NG 306 EAQ's

a (DiGeorge syndrome is a primary immune deficiency disorder in which T cells are affected. The B cells are affected in Bruton's X-linked agammaglobulinemia; common variable hypogammaglobulinemia; and selective immunoglobulin A (IgA), IgM, and IgG deficiency. Monocytes and polymorphonuclear cells are affected in chronic granulomatous disease and Job syndrome.)

Of which type of cells would DiGeorge syndrome create a deficiency? a. T cells b. B cells c. Monocytes d. Polymorphonuclear cells

a (High levels of calcium in the serum cause nausea, vomiting, weight loss, and epigastric pain (pain in the upper abdomen). The client may have hypercalcemia. Hypernatremia is manifested as altered cerebral functioning. Hypermagnesemia is manifested as bradycardia, peripheral vasodilation, and hypotension. Hyperphosphatemia is manifested as hypocalcemia that results when serum phosphorus levels increase.)

A client with a parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the client's clinical manifestations? a. Hypercalcemia b. Hypernatremia c. Hypermagnesemia d. Hyperphosphatemia

c (Eosinophils release vasoactive amines during allergic reactions to limit the extent of an allergic reaction. Neutrophils are phagocytes, and numbers increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms.)

Which leukocyte releases vasoactive amines during a client's allergic reaction? a. Neutrophil b. Monocyte c. Eosinophil d. Macrophage

a (A goniometer is a device that measures the angle of a joint and is used to assess range of motion. Mirror therapy is used to reduce phantom limb sensation. Buck's traction boot is a type of skin traction used to prevent hip flexion contractures. Splints are used to immobilize a joint after a fracture.)

For which purpose is a goniometer used? a. To assess range of motion b. To reduce phantom limb sensation c. To prevent hip flexion contractures d. To immobilize a joint during fracture

c (Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow exudate, and beige pus with a fishy odor are characteristics of purulent wound exudate.)

How would the nurse describe the exudate characteristic of a serosanguineous wound? a. Greenish-blue pus b. Creamy yellow exudate c. Blood-tinged amber fluid d. Beige pus with a fishy odor

a (All staff members use standard precautions for all clients in all settings, regardless of their diagnosis or presumed infectiousness. Practices associated with standard precautions require health care providers, not a client, to use hand washing and personal protective equipment to protect themselves and others from body fluids. Transmission-based precautions, known as airborne, droplet, and contact precautions, are based on a client's diagnosed infection.)

How would the nurse explain the purpose of standard precautions to the nursing assistant on a surgical unit? a. Decrease the risk of transmitting unidentified pathogens b. Used by staff when clients are suspected of having a communicable disease c. Ensure clients perform hygiene practices in a universal way d. Create categories requiring the client to follow additional precautions

c (Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.)

Which description is associated with fissures? a. Deep erosions that extend beneath the epidermis b. Thinning of the skin surface with a loss of skin markings c. Linear cracks in the epidermis that extend into the dermis d. Thickened areas of epidermis with accentuated skin markings

d (Electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual. Arthroscopy is used for the direct visualization of ligaments, menisci, and articular surfaces of a joint. A radiography is performed to detect bone density, alignment, swelling, and intactness of a joint. A myelography is performed to visualize the vertebral column, intervertebral discs, spinal nerve roots, and blood vessels)

Which diagnostic procedure is used to detect muscle weakness? a. Arthroscopy b. Radiography c. Myelography d. Electromyography

c (Tarsals are short bones, unlike the tibia, femur, and humerus, which are long bones. Short bones do not have epiphysis and diaphysis.)

Which is an example of a short bone? a. Tibia b. Femur c. Tarsals d. Humerus

a, b, e (The physiological changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.)

Which physiological changes of the musculoskeletal system would the nurse associate with aging? Select all that apply. One, some, or all responses may be correct. a. Slowed movement b. Cartilage degeneration c. Increased bone density d. Increased range of motion e. Increased bone prominence

c (Pronation is the movement involved in turning the palm downward. Eversion involves turning the sole outward away from the midline of the body. Inversion involves turning the sole inward towards the midline of the body. Supination involves turning the palm upward.)

Which synovial joint movement is involved in turning a client's palm downward? a. Eversion b. Inversion c. Pronation d. Supination

d (White hair appears in a client when a decrease in melanin and melanocytes occurs. Dry, coarse hair occurs when there is a decrease in oils. Thinning and loss of hair are due to decreased hair density. Facial hirsutism is due to decreased levels of estrogens.)

Which changes with a client's hair would be responsible developing white hair at the age of 23? a. Decreased oils b. Decreased density c. Decreased estrogen levels d. Decreased melanocytes

b (The mental changes associated with delirium have a rapid onset and are usually precipitated by an infection or medication change. Clients with dementia may sleep more during the day, and the duration of the disease lasts several years with a progressive deterioration of body systems. Clients with depression may display apathy, but this mental change is not specific to delirium or dementia.)

Which characteristic mental change occurs with delirium and differentiates it from dementia? Select all that apply. One, some, or all responses may be correct. a. Daytime sleepiness b. Rapid-onset confusion c. Lasts over several years d. Progressive deterioration e. Apathetic thought process

a (Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.)

Which information would the nurse consider when planning care for a client with scabies? a. Scabies is highly contagious. b. It is caused by a fungus. c. Chronic with exacerbations are classic symptoms. d. There is a correlation with other allergies.

c, e (Typhoid fever and Rocky Mountain spotted fever are caused by rickettsial infections. Spirochetes and Mycobacterium leprae cause leprosy. Borrelia burgdorferi cause Lyme disease. The West Nile virus causes West Nile fever.)

The nurse would teach clients that which diseases may occur due to rickettsial infections? Select all that apply. One, some, or all responses may be correct. a. Leprosy b. Lyme disease c. Epidemic typhus d. West Nile fever e. Rocky Mountain spotted fever

b (Amphiarthrodial joints are those that permit slight movements. The pelvic joint is an example of amphiarthrodial joint. Knee and elbow joints are the examples of diarthrodial joints, which are freely movable. A cranial joint is an example of a synarthrodial joint, which is immovable.)

When a client injures the amphiarthrodial joint, which joint did the client injure? a. Knee joint b. Pelvic joint c. Elbow joint d. Cranial joint

b (Suppression of bone marrow causes decreased number of red blood cells, white blood cells, and platelets and leads to fatigue, increased infection risk, and increased bleeding risk. The client will need to take actions to prevent infection and injuries that might lead to bleeding. Myelosuppression will not increase calcium and vitamin D needs. Anemia caused by myelosuppression causes fatigue and clients will need increased rest to conserve energy. Although chemotherapy may cause nausea, myelosuppression is not a cause of nausea and vomiting.)

When a client who is receiving chemotherapy develops myelosuppression, which information will the nurse include in client teaching? a. Increase calcium and vitamin D intake. b. Minimize risk for infection and bleeding. c. Exercise frequently to improve energy level. d. Use antiemetics to prevent nausea and vomiting.

d (With an abdominal aortic aneurysm, a pulsating midline mass can be palpated with each heartbeat. Signs of shock such as tachycardia would not be expected unless the aneurysm ruptures or dissects. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not typical for an abdominal aortic aneurysm, but may be seen with enlargement or rupture of the aneurysm.)

When a client with a large abdominal aortic aneurysm is admitted for elective surgery, which clinical finding would the nurse expect when completing the admission assessment? a. Elevated heart rate b. Visible peristaltic waves c. Radiating abdominal pain d. Pulsating abdominal mass

b, c (Flat bones such as the scapula and sternum are compact bones separated by a layer of cancellous bone that contains bone marrow. Bones such as the sacrum and mandible are irregular bones; they appear in a variety of shapes and sizes. The humerus is a long bone with a central shaft and two widened ends.)

Which bones are examples of a client's flat bones? Select all that apply. One, some, or all responses may be correct. a. Sacrum b. Scapula c. Sternum d. Humerus e. Mandible

c (The fiber component of complex carbohydrates helps bind and eliminate dietary cholesterol and fosters growth of intestinal microorganisms to break down bile salts and release the cholesterol component for excretion. It is what the client eats, not the amount at each meal that is important. Proteins need not be decreased in a heart healthy diet. Although no more than 25% to 35% of daily calories should be from fats, monosaturated fats are considered heart healthy.)

Which information would the nurse include when teaching a client about dietary guidelines to reduce heart disease risk? a. Eat small, frequent meals. b. Decrease the amount of proteins. c. Increase complex carbohydrates. d. Avoid monounsaturated fats.

c (Eating smaller meals 5 to 6 times per day reduces the chance of a large amount of food emptying too quickly into the duodenum. Ambulating after meals speeds gastric emptying and should be avoided. A diet low in fat speeds gastric emptying and should be avoided. Clients should avoid increasing fluid intake when eating food, because the fluids speed gastric emptying.)

Which intervention would the nurse teach a client scheduled for a subtotal gastrectomy for stomach cancer to minimize postoperative dumping syndrome? a. Ambulate after every meal. b. Remain on a diet low in fat. c. Eat 5 or 6 small meals per day. d. Increase fluid intake when eating food.

a, b, d (Presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus are signs of varicose veins, due to poor venous return and increased venous pressure. Diminished peripheral pulses occur with decreased arterial blood flow. Intermittent claudication (as evidenced by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion.)

When assessing a client with varicose veins, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. a. Presence of ankle edema b. Increased leg fatigue c. Diminished peripheral pulses d. Report of leg fullness and pruritus e. Leg pain with activity that resolves with rest

a (The definition of osteopenia is bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. Osteomyelitis is infection of bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.)

When teaching a client about their disease process, which term would the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis? a. Osteopenia b. Osteomyelitis c. Osteomalacia d. Osteoarthritis

d (Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.)

Which condition can be identified in a client using Phalen's test? a. Atrophy b. Bone tumor c. Rotator cuff injury d. Carpal tunnel syndrome

c (A hematoma may cause visible swelling due to the extravasation of a sufficient amount of blood. The occurrence of red patches of variable sizes and shapes indicates erythema. The thickening of the skin with accentuated normal skin markings indicates lichenifications. Petechiae are the pinpoint, discrete deposits of blood in the extravascular tissues.)

Which description is associated with a hematoma? a. The occurrence of redness in patches of variable size and shape b. The thickening of the skin with accentuated normal skin markings c. The visible swelling due to extravasation of blood of sufficient size d. The pinpoint, discrete deposits of blood in the extravascular tissues

a, c, e (The fulminant stage of inhalation of anthrax is manifested by dyspnea, diaphoresis, and a high body temperature. The prodromal stage of inhalation of anthrax is manifested by a dry cough and mild chest pain.)

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. One, some, or all responses may be correct. a. Dyspnea b. Dry cough c. Diaphoresis d. Mild chest pain e. High temperature

b (Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.)

A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother? a. If she has ever kissed the baby and how b. If the mother is breast-feeding her baby c. When the baby last received antibiotics d. How long she has been caring for the baby

a (The ache in muscles that have been vigorously worked without adequate oxygen supply is caused in part by the buildup of lactic acid. During rest, the lactic acid is oxidized completely to carbon dioxide and water, providing adenosine triphosphate for further muscular contraction. Beta-hydroxybutyric acid and acetoacetic acid are not products of muscle contraction; they are ketone bodies resulting from incomplete oxidation of fatty acids. Hydrochloric acid is not a product of muscle contraction; it is present in the stomach to facilitate the digestive process.)

A student athlete reports muscle pain after a practice session. Which product of muscle metabolism would the nurse explain as being a cause of pain? Lactic acid Acetoacetic acid Hydrochloric acid Beta-hydroxybutyric acid

c (The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from TB is declining because of improved medication therapy. (Canada: According to the Public Health Agency of Canada, 1607 new active and retreatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.)

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? a. Death from TB is on the increase in older populations. b. The roommate is causing increased anxiety and stress in the client. c. TB adversely affects older adults with chronic illness. d. Most likely, the roommate prevents the client from getting proper sleep.

b (Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.)

On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first? a. Assist the client to ambulate. b. Obtain the client's vital signs. c. Administer the prescribed analgesic. d. Encourage use of the incentive spirometer

c (Because of chronic inflammation, the colon becomes thin and may perforate, causing peritonitis. Perforation will lead to a life-threatening sepsis. Other common complications such as ileus, pain, or obstruction require urgent intervention but are not initially life-threatening. Signs of acute perforation include severe abdominal pain, fever, chills, nausea, and vomiting.)

The nurse is caring for a client with chronic inflammation of the bowel. For which most serious complication would the nurse monitor in this client? a. Ileus b. Pain c. Perforation d. Obstruction

a (When the nurse is unable to palpate pulses, the next action would be to determine whether pulses are audible with a Doppler device. Notification of the health care provider is not immediately necessary because decreased pulse quality is expected in clients with peripheral arterial disease. The catheterization staff will be notified of the absent or decreased pedal pulses after the nurse has ascertained whether pulses are audible with the Doppler. Assessment findings will be documented in the client's record after the nurse has all the data necessary about the presence or absence of pulses with the Doppler)

When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next? a. Check the pulses with a Doppler device. b. Notify the primary health care provider. c. Notify the staff in the catheterization laboratory. d. Document the findings in the client's medical record.

b, c, e, f (Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest pain after rigorous exercise, and continued chest pain after use of nitroglycerin are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical intervention. Dyspnea on vigorous exertion and fatigue the day after a rigorous walk are expected.)

When discharging a client who has had insertion of a coronary artery stent, the nurse will instruct the client to seek immediate medical attention for which signs and symptoms? Select all that apply. One, some, or all responses may be correct. a. Dyspnea with vigorous exertion b. Unexplainable profuse diaphoresis c. Indigestion not relieved by antacids d. Fatigue the day after a rigorous walk e. Acute chest pain after rigorous exercise f. Continued chest pain after nitroglycerin use

d (Inactivity over an extended time increases stiffness and pain in joints. The client typically has morning stiffness, or gel phenomenon. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The pain is not as severe in the evening as in the morning)

When would the nurse expect the client who has rheumatoid arthritis to experience the most joint pain and stiffness? a. After assistive exercise b. When the room is cool c. During the evening hours d. In the morning on awakening

c (Positions for these 6 leads are as follows: V1: fourth intercostal space, right sternal border; V2: fourth intercostal space, left sternal border; V3: halfway between V2 and V4; V4: fifth intercostal space, left midclavicular line; V5: fifth intercostal space, left anterior axillary line; V6: fifth intercostal space, left midaxillary line.)

Where will the nurse place the V1 lead when obtaining a 12-lead electrocardiogram? a. Fifth intercostal space, left midaxillary line b. Second intercostal space, left sternal border c. Fourth intercostal space, right sternal border d. Fifth intercostal space, left midclavicular line

b (Atrophy of the eccrine sweat glands will result in dry skin and decreased body odor. Increased capillary fragility and permeability will result in ecchymosis. Decreased subcutaneous fat, degeneration of elastic fibers, and stiffening of the collagen fibers will result in wrinkles. Decreased subcutaneous fat will result in shearing of the skin.)

Which changes to the client's skin are caused by the atrophy of eccrine sweat glands? a. Ecchymosis b. Dry skin c. Wrinkles d. Skin shearing

d (Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.)

Which sexually transmitted infection causes condylomata acuminate? a. Chlamydia b. Gonorrhea c. Herpes simplex d. Human papillomavirus (HPV)

b (A positive Romberg sign indicates abnormal proprioception; clients with this condition are unable to maintain balance with their eyes closed. A positive Kernig sign and a positive Brudzinski sign indicate meningitis. A positive Babinski sign indicates the presence of central nervous system disease.)

Which sign would the nurse document as being positive after observing that the client sways with eyes closed? a. Kernig b. Romberg c. Babinski d. Brudzinski

a (Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.)

Which type of hepatitis virus spreads through contaminated food and water? a. Hepatitis A virus b. Hepatitis B virus c. Hepatitis C virus d. Hepatitis D virus

b (Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.)

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? a. Surgery b. Comfort c. Education d. Motivation

c (Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Enterococcus faecalis (previously known as Streptococcus faecalis) causes genitourinary tract infections and infection of surgical wounds. Group A streptococcus may cause toxic shock syndrome. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.)

Which bacteria may cause toxic shock syndrome in female clients? a. Treponema pallidum b. Enterococcus faecalis c. Staphylococcus aureus d. Neisseria gonorrhoeae

b (A chalazion is the painless inflammation of a sebaceous gland in the eyelid; a client with chalazion reports light sensitivity and excessive tearing. A hordeolum is an infection of the eyelid sweat glands that leads to painful areas on the skin surface of the eyelid. Entropion is an eyelid disorder in which the client always feels a foreign body in the eyes. Keratoconjunctivitis sicca, or dry eye syndrome, is a condition in which the client may experience a foreign body sensation and burning and itching eyes.)

Which client statement is consistent with the presence of a chalazion? a. "I feel severe pain in my eyes." b. "I am unable to tolerate bright light." c. "I feel something is in my eyes." d. "I am unable to stop scratching at my eyes."

A, B, E (Beef is low in sodium. Broccoli and mushrooms do not have significant sodium levels. Aged cheeses are high in sodium and saturated fat. Luncheon meat is processed and has high sodium levels to help with its preservation.)

Which foods would the nurse recommend for a client who is to begin a 2-g sodium diet? Select all that apply. One, some, or all responses may be correct. A. Beef steaks B. Mushrooms C. Aged cheeses D. Luncheon meats E. Cooked broccoli

b (Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.)

Which term describes the practice of placing clients with the same infection in a semi-private room? a. Isolating b. Cohorting c. Colonizing d. Cross-referencing

d (Type IV hypersensitivity reaction occurs when the sensitized T cytotoxic cells are involved as the mediators of injury, such as a tuberculin test (Mantoux skin test) or contact dermatitis. Type I IgE-mediated reaction will occur when histamine is involved as the mediator of injury. Type II cytotoxic reaction will occur when complement lysis is the mediator of injury. Type III immune complex reaction will occur when neutrophils are involved as the mediators of injury.)

Which type of hypersensitivity reaction occurs when the client's sensitized T cytotoxic cells are involved as the mediators of injury? a. Type I b. Type II c. Type III d. Type IV

b (In foot problems, a callus description is a flat, poorly defined mass on the sole over a bony prominence that is caused by pressure. Plantar wart is a painful papillomatous growth caused by a virus. A sliver of toenail penetrating the skin and causing inflammation results in ingrown nail. A hypertrophic ungual labium is a chronic hypertrophy of the nail lip caused by improper nail trimming.)

When performing a physical assessment on a client, which term would the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence and caused by pressure? a. Plantar wart b. Callus c. Ingrown nail d. Hypertrophic ungual labium

d (Dark brown or black stools (melena) indicate gastrointestinal bleeding and need to be reported. Frothy stools are indicative of inadequate fat absorption and are associated with sprue. Ribbon-shaped stools indicate a bowel mass or obstruction. Clay-colored stools usually are related to problems that cause a decrease in bile.)

A client is diagnosed with a peptic ulcer. The nurse instructs the client to contact the health care provider immediately if the client's stool has which appearance? a. Frothy b. Ribbon-shaped c. Pale or clay-colored d. Dark brown or black

a (Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.)

Which clinical manifestation is associated with cellulitis? a. Lymphadenopathy b. Occasional papules c. Vesicles that evolve into pustules d. Isolated erythematous pustules

d (Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria is caused by decreased renal perfusion associated with left ventricular failure. Pallor is caused by decreased systemic perfusion secondary to left ventricular failure. Cool extremities are a symptom of decreased systemic perfusion associated with left ventricular failure.)

Which finding would the nurse expect when caring for a client with right-sided heart failure? a. Oliguria b. Pallor c. Cool extremities d. Distended neck veins

c (The spleen is normally not palpable, but splenomegaly usually accompanies chronic myelogenous leukemia, leading to a palpable and tender mass in the left upper abdomen. The urinary output is not affected with these conditions. Leukemias increase metabolic rate, leading to weight loss. With leukemia and splenomegaly there is decreased production and increased destruction of erythrocytes, leading to anemia.)

When a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital, which finding will the nurse expect during the assessment? a. Increased urinary output b. Report of recent weight gain c. Left upper quadrant tenderness d. Elevated numbers of erythrocytes

a (Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.)

Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c (Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically. Lice leave excrement and eggs on skin and hair, live in seams of clothing (if body lice) and in hair as nits. A diagnosis of Lyme disease caused by ticks is often based on clinical manifestations, in particular the erythema migrans lesion, and a history of exposure in an endemic area. If the enzyme immunoassays is positive or inconclusive, a Western blot test is done to confirm the infection. The microscopic examination of skin lesions in 10% to 20% potassium hydroxide is a diagnostic measure to determine the presence of a fungus.)

Which organism infestation is diagnosed with the help of the mineral oil test? a. Lice b. Ticks c. Mites d. Fungus

b (Bones are the framework of the body; they support and protect internal organs. They also help in stem cell production from bone marrow, and they store minerals. Joints (articulations) help articulate the bones. Muscles are the bundles of fibrous tissue that contract to produce movement and maintain body posture. Cartilage is a hyaline, elastic, and fibrous tissue that often functions as a shock absorber.)

Which structures protect a client's internal organs, support blood cell production, and store minerals? a. Joints b. Bones c. Muscles d. Cartilages

c ("It is very upsetting to have to wait for a biopsy report," addresses the fact that the client's feelings of anxiety are valid. Stating, "Worrying is not going to help the situation," or "Let's wait until we hear what the biopsy report says," does not address the client's concerns and may inhibit the expression of feelings. Telling the client that operations are not performed unless there are no other options is irrelevant and does not address the client's concerns.)

How would the nurse respond to a client who expresses malignancy fears associated with the pending bone biopsy report? a. "Worrying is not going to help the situation." b. "Let's wait until we hear what the biopsy report says." c. "It is very upsetting to have to wait for a biopsy report." d. "Operations are not performed unless there are no other options."

b (Bile is irritating to the skin; cleansing the area around the T-tube to prevent skin breakdown is a priority. Suction is contraindicated; drainage is via gravity. The T-tube is attached to a bag for straight drainage via gravity, not suction that uses negative pressure. Repositioning the client is vital to prevent venous and pulmonary stasis, not for facilitating the drainage of bile.)

The nurse is providing care for a client who has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action would the nurse take postoperatively? a. Maintain intermittent low suction to limit trauma. b. Cleanse the area around the insertion site to prevent skin breakdown. c. Attach the tube to a negative-pressure drainage system to promote drainage. d. Reposition the client frequently to increase the flow of bile through the tube.

a, b, d, e (Eggs, potatoes, dark green vegetables such as spinach, and dried apricots are high in iron. Carrots are not particularly high in iron. Sliced oranges are not a good source of dietary iron.

Which dietary choices by a client with iron deficiency anemia indicate that the nurse's dietary teaching has been effective? Select all that apply. One, some, or all responses may be correct. a. Scrambled eggs b. Baked potato c. Steamed carrots d. Spinach salad e. Dried apricots d. Sliced orange

d (According to the common scale for grading muscle strength, a client who can complete range of motion with some resistance is given the rating 4. Rating 1 is given to a client with no joint motion and slight evidence of muscle contractility. Rating 2 is given to a client who can complete range of motion with gravity eliminated. Rating 3 is given to a client who can complete range of motion against gravity.)

Which muscle-strength rating would the nurse record for a client who can complete range of motion with some resistance? a. 1 b. 2 c. 3 d. 4

a (A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client's dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.)

Which statement would the nurse include in the teaching plan of a client anticipating discharge with acquired immunodeficiency syndrome (AIDS)? a. "Wash used dishes in hot, soapy water." b. "Let dishes soak in hot water for 24 hours before washing." c. "You should boil the client's dishes for 30 minutes after use." d. "Have the client eat from paper plates so they can be discarded."

d (Abduction is a synovial joint movement that involves movement of a part away from the midline of the body. Inversion is turning of the sole inward toward the midline of the body. Pronation is a synovial joint movement that involves the turning of the palm downward. Extension is a synovial joint movement that involves a straightening of joint that increases the angle between two bones.)

Which term describes synovial joint movement away from the midline of the body? a. Inversion b. Extension c. Pronation d. Abduction

c (A BMI between 25 and 29.9 kg/m2 places the client in the overweight category. A BMI of 30 kg/m2 is considered obese. A normal BMI is between 18.5 kg/m2 and 24.9 kg/m2. A BMI below 18.5 kg/m2 is considered underweight.)

The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m2? a. Obese b. Normal c. Overweight d. Underweight

c (Bence Jones protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma. Occult blood in the stool is not specific for the diagnosis of multiple myeloma; it is a late complication of multiple myeloma related to coagulation defects. Hypercalcemia, not hypocalcemia, occurs with multiple myeloma because of bone erosion. Multiple myeloma is not caused by a bacterial infection.)

When caring for a client with multiple myeloma, which diagnostic test result will the nurse expect? a. Occult blood in the stool b. Low serum calcium levels c. Bence Jones protein in the urine d. Positive bacterial culture of sputum

b (Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.)

Which surgery is used to treat excessive wrinkling or sagging of facial skin a. Rhinoplasty b. Rhytidectomy c. Dermabrasion d. Blepharoplasty

a (Arthroscopy is a diagnostic test that uses an arthroscope to directly visualize the ligaments, menisci, and articular surfaces of a joint. A muscle biopsy is conducted to diagnose atrophy and inflammation. An ultrasonography is used to view soft tissue disorders, traumatic joint injuries, and osteomyelitis. An electromyography may be performed to evaluate diffuse or localized muscle weakness.)

Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints? a. Arthroscopy b. Muscle biopsy c. Ultrasonography d. Electromyography

b (Cranial nerve VI (abducens) helps eye movement with the lateral rectus muscles. Cranial nerve III (oculomotor) helps in the lid elevation with the levator muscle. Cranial nerve III (oculomotor) helps in the eye movement with medial rectus muscles. Cranial nerve IV (trochlear) helps in eye movement with the superior oblique muscles)

Which eye muscle is controlled by cranial nerve VI? a. Levator b. Lateral rectus c. Medial rectus d. Superior oblique

a (The gray color of the tongue and lips is due to cyanosis. A yellow color to the oral mucous membranes is due to jaundice. If the affected area of the body shows swelling and darkening of the skin when compared with an unaffected area, then it is due to skin bleeding. When the affected area is warm, and the skin color is changed, it is inflammation.)

A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? a. Cyanosis b. Jaundice c. Bleeding d. Inflammation

a (Because 1 liter of fluid weighs approximately 2.2 pounds (1 kg), daily weights are the best way to monitor fluid volume status. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client. Subjective symptoms such as dyspnea may vary for other reasons than fluid balance status.)

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? a. Weighing the client b. Monitoring the intake and output c. Assessing the extent of pitting edema d. Asking the client about subjective symptoms

b (Osteomyelitis is infection of bone or bone marrow. Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency. Herniated disc is caused by structural damage of the intervertebral discs in which the nucleus pulposus seeps through a torn or stretched annulus. Spinal stenosis is narrowing of the spinal canal.)

Which condition is characterized by infection of a client's bone or bone marrow? a. Osteomalacia b. Osteomyelitis c. Herniated disc d. Spinal stenosis

d (RA is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.)

Which type of hypersensitivity reaction would the nurse teach a client with rheumatoid arthritis (RA)? a. Delayed b. Cytotoxic c. Immunoglobulin E (IgE)-mediated d. Immune complex

b (Bed rest in the right side-lying position for 2 hours after the procedure applies pressure to the insertion site and reduces the risk of bleeding. A needle biopsy requires a puncture wound over the liver, not an abdominal incision. A liver biopsy is done with local anesthesia. The supine position is contraindicated. The client should be positioned in the right side-lying position for 2 hours after the procedure; this applies pressure to the insertion site and reduces the risk of bleeding.)

A client is admitted to the hospital for a needle biopsy of the liver. A diagnosis of liver cancer is suspected. Which would the nurse include in the client's preoperative teaching plan? a. A midline abdominal incision will be used. b. Bed rest must be maintained after the procedure. c. General anesthesia will be used during the biopsy. d. A supine position will be maintained after the procedure.

a (Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that decrease the friction between moving parts. Olecranon bursae are found between the olecranon process of the elbow and the skin. Prepatellar bursae are found between the patella and the skin. Subacromial bursae are found between the head of the humerus and the acromion process of the scapula. Trochanteric bursae are found between the greater trochanter of the proximal femur and the skin.)

Which bursae are between the client's elbow and the skin? a. Olecranon b. Prepatellar c. Subacromial d. Trochanteric

b (SIADH is manifested in the form of retention of free water. This is because of excessive secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus. Generally, pedal (dependent) edema is not seen in SIADH despite the water retention.)

Which finding in a client who has syndrome of inappropriate antidiuretic hormone (SIADH) is an expected finding? a. Preservation of salt b. Retention of water c. Decrease of vasopressin d. Presence of pedal edema

a (Loss of height and deformity and shortening of the trunk are common in older adults because of vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age because of loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult because of slow impulse conduction along motor units. Range of motion (ROM) is limited in the older adult because of cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.)

Which finding in older adult clients is associated with aging? a. Decrease in height b. Decreased neck rigidity c. Increased fine-motor dexterity d. Increased range of motion (ROM)

a (Clients with early-onset AD may forget their home address or be unable to navigate themselves home. Information overload can cause clients to struggle with multitasking, but it is not indicative of AD. Being unable to locate food in the freezer could indicate that the client is experiencing disorganization, but this is not a specific indicator of AD. Neglecting to balance one's checkbook is a fairly common oversight and does not suggest that the client has AD. Wearing pajama bottoms to run a quick errand is common and does not suggest AD.)

Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer disease (AD)? Select all that apply. One, some, or all responses may be correct. a. Forgets home address b. Has difficulty multitasking c. Unable to find food in freezer d. Neglects balancing checkbook e. Wears pajama bottoms to store

d (The sacroiliac joint connects the sacrum with the pelvis. It is a type of gliding joint, because one surface of the bone moves over another surface. The wrist joint is an example of a condyloid joint. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball-and-socket joint.)

Which joint is an example of a gliding joint? a. Wrist b. Elbow c. Shoulder d. Sacroiliac

a (With a nasogastric (NG) tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking its placement can determine whether it is in the stomach; once placement is verified, fluid then can be instilled to ensure patency. The antiemetic may relieve the discomfort, but it will not determine the cause. Auscultation of the client's abdomen should occur with the nurse's other assessments, but it will not help determine the cause of the nausea. The nurse should assess the situation before notifying the health care provider.)

After abdominal surgery, a client's postoperative prescriptions include a nasogastric (NG) tube to lower intermittent wall suction and an antiemetic every 6 hours as needed for nausea. When the client reports feeling nauseated, which action would the nurse take first? a. Check for correct placement of the NG tube. b. Administer the prescribed antiemetic. c. Assess the client's bowel sounds. d. Notify the primary health care provider

b (Keeping the irrigating container 18 to 24 inches (46-61 cm) above the stoma permits the solution to flow slowly with little force so that excessive peristalsis is not precipitated immediately. The client may assume any comfortable position and may sit on a chair in front of the toilet or on the toilet or commode. The amount of solution necessary for bowel evacuation is individualized, but generally, 1000 mL is the maximum used. If cramping occurs, the flow should be stopped until cramping subsides.)

The nurse begins to teach a client how to perform a colostomy irrigation. The nurse knows that the instructions have been understood when the client makes which statement? a. "I should lie on my left side while instilling the irrigating solution." b. "I should keep the irrigating container 18 to 24 inches (46-61 cm) above the stoma." c. "I should instill a minimum of 1200 mL of irrigating solution to stimulate evacuation of the bowel." d. "I should insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure."

c (Bearing down stimulates a vagal nerve response that results in a decrease in heart rate and blood pressure leading to syncope (loss of consciousness). Blood flow to hemorrhoids is not the cause of syncope. Bearing down decreases the heart rate through a vagal response, not ischemic disease leading to myocardial infarction (heart attack). Straining, not dehydration, is a direct cause of vagal stimulation.)

When a client with syncope from a vagal response asks why it is important to avoid bearing down during a bowel movement, which response by the nurse is correct? a. "Straining can decrease blood flow to your brain because it is filling hemorrhoids." b. "Trouble moving your bowels is stressing your heart and may lead to a heart attack." c. "Bearing down stimulates a nerve response that decreases your heart rate and blood pressure." d. "Difficulty with a bowel movement means you are dehydrated, which causes low blood pressure."

b (Rough and thick skin may indicate chronic eczema. Localized edema is associated with trauma or inflammation. A decrease in skin turgor may indicate severe dehydration. An increase in skin temperature may be a sign of fever.)

Which assessment finding is associated with chronic eczema? a. Localized edema b. Rough, thick skin c. Decreased skin turgor d. Increased skin temperature

c (Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.)

Which hormone aids in regulating intestinal calcium and phosphorous absorption? a. Insulin b. Thyroxine c. Glucocorticoids d. Parathyroid hormone

a (Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is more common in a client infected with acquired immunodeficiency syndrome (AIDS). It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.)

Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? a. Oropharyngeal candidiasis b. Cryptosporidiosis c. Toxoplasmosis encephalitis d. Pneumocystis jiroveci pneumonia

d (Decreasing blood pressure postoperatively may indicate hemorrhage and requires prompt interventions such as increasing fluid infusions, transfusion, or return to the operating room. Attempting to push out the airway is an indication that the client may be able to breathe independently, a normal response after general anesthesia. Clients who have had general anesthesia are unresponsive to verbal stimulation until they start to recover from the effects of general anesthesia. A respiratory rate of 16 breaths/minute is within the normal range.)

When caring for a client who is in the postanesthesia care unit after receiving general anesthesia, which assessment finding would be most important for the nurse to report to the health care provider? a. Attempting to push the airway out b. Unresponsive to verbal stimulation c. Respirations at 16 breaths/minute and unlabored d. Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg

b (The nurse would instruct the client who is recovering after surgical removal of the pituitary gland to consume high-fiber food. Intracranial pressure is raised if the client strains during defecation. Fibrous foods reduce the risk of constipation and thereby reduce bowel strain. The client would be instructed to drink sufficient water to facilitate easy bowel movements and soften the stools. The nurse would teach the client to bend the knees and then lower the body to pick up fallen objects; bending at the waist increases intracranial pressure. The client would use dental floss and avoid brushing postoperatively for at least 2 weeks to prevent disturbance of the operative site.)

Which instruction given by the nurse promotes healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach? a. "Decrease fluid intake." b. "Increase high-fiber food intake." c. "Bend over from the waist to pick up fallen objects." d. "Brush teeth regularly with a medium-bristle brush."

d (The client is experiencing an allergic reaction to the transfusion. The nurse would stop the transfusion immediately. The health care provider then should be notified. An antihistamine may be indicated but must be prescribed. Flushing red blood cells with dextrose will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate but continuing the infusion will make the situation worse.)

Several minutes after the start of a red blood cell infusion, the client reports itching. The nurse observes hives on the client's chest. Which action would the nurse take? a. Administer an antihistamine. b. Flush the red blood cells with 5% dextrose. c. Slow the rate of infusion. d. Stop the transfusion.

c (Duplex venous Doppler records an ultrasound of the veins, including blood flow abnormalities of the lower extremities, aiding detection of deep vein thrombosis. Thermography, which measures the heat radiating from the skin surface, is used to determine client response to anti-inflammatory medication therapy and inflamed joints. Plethysmography is used to record variations in volume and pressure of blood passing through tissues; the test is nonspecific. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease.)

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? a. Thermography b. Plethysmography c. Duplex venous Doppler d. Somatosensory evoked potential

A (The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.)

Which feature is associated with the "maturation phase" of normal wound healing? a. The scar is firm and inelastic on palpation. b. Fibrin strands form a scaffold or framework. c. White blood cells migrate into the wound. d. Epithelial cells are grown over the granulation tissue bed

d (The ESR measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. An elevated ESR (20 mm/hr) indicates inflammation or infection somewhere in the body. The ESR is chronically elevated with inflammatory arthritis. Leukocytes will be elevated when a bacterial infection is present. Hemoglobin and hematocrit are not used to determine the presence of inflammation. Blood urea nitrogen and creatinine levels are used to determine renal function.)

Which laboratory test will be elevated in a client with inflammatory arthritis? a. Leukocyte count b. Hemoglobin and hematocrit c. Blood urea nitrogen and creatinine d. Erythrocyte sedimentation rate (ESR)

a (Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of-motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not during, a procedure.)

Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? a. Deep breathing exercises b. Progressive muscle relaxation c. Active range-of-motion exercises d. Important elements of wound care

d (There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.)

Which relationship between a client's burned body surface area and fluid loss would the nurse consider when evaluating fluid loss in a client with burns? a. Equal b. Unrelated c. Inversely related d. Directly proportional

b (Eversion is a synovial joint movement that describes turning the sole outward away from the midline of the body. Pronation is a synovial joint movement that describes turning the palm downward. Adduction is a synovial joint movement that describes movement toward midline of the body. Supination is a synovial joint movement that describes turning the palm upward.)

