NCLEX QUESTION ADULT HEALTH W/ RATIONALES

A client with prostatitis following kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that education was effective if the client makes which statement?

"I should use warm baths and analgesics to increase comfort." R- Treatment of prostatitis includes medication with antibiotic, analgesic, and stool softeners. The nurse also teaches the client too rest, increase fluid intake, and use sitz baths or warm tub baths for comfort. Antimicrobial therapy is always continued until the prescription is finished.

The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction?

"I will return tomorrow to have the sutures removed." R- Sutures usually are removed 7 to 10 days after a skin biopsy, depending on primary health care provider (PHCP) preference. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours as prescribed. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The PHCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. The site may be closed with sutures or may be allowed to heal without suturing.

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education?

"It is important that I limit protein intake." Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching?

"The medication will cause constipation." R- Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions?

"You will need to wear dark eye goggles during the treatment." R- Safety precautions are required during UV light therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UV light; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UV light. Direct contact with the lightbulbs used for the treatment should be avoided to prevent burning of the skin.

The nurse is preparing to teach ostomy care to a client who has just had a urinary diversion; the client expresses concern about body appearance. Which client action indicates that the best initial positive adaptation is being made?

Agrees to look at the ostomy R-The best initial positive step in learning to care for an ostomy and to accept it as a part of the self is to be able to look at the ostomy. Once the client is able to look at the ostomy and touch it, the client can proceed more successfully to learn about ostomy care. The other options all indicate a deferral or refusal on the part of the client, which makes them less than optimal choices.

The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure?

Apply an emollient lotion to the skin to enhance softening. The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight.

A home care nurse is making home visits to an older client with urinary incontinence who is very concerned about the incontinent episodes. Which finding by the nurse indicates that the client has an environmental barrier to normal voiding?

Bathroom located on the second floor, bedroom on the first floor Having the bathroom on the second floor and the bedroom on the first floor may pose a problem for the older client with incontinence. The need to negotiate the stairs and the distance both may interfere with reaching the bathroom in a timely fashion. It is more helpful to the incontinent client to have a bathroom on the same floor as the bedroom or to have a commode rented for use. Hand railings and night lights are helpful to the client in reaching the bathroom quickly and safely.

The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma?

Cleanse the peristomal skin meticulously. R- The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client?

Dry skin R- Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features; dry skin; and dry, coarse hair and eyebrows. The remaining options are noted in the client with hyperthyroidism.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

Headache, deteriorating level of consciousness, and twitching R- Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. Tachycardia and fever are associated with infection. Generalized weakness is associated with low blood pressure and anemia. Restlessness and irritability are not associated with disequilibrium syndrome.

A client asks the nurse about obtaining a home test kit for HIV status. What should the nurse tell the client?

Home test kits ay not be as reliable as lab blood test. R- HIV can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Should a client wish to know his or her HIV status, testing is available from a PHCP or a local public health clinic, or a home test kit can be used. Some test kits may not be as reliable as a laboratory blood test. It is also recommended that a home test be performed at least 3 months after a risk event occurs. If a positive result on a home test occurs, then the individual requires additional testing.

A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client?

Hypertension R- AKI caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of AKI commonly manifests with hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. AKI from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure.

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform?

Inspect the skin at least every 8 hours for signs of irritation or inflammation. R-It is important for the skin to be assessed at least every 8 hours. Weights should be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and should always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.

The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client?

Keep the test sites dry. The nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

Which are possible causes of upper airway obstruction? Select all that apply.

Laryngeal edema Head and neck cancer Foreign body aspiration Lymph node enlargement Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The nurse is creating a plan of care for a client with chronic kidney disease and uremia. The nurse is developing interventions to assist in promoting an increased dietary intake while at the same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care?

Maintain a diet high in calories with frequent snacks. R- Uremia usually is accompanied by nausea, anorexia, and an unpleasant taste in the mouth. Most clients experience nausea and vomiting in the morning. Therefore, to maintain optimal nutrition, it is best for these clients to eat a diet that is high in calories with frequent snacks and a light breakfast in the morning and larger meals later in the day. Dietary management is usually aimed at restricting protein, sodium, and potassium.

The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (ckd). Which factor will enhance the educational process?

Presence of family. R- The client with CKD may have several barriers to learning. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. Anxiety about the disease and its ramifications frequently interferes with learning. Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. Mental functioning usually improves once hemodialysis has begun.

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit?

Pulse rate increases from 100 beats/min to 136 beats/min R- The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response?

Sympathetic nervous system The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse should report the cardiac rhythm to be which rhythm?

