a voluntary basis. d. Impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance.

a. Failure to recognize familiar objects perceived by the senses.

The nurse is caring for a patient in the emergent/resuscitative phase of a burn injury. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate: a. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis b. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis c. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis d. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

a. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

After receiving change of shift report about the following four patients, which patient should the nurse assess first? a. A 31 year old female with Cushing syndrome with a blood glucose level of 244 mg/dL (disorder of adrenal cortex, excess corticosteroids (esp glucocorticoids), moon-shaped face) b. A 70 year old female taking levothyroxine (synthroid) who has an irregular pulse of 134 c. A 53 year old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (solu-cortef) (adrenocorticoid insufficiency, three classes of adrenal corticoids reduced (mineral corticoids, antrogens, glucocorticoids) d. A 22 year old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L (sodium level of 130 is low, but not too low, normal 135-145).

b. A 70 year old female taking levothyroxine (synthroid) who has an irregular pulse of 134

Which nursing assessment of a 69 year old patient is most important to make during initiation of thyroid replacement with levothyroxine? a. Fluid balance b. Apical pulse rate (metabolic rate is slowed with hypothyroidism, have to make sure with replacement that the metabolic rate is GRADUALLY increasing, not rapidly) c. Nutritional intake d. Orientation and alertness

b. Apical pulse rate (metabolic rate is slowed with hypothyroidism, have to make sure with replacement that the metabolic rate is GRADUALLY increasing, not rapidly)

The nurse is assessing a 41 year old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include: High blood pressure a. High BP b. Decreased facial hair (surgery and radiation are treatment, then need lifetime hormone therapy) c. Elevated blood glucose d. Tachycardia and cardiac palpitations

b. Decreased facial hair (surgery and radiation are treatment, then need lifetime hormone therapy)

A 63 year old with primary hyperparathyroidism has a serum phosphorous level of 1.7 mg/dL (low) and calcium of 14 mg/dL (high). Which nursing action should be included in the plan of care? a. Restrict the patient to best rest b. Encourage 4000mL of fluids daily c. Institute routine seizure precautions d. Assess for positive Chvostek's sign (positive sign seen in hypocalcemia); tap facial nerve just below earlobe, positive is twitching of facial spams)

b. Encourage 4000 mL of fluids daily normal calcium: 8.5-10.2 normal phosphorus: 2.4-4.1

Which information will the nurse teach a 48- year old patient who has been newly diagnosed with Grave's disease? a. Exercise is contraindicated to avoid increasing metabolic rate b. Restriction of iodine intake is needed to reduce thyroid activity c. Antithyroid medications may take several months for full effect d. Surgery will eventually required to remove the thyroid gland

c. Antithyroid medications may take several months for full effect ** protruding eyes, thin

After 3 weeks of radiation therapy, H.J. has lost 10 pounds and does not eat well because of mucositis. An appropriate nursing diagnosis for the patient is: a. Risk for infection related to poor nutrition b. Ineffective self-health management related to refusal to eat c. Imbalanced nutrition: less than body requirements related to oral inflammation and ulceration d. Ineffective health maintenance related to lack of knowledge of nutritional requirements during radiation therapy

c. Imbalanced nutrition: less than body requirements related to oral inflammation and ulceration

Which assessment finding for a 33 year old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? a. Bilateral exophthalmos (normal finding) b. Heart rate of 136/minute (high but not most concerning) c. Temperature of 103.8 F (risk of Grave's disease: thyroid toxicosis (or crisis or storm) is an acute/severe situation, rare, life threatening, usually precipitated by infection or surgery) d. Blood pressure 166/100 mmHg (high but not most concerning)

c. Temperature of 103.8 F (risk of Grave's disease: thyroid toxicosis (or crisis or storm) is an acute/severe situation, rare, life threatening, usually precipitated by infection or surgery)

What is a positive Kernig's sign? a. Extreme sensitivity to light. b. Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. c. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. d. When the patient's neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.

c. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended.