nclex questions med surg/patho EXAM 4

A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? 1.Iodine 2.Calcium 3.Phosphorus 4.Magnesium

1 Rationale:Adequate dietary iodine is needed to produce T3 and T4. The other requirements for adequate T3 and T4 production are an intact thyroid gland and a functional hypothalamus-pituitary-thyroid feedback system. The remaining options are not responsible for the abnormal amounts of circulating T3 and T4.

A 33-year-old female client is admitted to the hospital with a tentative diagnosis of Graves' disease. Which symptom related to the menstrual cycle would the client be most likely to report during the initial assessment? 1.Amenorrhea 2.Menorrhagia 3.Metrorrhagia 4.Dysmenorrhea

1 Rationale:Amenorrhea or a decreased menstrual flow occurs in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they are not typical manifestations of Graves' disease.

The nurse is assessing a client who has a diagnosis of goiter. Which should the nurse expect to note during the assessment of the client? 1.An enlarged thyroid gland 2.The presence of heart damage 3.Client complaints of chronic fatigue 4.Client complaints of slow wound healing

1 Rationale:An enlarged thyroid gland develops in the client with goiter because of an excessive amount of thyroxine in the thyroid gland. Heart damage occurs with selenium deficiency. In addition, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests in addition to the assessment would be necessary to determine heart damage. Chronic fatigue occurs with iron deficiency. Slow wound healing occurs with zinc deficiency.

A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder? 1.Polyuria 2.Diarrhea 3.Polyphagia 4.Weight gain

1 Rationale:Hypercalcemia classically occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis, making polyuria the correct option. The other manifestations listed are not associated with this disorder.

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? 1.Hypotension and fever 2.Mental status changes and hypertension 3.Subnormal temperature and hypotension 4.Complaints of weakness and hypertension

1 Rationale:The nurse should be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. The remaining options are incorrect.

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. 1.Fever 2.Weight loss 3.Night sweats 4.Visual changes 5.Enlarged, painless lymph nodes

1, 2,3, 5 Rationale: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 developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. 1.Monitor for changes in mentation. 2.Encourage an intake of low-protein foods. 3.Encourage an intake of low-sodium foods. 4.Encourage fluid intake of at least 3000 mL per day. 5.Monitor vital signs, skin turgor, and intake and output.

1, 4, 5 Rationale:The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.

Cholestyramine resin is prescribed for a client with an elevated serum cholesterol level. The nurse should instruct the client to take the medication in which way? 1.After meals 2.Mixed with fruit juice 3.Via a rectal suppository 4.At least 3 hours before meals

2 Rationale:This medication binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 ounces of water, milk, fruit juice, or soup. It should be administered before meals. It is not administered via rectal suppository.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."

2 Rationale:To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

A client visits the health care provider's office for a routine physical examination and reports a new onset of intolerance to cold. Since hypothyroidism is suspected, which additional information would be noted during the client's assessment? 1.Weight loss and tachycardia 2.Complaints of weakness and lethargy 3.Diaphoresis and increased hair growth 4.Increased heart rate and respiratory rate

2 Rationale:Weakness and lethargy are the most common complaints associated with hypothyroidism. Other common symptoms include intolerance to cold, weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

The nurse is teaching a group of adults about the warning signs of cancer. Which signs and symptoms should the nurse mention to the group? Select all that apply. 1.Areas of alopecia 2.Sores that do not heal 3.Nagging cough or hoarseness 4.Indigestion or difficulty swallowing 5.Change in bowel or bladder habits 6.Absence or decreased frequency of menses

2, 3, 4, 5 Rationale:Cancer is a neoplastic disorder that can involve all body systems. In cancer, cells lose their normal growth-controlling mechanism. Some signs and symptoms include sores that do not heal, a nagging cough or hoarseness, indigestion or difficulty swallowing, and a change in bowel or bladder habits. Areas of alopecia occur following cancer chemotherapy. Absence of menses is not a specific sign; however, abnormal occurrence of menses may be.

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands instructions? 1."I will decrease my carbohydrate intake." 2."High fat intake is essential with this disease." 3."I will maintain a normal sodium intake in my diet." 4."I will need to restrict the amount of protein in my diet."

3 Rationale:A high-complex carbohydrate, high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high-fat diet is not prescribed.

A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 1.Creatinine level 2.Potassium concentration 3.Complete blood cell (CBC) count 4.Blood urea nitrogen (BUN) level

3 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Common adverse effects of zidovudine are agranulocytopenia and anemia. The nurse should monitor the CBC count for these changes. Creatinine, potassium, and BUN are unrelated to this medication.

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? 1.Bradycardia 2.Flaccid paralysis 3.Tingling around the mouth 4.Absence of Chvostek's sign

3 Rationale:After thyroidectomy the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and in the fingertips, muscle twitching or spasms, palpitations or arrhythmias, and Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of Chvostek's sign are not signs of hypocalcemia.

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1."I should avoid blowing my nose." 2."I may need a platelet transfusion if my platelet count is too low." 3."I'm going to take aspirin for my headache as soon as I get home." 4."I will count the number of pads and tampons I use when menstruating."

3 Rationale:During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? 1.Edema 2.Obesity 3.Hirsutism 4.Hypotension

4 Rationale:Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. The remaining options do not occur with this disease.

The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? 1.Liver 2.Stomach 3.Pancreas 4.Gallbladder

1 Rationale:An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and should be monitored carefully for adverse effects. Diseases of the stomach, pancreas, and gallbladder are a lesser concern for prolonged medication effects.

During physical examination of a client, which finding is characteristic of hypothyroidism? 1.Periorbital edema 2.Flushed, warm skin 3.Hyperactive bowel sounds 4.Heart rate of 120 beats/min

1 Rationale:Because cellular edema occurs in hypothyroidism, the client's appearance is changed. Nonpitting edema occurs, especially around the eyes and in the feet and hands. Knowing this should direct you to option 1. Flushed, warm skin; hyperactive bowel sounds; and tachycardia (heart rate >100 beats/min) are clinical manifestations of hyperthyroidism, which occurs as a result of excess thyroid hormone secretion, resulting in a hypermetabolic state.

The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client? 1.Low fat 2.High protein 3.High carbohydrate 4.Low in water-soluble vitamins

1 Rationale:Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1.Fatigue 2.Pale urine 3.Weight gain 4.Spider angiomas

1 Rationale:Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? 1.Skin biopsy 2.Anti-Smith test 3.Extractable nuclear antigens 4.Anti-deoxyribonucleic acid (DNA)

1 Rationale:Discoid lupus erythematosus (DLE) is one classification of lupus. Because DLE is not a systemic condition and affects only the skin; therefore, the only significant test is a skin biopsy. A microscopic evaluation of skin cell scrapings from the rash will reveal the characteristic lupus cell and a number of inflammatory cells. Other specific immunological tests, such as anti-SS-a (RO), anti-SS-b (La), anti-Smith, anti-DNA, and extractable nuclear antigens, may be performed. High titers of some of these antibodies are associated with lupus, but some can also be found in persons without the disease.

A nurse is assessing the status of a client who returned to the surgical nursing unit after a parathyroidectomy procedure. The nurse would place highest priority on which assessment finding? 1.Laryngeal stridor 2.Difficulty voiding 3.Mild incisional pain 4.Absence of bowel sounds

1 Rationale:During the early postoperative period, the nurse carefully observes the client for signs of bleeding, which may cause swelling and compression of adjacent tissues. Laryngeal stridor results from compression of the trachea and is a harsh, high-pitched sound heard on inspiration and expiration. Laryngeal stridor is an acute emergency, necessitating immediate attention to avoid complete obstruction of the airway. The other options describe usual postoperative problems that are not life threatening.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1.Increased calcium level 2.Increased white blood cells 3.Decreased blood urea nitrogen level 4.Decreased number of plasma cells in the bone marrow

1 Rationale:Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort

1 Rationale:Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client? 1."It establishes the stage of HIV infection." 2."It confirms the presence of HIV infection." 3."It identifies the cell-associated proviral DNA." 4."It determines the presence of HIV antibodies in the bloodstream."

1 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count.

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1.Encouraging fluids 2.Providing frequent oral care 3.Coughing and deep breathing 4.Monitoring the red blood cell count

1 Rationale:Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but are not the priority in this client.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period? 1.Vital signs 2.Fluid balance 3.Anxiety level 4.Creatinine levels

1 Rationale:Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1."I should limit my fluids to 1 liter per day." 2."I should use my treadmill or go for walks daily." 3."I should follow a moderate-calcium, high-fiber diet." 4."My alendronate helps to keep calcium from coming out of my bones."

1 Rationale:In hyperparathyroidism, clients experience excess parathyroid hormone (PTH) secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are high, there is excess bone resorption (calcium is pulled from the bones). In clients with elevated serum calcium levels, there is a risk of nephrolithiasis. One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly weight-bearing activity, minimizes bone resorption and helps to protect against pathological fracture. Walking, as an exercise, should be encouraged in the client with hyperparathyroidism. Clients should follow a moderate-calcium, high-fiber diet. Even though serum calcium is already high, clients should follow a moderate-calcium diet because a low-calcium diet will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is deposited into the serum.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider? 1.Elevated serum bilirubin level 2.Below normal hemoglobin concentration 3.Elevated blood urea nitrogen (BUN) level 4.Elevated erythrocyte sedimentation rate (ESR)

1 Rationale:Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

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? 1.Dry skin 2.Thin, silky hair 3.Bulging eyeballs 4.Fine muscle tremors

1 Rationale: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.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1.Assist the client in expressing feelings. 2.Restrict visitors until the jaundice subsides. 3.Perform most of the activities of daily living for the client. 4.Provide information to the client only when he or she requests it

1 Rationale: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.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1.Protecting the client from infection 2.Providing emotional support to decrease fear 3.Encouraging discussion about lifestyle changes 4.Identifying factors that decreased the immune function

1 Rationale:The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? 1.Cystic duct 2.Liver canaliculi 3.Common bile duct 4.Right hepatic duct

1 Rationale:The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

A nursing instructor is reviewing information on the organs of the immune system. The instructor asks a nursing student to name the location of Kupffer cells. Which organ identified by the nursing student indicates successful teaching? 1.The liver 2.The spleen 3.The tonsils 4.Bone marrow

1 Rationale:The liver contains a large number of macrophages called Kupffer cells. Kupffer cells are a part of the body's reticuloendothelial system and is a protective function of the liver.They help filter blood by phagocytizing microorganisms and other foreign particles passing through the liver. The organs in the remaining options are incorrect

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an immune disorder, and they discuss the classes of human antibodies. Which statement by the nursing student indicates a need for further teaching? 1."Immunoglobulin G (IgG) is the minor serum antibody." 2."Immunoglobulin M (IgM) is the first antibody produced in response to antigen." 3."Immunoglobulin E (IgE) accounts for less than 1% of the total antibody level in the blood." 4."The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies."

1 Rationale:The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies. It is antiviral, antibacterial, and effective against toxins. IgM is the first antibody produced in response to antigen and makes up about 7% of the total serum antibodies. IgE accounts for only about 0.5% of the total antibody level in the blood.

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? 1.Thyroid 2.Pituitary 3.Parathyroid 4.Adrenal cortex

1 Rationale:The thyroid gland is responsible for a number of metabolic functions in the body. Among these are metabolism of nutrients such as fats and carbohydrates. Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. A client with increased activity of the thyroid gland will experience weight loss from the higher metabolic rate and will have an increased pulse rate. The anterior pituitary gland produces growth hormone, luteinizing hormone, and follicle-stimulating hormone. Antidiuretic hormone (ADH) and oxytocin are secreted by the posterior pituitary gland. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1.Bleeding 2.Infection 3.Dehydration 4.Malnutrition

1 Rationale:Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes.

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1.Fever and tachycardia 2.Pallor and tachycardia 3.Agitation and bradycardia 4.Restlessness and bradycardia

1 Rationale:Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100°F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1."I should take hot baths because they are relaxing." 2."I should sit whenever possible to conserve my energy." 3."I should avoid long periods of rest because it causes joint stiffness." 4."I should do some exercises, such as walking, when I am not fatigued."

1 Rationale:To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1.Injection drug abusers 2.Prostitutes and their clients 3.People with sexually transmitted infections (STIs) 4.People who have had frequent episodes of pneumonia 5.People who recently received a blood transfusion for a surgical procedure

1, 2, 3 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Injection drug abusers, those engaged in prostitution, and people with STIs are high-risk groups that should be tested for HIV per the Centers for Disease Control and Prevention's recommendations. Those who have had frequent episodes of pneumonia and those who recently received a blood transfusion for a surgical procedure are not at risk for HIV unless another compounding factor places them at risk. However, if a blood transfusion was received between 1978 and 1985, the client should be tested.

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Monitor intake and output. 3.Assess extremities for edema. 4.Maintain a high-sodium diet. 5.Maintain a low-potassium diet.

1, 2, 3 Rationale:The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water.

The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions should be included on the list? Select all that apply. 1.The signs and symptoms of hypoadrenalism 2.The signs and symptoms of hyperadrenalism 3.Instructions to take the medications exactly as prescribed 4.The importance of maintaining regular outpatient follow-up care 5.A reminder to read the labels on over-the-counter medications before purchase

1, 2, 3, 4 Rationale:The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the health care provider (HCP) before purchasing any over-the-counter medications, and maintaining regular outpatient follow-up care. The nurse also should instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply. 1.Irritability 2.Complaints of nausea 3.Sodium level of 128 mEq/L (128 mmol/L) 4.Potassium level of 3.2 mEq/L (3.2 mmol/L) 5.Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg

1, 2, 3, 5 Rationale:Findings consistent with a diagnosis of adrenal insufficiency include nausea, vomiting, and diarrhea; hyponatremia; salt craving; hyperkalemia; and orthostatic hypotension. Irritability and depression may also occur in primary adrenal hypofunction.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1.Fever 2.Nausea 3.Lethargy 4.Tremors 5.Confusion 6.Bradycardia

1, 2, 4, 5 Rationale:Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. 1.Fatigue 2.Anorexia 3.High fever 4.Weight loss 5.Generalized weakness

1, 2, 5 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, paresthesias. Weight loss is one of the late manifestations.

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. 1.Hypotension 2.Leukocytosis 3.Hyperkalemia 4.Hypercalcemia 5.Hypernatremia

1, 3 Rationale:In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with Addisonian crisis.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1.Polyuria 2.Headache 3.Bone pain 4.Nervousness 5.Weight gain

1, 3 Rationale:The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1.Jaundice 2.Flulike symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine

1, 3, 4, 5 Rationale:There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1.Fever 2.Positive Cullen's sign 3.Complaints of indigestion 4.Palpable mass in the left upper quadrant 5.Pain in the upper right quadrant after a fatty meal 6.Vague lower right quadrant abdominal discomfort

1, 3, 5 Rationale:During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1."I will need to limit the amount of protein in my diet." 2."I should eat foods that have a lot of potassium in them." 3."I am fortunate that I can eat all of the salty foods I enjoy." 4."I am fortunate that I do not need to follow any special diet."

2 Rationale:A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue

A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? 1.The histoplasmosis is resolving. 2.The client has disseminated histoplasmosis infection. 3.This is a side effect of the medications given to treat AIDS. 4.The client probably has another infection that is developing.

2 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining options are incorrect

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital? 1.Bathe before eating breakfast. 2.Sit for as many activities as possible. 3.Stand in the shower instead of taking a bath. 4.Group all tasks to be performed early in the morning.

2 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client also should sit in a shower chair instead of standing while bathing. The client needs to prioritize activities, such as eating breakfast before bathing, and should intersperse each major activity with a period of rest.

A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? 1.Western blot 2. CD4+ cell count 3.Enzyme-linked immunosorbent assay (ELISA) 4.Complete blood cell (CBC) count with differential

2 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4+ cell count. The Western blot and the ELISA are performed to diagnose the infection initially. A CBC count with differential may be done as part of ongoing monitoring of the status of the client with AIDS and to detect adverse effects of other medications.

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? 1.Maintain a supine position. 2.Monitor neck circumference every 4 hours. 3.Maintain a pressure dressing on the operative site. 4.Encourage deep-breathing exercises and vigorous coughing exercises.

2 Rationale:After thyroidectomy, neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client should be placed in an upright position to facilitate air exchange. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. The nurse should assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? 1.Weight loss 2.Peripheral edema 3.Capillary refill of 5 seconds 4.Bleeding from previous puncture sites

2 Rationale:Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1.Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only 3 large meals daily.

2 Rationale:Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

A client has overactivity of the thyroid gland. The nurse should expect which finding? 1.Weight gain 2.Nutritional deficiencies 3.Low blood glucose levels 4.Increased body fat stores

2 Rationale:Although the client may experience an increased appetite with overactivity of the thyroid gland, food intake does not meet energy demands, and nutritional deficiencies can develop. Weight loss occurs as a result of the increased metabolic activity. Glucose tolerance is decreased, and the client experiences hyperglycemia. Overactivity of the thyroid gland also causes increased metabolism, including fat metabolism. This leads to decreased levels of fat in the bloodstream, including cholesterol, and decreased body fat stores.

A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse should expect which electrolyte abnormality? 1.Sodium 2.Calcium 3.Potassium 4.Magnesium

2 Rationale:The C cells of the thyroid gland are helpful in maintaining normal plasma calcium levels. They do not affect the levels of sodium, potassium, or magnesium.

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? 1."They activate T cells." 2."They produce antibodies." 3."They initiate phagocytosis." 4."They attack and kill the target cell directly."

2 Rationale:B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis.

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1.Rice 2.Whole milk 3.Broiled fish 4.Baked chicken

2 Rationale:Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be monitored? 1.Platelet count 2.Bone marrow biopsy 3.White blood cell count 4.Complete blood cell count

2 Rationale:Bone marrow aspiration or biopsy allows examination of blast cells and other hypercellular activity. Blood studies will not provide a definitive diagnosis of leukemia.

The nurse has conducted a cancer prevention seminar for clients in an ambulatory setting. The nurse determines that teaching was effective if the clients select which food item on the menu? 1.Broiled beef, canned corn, rice 2.Broccoli, baked fish, mashed potato 3.Bacon, scrambled eggs, french fries 4.Bologna, canned asparagus, white bread

2 Rationale:Broccoli is a cruciferous vegetable, which is helpful in reducing the risk of cancer. Other cruciferous vegetables are cauliflower, Brussels sprouts, and cabbage. Red meat (bacon) and meats with nitrites (bologna and broiled beef) can increase the risk of developing cancer.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids? 1.Nuts 2.Meats 3.Cereals 4.Vegetables

2 Rationale:Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse should expect an excess of which substance? 1.Calcium 2.Cortisol 3.Epinephrine 4.Norepinephrine

2 Rationale:Cushing's syndrome is characterized by an excess of cortisol, a glucocorticoid. Glucocorticoids are produced by the adrenal cortex. Calcium would be decreased in this disorder. Epinephrine and norepinephrine are produced by the adrenal medulla.

A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse should prepare the client for which diagnostic test to confirm the presence of histoplasmosis? 1.Skin biopsy 2.Sputum culture 3.Western blot test 4.Upper gastrointestinal series

2 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Histoplasmosis is an opportunistic infection that affects the lungs and can occur in the client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, and bronchoscopy. The other options are incorrect. A Western blot test is used to confirm a diagnosis of HIV. A skin biopsy may be done if the client had Kaposi's sarcoma. Gastrointestinal series are done for a client suspected to have a gastrointestinal disorder.

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? 1.No further diagnostic studies are needed. 2.A Western blot will be done to confirm these findings. 3.The client probably will have a bone marrow biopsy done. 4.A CD4+ cell count will be done to measure T helper lymphocytes.

2 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus. The remaining options are incorrect.

A client asks the nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What should the nurse tell the client? 1.Home test kits are not available for testing at this time. 2.Home test kits may not be as reliable as laboratory blood tests. 3.Home test kits are most reliable immediately after a risk event occurs. 4.Home test kits should not be used; rather, it is important to contact the health care provider (HCP) with concerns about the HIV status.

2 Rationale:Human immunodeficiency virus (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 HCP 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 with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? 1."Don't be concerned; this problem can be covered with clothing." 2."Usually these physical changes slowly improve following treatment." 3."This is permanent, but looks are deceiving and are not that important." 4."Try not to worry about it; there are other things to be concerned about."

2 Rationale:The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. All other options are not therapeutic responses.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis encephalitis. On the basis of this information, the nurse would assess for which manifestation? 1.Lesions on the skin 2.Mental status changes 3.Changes in bowel pattern 4.Lesions on the oral mucosa

2 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Toxoplasmosis encephalitis, caused by Toxoplasma gondii, is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat. It manifests with signs and symptoms such as an altered mental status, neurological deficits, headaches, and fever. Additional manifestations include difficulties with speech, gait, and vision; and seizures.The other options are not associated with toxoplasmosis.

The nurse is preparing to care for a client after parathyroidectomy. The nurse should plan for which action for this client? 1.Maintain an endotracheal tube for 24 hours. 2.Administer a continuous mist of room air or oxygen. 3.Place the client in a flat position with the head and neck immobilized. 4.Use only a rectal thermometer for temperature measurement.

2 Rationale:Humidification of air or oxygen helps to liquefy mucous secretions and promotes easier breathing after parathyroidectomy. Pooling of thick mucous secretions in the trachea, bronchi, and lungs will cause respiratory obstruction. The client will not necessarily have an endotracheal tube in place. Tympanic temperatures can be taken. Semi Fowler's position is the position of choice to assist in lung expansion and prevent edema. Rectal temperatures only are not required.

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? 1.Dry skin 2.Bulging eyeballs 3.Periorbital edema 4.Coarse facial features

2 Rationale:Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? 1.Unresponsive pupils 2.Positive Trousseau's sign 3.Negative Chvostek's sign 4.Hypoactive bowel sounds

2 Rationale:Hypoparathyroidism is related to a lack of parathyroid hormone secretion or a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit Chvostek's and Trousseau's signs, which indicate potential tetany. The remaining options are not related to the presence of hypocalcemia.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1.Encourage foods that are high in protein. 2.Monitor for fluid and electrolyte imbalance. 3.Explain that high-fat diets usually are better tolerated. 4.Explain that most daily calories need to be consumed in the evening hours.

2 Rationale:If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1.Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.

2 Rationale:Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? 1.Anemia 2.Anorexia 3.Amenorrhea 4.Night sweats

2 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1.Maintain bed rest as much as possible. 2.Administer corticosteroids as prescribed for inflammation. 3.Advise the client to remain supine for 1 to 2 hours after meals. 4.Keep the room temperature warm during the day and cool at night.

2 Rationale:Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present.

For the client with stomatitis resulting from chemotherapy, the care plan should include which intervention? 1.Inspect the mouth every week for fungus. 2.Encourage foods with neutral or cool temperatures. 3.Give the client spicy foods to stimulate the sense of taste. 4.Perform frequent oral hygiene using a commercial alcohol-based mouthwash.

2 Rationale:Stomatitis is inflammation of the oral cavity, and using commercial mouthwashes containing alcohol or encouraging spicy foods will cause pain. Foods are better tolerated by the client with stomatitis when the food is cool or of neutral temperature. It is important to monitor for oral fungal infections, but this assessment should be completed at least daily.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1.Fresh fruit 2.Brown gravy 3.Fresh vegetables 4.Poultry without skin

2 Rationale:The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

The nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instruction? 1."I should avoid bed rest." 2."I need to avoid doing any exercise at all." 3."I need to space activity throughout the day." 4."I should gauge my activity level by my energy level."

2 Rationale:The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to avoid bed rest and use energy levels as a guide to activity. The client also should be instructed to avoid high-impact activity or contact sports.

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1.A client with hypothyroidism 2.A client with Graves' disease who is having surgery 3.A client with diabetes mellitus scheduled for a diagnostic test 4.A client with diabetes mellitus scheduled for debridement of a foot ulcer

2 Rationale:Thyrotoxicosis usually is seen in clients with Graves' disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy. The client conditions in the remaining options are not associated with thyrotoxicosis.

A client who visits the health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse should check for which manifestations? 1.Weight loss and thinning skin 2.Complaints of weakness and lethargy 3.Diaphoresis and increased hair growth 4.Increased heart rate and respiratory rate

2 Rationale:Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? 1."Do you have tremors in your hands?" 2."Are you experiencing pain in your joints?" 3."Do you notice swelling in your legs at night?" 4."Have you had problems with diarrhea lately?"

2 ationale:Hyperparathyroidism is associated with oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and, sometimes, pathological fractures. Tremors and diarrhea relate to assessment findings of hypoparathyroidism. Swelling in the legs at night is unrelated to hyperparathyroidism

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1.Ibuprofen 2.Ranitidine 3.Acetaminophen 4.Acetylsalicylic acid

3 Rationale:Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? 1.Protein 2.Glucose 3.Amylase 4.Cholesterol

3 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Didanosine is toxic to the pancreas and the liver. A serum amylase level that is increased by 1.5 to 2 times normal may signify pancreatitis and may be fatal in the client with AIDS. Therefore, the nurse should monitor the results of amylase and liver function studies closely. Alterations in protein, glucose, and cholesterol levels are unrelated to this medication.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment? 1.Western blot 2.B lymphocyte count 3.CD4+ cell or T lymphocyte count 4.Enzyme-linked immunosorbent assay (ELISA)

3 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV),which destroys T cells, thereby increasing susceptibility to infection and malignancy. The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count should increase if the client is responding and should decrease if the client's response is poor. The Western blot and ELISA are tests to assist in diagnosing human immunodeficiency virus infection. The B lymphocyte count is not a priority marker to monitor with AIDS clients.

The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client? 1."You can take either hydrocortisone or fludrocortisone for replacement." 2."You need to take your fludrocortisone 3 times a day to prevent a crisis." 3."You need to increase salt in your diet, particularly during stressful situations." 4."You need to decrease your dosages of glucocorticoids and mineralocorticoids during stressful situations."

3 Rationale:Addison's disease is a result of adrenocortical insufficiency, and management is focused on treating the underlying cause. Hormone therapy is used for replacement. Hydrocortisone has both glucocorticoid and mineralocorticoid properties and needs to be taken 3 times daily, with two thirds of the daily dose taken on awakening. Fludrocortisone is taken once daily in the morning. Salt additives are necessary, particularly during times of stress, to compensate for excess heat or humidity as a result of the condition. There needs to be an increased dose of cortisol given for stressful situations such as surgery or hospitalization. Therefore, option 3 is the correct answer.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1.Evaluating for asterixis 2.Inspecting for petechiae 3.Palpating for peripheral edema 4.Evaluating for decreased level of consciousness

3 Rationale:Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

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? 1.Peripheral edema 2.Bilateral exophthalmos 3.Signs and symptoms of hypovolemia 4.Signs and symptoms of hypocalcemia

3 Rationale: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 nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction? 1."I need to wear a MedicAlert bracelet." 2."I need to purchase a travel kit that contains cortisone." 3."I will need to take daily medications until my symptoms decrease." 4."I need an increased dose of glucocorticoid medication during stressful minor illnesses."

3 Rationale:Client teaching includes the need for lifelong daily medications. The client also is instructed to carry or wear a medical identification card or bracelet. A travel kit will need to be purchased. It should contain oral cortisone along with intramuscular preparations for self-injection and intravenous vials for emergency injection by a health care provider. Increased glucocorticoid dosage during stressful minor illnesses will be necessary.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem? 1."Do you have a fever?" 2."Are you losing weight?" 3."Have you enjoyed having visitors?" 4."Do you rest sometime during the day?"

3 Rationale:Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit a sign of thyroid storm. Which is an early indicator of this complication? 1.Bradycardia 2.Constipation 3.Hyperreflexia 4.Low-grade temperature

3 Rationale:Clinical manifestations of thyroid storm include a fever as high as 106°F, hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severe tachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascular collapse.

The nurse is caring for a client with altered protein metabolism as a result of liver dysfunction. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Increased lactase level 2.Decreased albumin level 3.Increased ammonia level 4.Decreased lactic acid level

3 Rationale:During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. The remaining options are incorrect

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1."I don't believe that." 2."Everything will be all right." 3."I'm not sure that I understand. Would you please explain?" 4."I think you should talk more with the health care provider about this."

3 Rationale:Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the health care provider for further information is a block to communication.

The nurse is providing instructions to the client who is receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? 1."I will dry affected areas with patting motions." 2."I will wear soft clothing over the affected site." 3."I will use a washcloth to wash the affected area." 4."I need to make sure I carry my purse on the unaffected side."

3 Rationale:External radiation therapy requires that markings be placed on the skin so that therapy can be aimed at the affected areas. The hand rather than a washcloth should be used to wash the area to avoid irritation. The nurse should instruct the client who is undergoing external radiation therapy to dry affected areas with a patting (rather than rubbing) motion so as not to disrupt the markings on the skin. Soft clothing should be worn so that the affected area is not irritated. The client should be sure to carry her purse on the unaffected side.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1.Clamp the T-tube. 2.Irrigate the T-tube. 3.Document the findings. 4.Notify the health care provider.

3 Rationale:Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1."I have had unprotected sex with multiple partners." 2."I ate shellfish about 2 weeks ago at a local restaurant." 3."I was an intravenous drug abuser in the past and shared needles." 4."I had a blood transfusion 30 years ago after major abdominal surgery."

3 Rationale:Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners.

The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information? 1.It indicates nerve damage. 2.The hoarseness is permanent. 3.It is normal during this time and will subside. 4.It will worsen before it subsides, which may take 6 months.

3 Rationale:Hoarseness in the postoperative period usually is the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. The other options are incorrect.

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client? 1.HIV infection has been confirmed. 2.The client probably has a gastrointestinal infection. 3.The test will need to be confirmed with a Western blot. 4.A positive test result is normal and does not mean that the client has acquired HIV.

3 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A negative result on an ELISA indicates that infection is absent or that not enough time has passed since exposure for seroconversion. A positive ELISA result must be confirmed with a Western blot. The other options are incorrect.

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? 1.To treat thyroid storm 2.To prevent cardiac irritability 3.To treat hypocalcemic tetany 4.To stimulate release of parathyroid hormone

3 Rationale:Hypocalcemia, resulting in tetany, can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes; muscle spasms; or twitching, the health care provider is notified immediately. Calcium gluconate should be readily available in the nursing unit.

The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? 1."I should avoid contact sports." 2."I should check my ankles for swelling." 3."I need to avoid foods high in potassium." 4."I need to check my blood glucose regularly."

3 Rationale:Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients with this condition experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1.Pruritus 2.Right upper quadrant pain 3.Fatigue, anorexia, and nausea 4.Jaundice, dark-colored urine, and clay-colored stools

3 Rationale:In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? 1."They are produced by several types of cells." 2."They are effective against a wide variety of viruses." 3."They are effective against a wide variety of bacteria." 4."They have been effective to some degree in the treatment of melanoma."

3 Rationale:Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

A nurse is reviewing the health care provider's prescriptions for a client diagnosed with hypothyroidism. Which medication prescription should the nurse question and verify? 1.Acetaminophen 2.Docusate sodium 3.Morphine sulfate 4.Levothyroxine sodium

3 Rationale:Medications are administered very cautiously to the client with hypothyroidism because of altered metabolism and excretion and depressed metabolic rate and respiratory status. Morphine sulfate would further depress bodily functions. Hormone replacement with levothyroxine sodium, a thyroid hormone, is a component of therapy. Stool softeners, such as docusate sodium, are prescribed to prevent constipation. Acetaminophen can be taken.

A multidisciplinary health care team is developing a plan of care for a client with hyperparathyroidism. The nurse should include which priority intervention in the plan of care? 1.Describe the use of loperamide. 2.Restrict fluids to 1000 mL per day. 3.Walk down the hall for 15 minutes 3 times a day. 4.Describe the administration of aluminum hydroxide gel.

3 Rationale:Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted. Discussing the use of medications is not the priority with this client.

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1.The diet should be low in calories. 2.Meals should be large to conserve energy. 3.Activity should be limited to prevent fatigue. 4.Alcohol intake should be limited to 2 ounces per day.

3 Rationale:Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? 1.Ascites 2.Emboli 3.Facial rash 4.Two hemoglobin S genes

3 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1.Fever 2.Fatigue 3.Skin lesions 4.Elevated red blood cell count

3 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? 1.A platelet count of 200,000 mm3 (200 × 109/L) 2.A blood glucose level of 110 mg/dL (6.28 mmol/L) 3.A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) 4.A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

3 Rationale:The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values listed in the remaining options would not be noted in the client with Cushing's syndrome.

The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement? 1."I need to avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I can resume a full activity level within 1 week." 4."I need to take the prescribed amounts of vitamin K."

3 Rationale:The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.

The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse should instruct the client that it is acceptable to include which item in the diet? 1.Fish 2.Cereals 3.Vegetables 4.Meat and poultry

3 Rationale:The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. Vegetables are allowed in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals.

A client with suspected Cushing's syndrome is scheduled for adrenal venography. A nurse has provided instructions to the client regarding the test. Which statement by the client indicates a need for further instruction? 1."I need to sign an informed consent." 2."The insertion site will be locally anesthetized." 3."I will be placed in a high-sitting position for the test." 4."I may feel a burning sensation after the dye is injected."

3 Rationale:The test aids in determining whether signs and symptoms are caused by abnormalities in the adrenal gland. The nurse assesses the client for allergies to iodine before the test. The client is informed that the supine position is necessary to access the femoral vein. An informed consent form is required, the insertion site will be locally anesthetized, and the client will experience a transient burning sensation after the dye is injected.

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1.Hypoglycemia 2.Level of hoarseness 3.Respiratory distress 4.Edema at the surgical site

3 Rationale:Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. 1.Provide a warm environment for the client. 2.Instruct the client to consume a low-fat diet. 3.A thyroid-releasing inhibitor will be prescribed. 4.Encourage the client to consume a well-balanced diet. 5.Instruct the client that thyroid replacement therapy will be needed. 6.Instruct the client that episodes of chest pain are expected to occur.

3, 4 Rationale:The clinical manifestations of hyperthyroidism are the result of increased metabolism caused by high levels of thyroid hormone. Interventions are aimed at reduction of the hormones and measures to support the signs and symptoms related to an increased metabolism. The client often has heat intolerance and requires a cool environment. The nurse encourages the client to consume a well-balanced diet because clients with this condition experience increased appetite. Iodine preparations are used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Thyroid replacement is needed for hypothyroidism. The client would notify the health care provider if chest pain occurs because it could be an indication of an excessive medication dose.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1.Tremors 2.Weight loss 3.Feeling cold 4.Loss of body hair 5.Persistent lethargy 6.Puffiness of the face

3, 4, 5, 6 Rationale:Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1.Provide a cool environment for the client. 2.Instruct the client to consume a high-fat diet. 3.Instruct the client about thyroid replacement therapy. 4.Encourage the client to consume fluids and high-fiber foods in the diet. 5.Inform the client that iodine preparations will be prescribed to treat the disorder. 6.Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

3, 4, 6 Rationale:The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.

The nurse is monitoring a client with chronic lymphocytic leukemia (CLL). Which sign should the nurse specifically monitor for and report to the health care provider? 1.Anemia 2.Bleeding 3.Pancytopenia 4.Lymphadenopathy

4 Rationale:CLL causes a slow increase in immature B cells. These cells infiltrate the bone marrow, lymph nodes, spleen, and liver. CLL eventually causes bone marrow failure; therefore, the client will have enlarged and swollen lymph nodes. Options 1 and 2 are clinical manifestations of acute leukemias. Option 3 is a clinical manifestation of hairy cell leukemia.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? 1."I will wash my hands frequently." 2."I will keep my child's immunizations up to date." 3."I will avoid direct unprotected contact with my child's body fluids." 4."I can send my child to day care if he has a fever, as long as it is a low-grade fever."

4 Rationale:AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center. Options 1, 2, and 3 are correct statements and would be actions a caregiver should take when the child has AIDS.

A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? 1.Monitor for signs of hyperglycemia. 2.Administer the medication without food. 3.Administer the medication with an antacid. 4.Ensure that the client uses an electric razor for shaving.

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid.

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding should the nurse anticipate? 1.Hyperactive bowel sounds 2.Complaints of watery diarrhea 3.Red lesions on the upper arms 4.Yellowish-white, curdlike patches in the oral cavity

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. In a person with AIDS, candidiasis (overgrowth of the Candida fungus) occurs because the immune system can no longer control fungal growth. Candida stomatitis or esophagitis occurs often in AIDS. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. The remaining options are not findings in this disorder.

A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? 1.Inadequate thermoregulation 2.Insufficient medication dosing 3.Toxic nervous system effects from the medication 4.Infection caused by leukopenic effects of the medication

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. Adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. The remaining options are inaccurate interpretations.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 1.Provide large, nutritious meals. 2.Serve foods while they are hot. 3.Add spices to food for added flavor. 4.Remove dairy products and red meat from the meal.

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication? 1.Polycythemia 2.Leukocytosis 3.Thrombocytosis 4.Agranulocytopenia

4 Rationale:Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Zidovudine is a neucloside-nucleotide reverse transcriptase inhibitor used to the virus. An adverse effect of this medication is agranulocytopenia with anemia. The nurse carefully monitors CBC count results for changes that could indicate this occurrence. With early infection and in the client who is asymptomatic, the CBC count is monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, the CBC count is monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The remaining options are not side or adverse effects of the medication.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? 1.Agitation 2.Diaphoresis 3.Restlessness 4.Severe abdominal pain

4 Rationale:Addisonian crisis is a serious life-threatening response to acute adrenal insufficiency that most commonly is precipitated by a major stressor. The client in addisonian crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. The remaining options do not identify clinical manifestations associated with addisonian crisis.

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? 1.Infertility 2.Gynecomastia 3.Sexual dysfunction 4.Body image changes

4 Rationale:Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia. Sexual dysfunction and infertility could occur if the entire thyroid is removed and the client is not placed on thyroid replacement medications.

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made? 1."The skin is considered a chemical barrier." 2."The mucous membranes act as chemical barriers." 3."The cilia lining the respiratory tract are chemical barriers." 4."Acids and enzymes found in body fluids function as chemical barriers."

4 Rationale:Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate? 1.Encourage the client's expression of feelings. 2.Assess the client's understanding of the disease process. 3.Encourage family members to share their feelings about the disease process. 4.Encourage the client to recognize that the body changes need to be dealt with.

4 Rationale:Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. The remaining options are appropriate because they address the client and family feelings regarding the disorder.

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1.Fatigue 2.Weakness 3.Weight gain 4.Enlarged lymph nodes

4 Rationale:Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse should check which diagnostic test noted in the client's record to determine the stage of the disease? 1.Blood studies 2.Bone marrow examination 3.Excisional lymph node biopsy 4.Positron emission topography (PET) scan

4 Rationale:Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue. It is characterized by painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Diagnostic testing for this disorder includes blood studies, excisional lymph node biopsy, bone marrow examination, and radiographic studies. These tests are used for evaluation purpose but are not definitive. PET scan with or without computed tomography is used to diagnose and determine the stage of the disease.

The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease? 1.Reed-Sternberg cells are present. 2.The lymph nodes, spleen, and liver are involved. 3.The prognosis depends on the stage of the disease. 4.The disease occurs most often in those older than 75 years of age.

4 Rationale:Hodgkin's lymphoma is a cancer that can occur at any age but appears to peak in 2 different age groups: in teens and young adults and in adults in their 50s and 60s. The remaining options are characteristics of this disease..

A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client expresses relief about not contracted HIV. What should the nurse emphasize when explaining the test results to the client? 1.No further testing is needed. 2.The test should be repeated in 1 month. 3.A negative HIV test result is considered accurate. 4.A negative HIV test result is not considered accurate immediately after exposure.

4 Rationale:Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A test for HIV should be repeated if results are negative. Seroconversion is the point at which antibodies appear in the blood. The average time for seroconversion is 2 months, with a range of 2 to 10 months. For this reason, a negative HIV test result is not considered accurate immediately after exposure. The remaining options are incorrect.

The nursing instructor is evaluating a nursing student for knowledge of antibody classes. Which statement by the nursing student indicates that teaching has been effective? 1."Immunoglobulin G (IgG) is the first antibody produced in response to antigen." 2."Immunoglobulin A (IgA) is the last antibody produced in response to antigen." 3."Immunoglobulin D (IgD) is the last antibody produced in response to antigen." 4."Immunoglobulin M (IgM) is the first antibody produced in response to antigen."

4 Rationale:IgM is the first antibody produced in response to antigen. IgM composes about 10% to 15% of the circulating antibody population. IgM is especially effective at the antibody actions of agglutination and precipitation because of having 10 potential binding sites per molecule. Because of their size, these antibodies are confined to the bloodstream. The remaining options are incorrect.

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1.Chest x-ray 2.Western blot 3.CD4+ cell count 4.p24 antigen assay

4 Rationale:Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? 1.The presence of inflammation 2.The presence of infection in the body 3.The presence of antigens of immunoglobulin A (IgA) 4.The presence of unusual antibodies of the IgG and IgM types

4 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The rheumatoid factor assay tests for the presence of unusual antibodies of the IgG and IgM types, which develop in a number of connective tissue diseases. The test result in a person without RA would be negative or <60 units/mL by nephelometric method of laboratory testing. The other options are incorrect.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1.Neutropenia 2.Hyperglycemia 3.Antigens of immunoglobulin A (IgA) 4.Unusual antibodies of the IgG and IgM type

4 Rationale:Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? 1.Hyperthyroidism 2.Pernicious anemia 3.Cardiopulmonary disorders 4.Systemic lupus erythematosus (SLE)

4 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A major skin manifestation of SLE is the appearance of a rash on both cheeks and across the nose. It is known as a "butterfly rash." Hyperthyroidism is associated with moist skin and increased perspiration. Pernicious anemia causes pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1.Decreased platelets only 2.Increased red blood cell count 3.Increased white blood cell count 4.Decreased number of all cell types

4 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a CBC count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? 1.Increased neutrophils 2.Increased red blood cell count 3.Increased white blood cell count 4.Decreased numbers of all cell types

4 Rationale:Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. In the client with SLE, a complete blood cell count commonly shows pancytopenia, a decrease in all cell types. This probably is caused by a direct attack on all blood cells or bone marrow by immune complexes. The other options are incorrect.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1."I will handle the area gently." 2."I will wear loose-fitting clothing." 3."I will avoid the use of deodorants." 4."I will limit sun exposure to 1 hour daily."

4 Rationale:The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

The nurse has provided instructions to a client receiving external radiation therapy. Which client statement would indicate a need for further instruction regarding self-care related to the radiation therapy? 1."I need to eat a high-protein diet." 2."I need to avoid exposure to sunlight." 3."I need to wash my skin with a mild soap and pat dry." 4."I need to apply pressure on the irritated area by wearing snug clothing to prevent bleeding."

4 Rationale:The client should avoid pressure on the irritated area and should wear loose-fitting clothing. Specific health care provider instructions would be necessary if an alteration in skin integrity occurred as a result of the radiation therapy. Options 1, 2, and 3 are accurate measures to implement after radiation therapy.

A client has been diagnosed with Cushing's syndrome. The nurse should assess the client for which expected manifestations of this disorder? 1.Dizziness 2.Weight loss 3.Hypoglycemia 4.Truncal obesity

4 Rationale:The client with Cushing's syndrome may exhibit a number of different manifestations. These may include moon face, truncal obesity, and a "buffalo hump" fat pad. Other signs include hyperglycemia, hypernatremia, hypocalcemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? 1.Prone 2.Supine 3.Left side 4.Right side

4 Rationale:To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, the remaining positions are incorrect.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? 1.Skin atrophy 2.The presence of sunken eyes 3.Drooping on 1 side of the face 4.A rounded "moonlike" appearance to the face

4 Rationale:With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin. The remaining options are not associated with the assessment findings in Cushing's syndrome.

The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms should the nurse monitor for? Select all that apply. 1.Anorexia 2.Dizziness 3.Weight loss 4.Moon face 5.Hypertension 6.Truncal obesity

4, 5, 6 Rationale:A client with Cushing's syndrome may exhibit a number of different manifestations. These could include moon face, truncal obesity, and a buffalo hump fat pad. Other signs include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.