Normal sinus rhythm R- Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team?

A social worker R- After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional can provide the most helpful information about resources available to the client. The clinical nurse specialist and the surgeon do not have information related to financial resources. The physical therapist has the best knowledge of techniques for increasing mobility and endurance.

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply.

Acknowledge the client's feelings; Assess the client and family's coping patterns; Explore the meaning of the illness with the client; Give the client information when the client is ready to listen. R- Clients with ESRD are likely to experience mood swings or express hostility, anger, and depression, among other responses. The nurse should acknowledge the client's feelings, allow the client to express those feelings, and be supportive. Options 1, 2, 3, and 5 are helpful and appropriate interventions for the client. Setting limits for this client is not client focused, does not allow the client to express concerns, and is nontherapeutic in this situation.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem?

An attempt to ignore or deny the need to make lifestyle changes R- Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question?

Are you rotating the injection site? R-The client should be instructed that insulin injection sites should be rotated within 1 anatomical area before moving on to another area. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. The remaining options are not associated with the condition (skin leakage of insulin) presented in the question.

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?

Ecchymosis Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse is assisting a primary health care provider (PHCP) with the insertion of a Miller-Abbott tube. The nurse understands that the procedure places the client at risk for aspiration and should therefore implement which action to decrease this risk?

Place the client in a semi-Fowler's to high-Fowler's position. The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is an PHCP responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A semi-Fowler's to high-Fowler's position decreases the risk of aspiration if vomiting occurs. A Valsalva maneuver is not helpful and is not used if the impulse to gag occurs.

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

Placing an eye patch over the client's affected eye. R-The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.

A client with a history of diabetes mellitus has a fingerstick blood glucose level of 460 mg/dL (25.6 mmol/L). The home care nurse anticipates that which additional finding would be present with further testing if the client is experiencing diabetic ketoacidosis (DKA)?

Presence of ketone bodies R- DKA is marked by the presence of excessive ketone bodies. As a result of the acidosis, the pH and serum bicarbonate level would decrease. Hyponatremia is not related to DKA.

A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if he or she makes which statement?

"I need to scrub the skin vigorously with soap and water." The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. People often want to scrub the dead skin away, but scrubbing irritates the skin and should not be done. The client should avoid overexposing the skin to the sunlight.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which primary health care provider (PHCP) prescription documented in the client's medical record?

Administer 30 mL of milk of magnesia (MOM). Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

A client with viral hepatitis states, "I am so yellow". What is the most appropriate nursing action?

Assist the client in expressing feelings. R- The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward. R- The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The primary health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment.

Ataxic. R- An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad based gait is seen as waddling, with the weight shifting from side to side and the legs apart.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separates into concentric rings and test positive for glucose. R- Leakage of CSF from the ears or nose may accompany basilar skull fracture. CSF can be distinguished in from other body fluids, because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which information should the nurse plan to include in the teaching session?

Keep follow-up appointments for repeat cultures in 4 to 7 days. R- Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics, which are not discontinued until the prescribed course is completed. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse should anticipate that which substance will be elevated?

Ketones R- Ketones are a byproduct of fat metabolism. When this process occurs to an extreme, the resulting condition is called ketoacidosis. The remaining options are not associated with the breakdown of fats.

The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis?

Maintain strict aseptic technique R- The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although changing the catheter site dressing daily may assist in preventing infection, this option relates to an external site. Adding heparin to the dialysate solution and monitoring the client's level of consciousness are unrelated to the major complication of peritoneal dialysis.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome?

Numbness and tingling in the fingers R- The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?

Restrict fluid intake for a period of 2 hours. R- After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the primary health care provider's prescriptions. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities.

The nurse is caring for a postoperative client who has had an adrenalectomy. What should the nurse check for during the client's focused assessment?

Signs and symptoms of hypovolemia R-Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. Thus, a deficiency can cause hypovolemia. A deficiency of adrenocortical hormones (such as after adrenalectomy) does not cause the clinical manifestations noted in the remaining options.

A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem?

The client's white blood cell (WBC) count remains within normal limits. R-General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the problem of risk for injury.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve?

Vagus CN X R- The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing.

The nurse should anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia?

Vitamin B12 injections R- A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

eye movements Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply.

fatigue & morning stiffness. R- Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply.

fever, weight loss, night sweats, and enlarged, painless lymph nodes. R- Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)?

glucose intolerance. R-Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply.

hemodialysis, kidney transplant, bilateral nephrectomy Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the cysts. The condition does not respond to immunosuppression.