Which synovial joint movement is described as turning the sole away from the midline of the body? a. Pronation b. Eversion c. Adduction d. Supination

b (A hip spica cast is now mainly used for femur fractures in children. A cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle. A prefabricated knee splint is a commonly used cast for lower extremity injuries. A Robert Jones dressing is composed of bulky padding materials, splints, and elastic wrap or stockinette used for lower extremity injuries.)

Which type of cast or splint will the nurse expect to see on a child with a fractured femur? a. Cylinder b. Hip spica c. Prefabricated knee d. Robert Jones

c (According to exchange lists for meal planning, green beans and broccoli are equivalent vegetable substitutes. Peas, corn, and mashed potatoes are all starches and are not equivalent vegetable substitutes for broccoli.)

While the nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food would the nurse suggest to substitute for broccoli? a. Peas b. Corn c. Green beans d. Mashed potatoes

a (Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocytelike precursor cells. Psoriasis is an autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells. Acne vulgaris is an inflammatory disorder of sebaceous glands. Plantar warts are formed due to a viral infection. Plantar warts appear on the bottom surface of the feet and grow inward because of pressure.)

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocytelike precursor cells? a. Nevi b. Psoriasis c. Acne vulgaris d. Plantar warts

a, b, d (The heart rate increases (tachycardia) and the respiratory rate increases (tachypnea, not bradypnea) in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/h because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.)

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct. a. Tachycardia b. Restlessness c. Warm, moist skin d. Decreased urinary output e. Bradypnea

a (A wound caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.)

Which color would the nurse anticipate when assessing a client's skin tears? a. Red b. Gray c. Black d. Yellow

a (Vitiligo is the abnormal condition in which chalky white patches appear on the skin. This is due to a complete absence of melanin. Jaundice is an abnormal condition in which the skin appears yellow or yellow-brownish in color due to increased bilirubin in the blood. Cyanosis is the condition in which the skin is slightly bluish or purple in color due to excessive or reduced hemoglobin in the capillaries. Erythema is the condition in which red-colored patches appear on the skin in variable sizes and shapes.)

Which condition presents as chalk white patches on the skin? a. Vitiligo b. Jaundice c. Cyanosis d. Erythema

b, c, d (Atopic diseases, bacterial infections, and anaphylactic shock are disease conditions that trigger humoral immunity. Tuberculosis and contact dermatitis result in cell-mediated immunity.)

Which conditions trigger humoral immunity? Select all that apply. One, some, or all responses may be correct. a. Tuberculosis b. Atopic diseases c. Bacterial infection d. Anaphylactic shock e. Contact dermatitis

d (There is no special diet for arthritis. A balanced diet, consisting of foods from all groups of the MyPlate dietary guidelines, is essential in maintaining nutrition. Limiting the diet to particular foods does not provide all the essential nutrients. If nutritional intake is adequate, large doses of multivitamins are unnecessary and are dangerous.)

Which daily diet recommendation would the nurse reinforce with a client who has arthritis? a. Wheat germ and yeast b. Yogurt and blackstrap molasses c. Multiple vitamin supplements in large doses d. Foods from a variety of food groups

b (The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge. People should not be pressured into performing self-care before they are physically and emotionally ready. The diet is not limited; however, the client should be encouraged to eat a high-protein diet or a regular diet with supplemental protein. A high-fluid intake should be maintained. Often, the client no longer needs a dressing on the incision at the time of discharge; a collection pouch is used over the stoma.)

A client has surgery for creation of an ileostomy. Before the client's discharge, which is a primary nursing intervention? a. Emphasizing that it is essential that the client can care for the ileostomy without assistance b. Evaluating the client's ability to care for the ileostomy c. Ensuring that the client understands the dietary limitations that must be followed d. Ensuring that the client is competent at changing the dry, sterile dressing on the incision

d (Lotions and powders can cause a skin reaction on irradiated areas and should be avoided. Gauze and tape may irritate the skin further and should be avoided. Warm compresses are contraindicated because they may precipitate skin breakdown. The client can assume a position of comfort.)

Which information about skin care would the nurse include in the teaching plan for a client who is receiving radiation therapy? a. "Cover the area with a sterile gauze bandage." b. "Put warm compresses on the site once a day." c. "Limit lying on the back and unaffected side when sleeping." d. "Avoid applying lotions and powders over the area."

c (Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs. The semi-Fowler position is more appropriate, and it promotes respiration.)

A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a nursing priority when caring for this client? a. Correcting nutritional deficiencies b. Measuring abdominal girth every day c. Providing for the client's physical safety d. Placing the client in the high-Fowler position

d (The response, "Let's talk about your concerns regarding the procedure," attempts to explore why the client is refusing the procedure and promotes communication. The response, "Then you shouldn't have signed the consent," is accusatory; the client has the right to withdraw consent at any time. The response, "I can understand why you changed your mind," draws a conclusion without adequate data; also, the statement may increase the client's anxiety level. The response, "Tell me why you decided to refuse the operation," may be too direct and authoritative; also the statement may put the client on the defensive.)

After signing a legal consent for hip replacement surgery and within hours before the surgery, the client states, "I decided not to go through with the surgery." Which response would the nurse use initially? a. "Then you shouldn't have signed the consent." b. "I can understand why you changed your mind." c. "Tell me why you decided to refuse the operation." d. "Let's talk about your concerns regarding the procedure."

D (Because sclerotherapy causes inflammation of the affected vein, swelling is expected and not a reason to return to the clinic. No general anesthesia is used for sclerotherapy, so clients may eat and drink normally. Ongoing use of compression stockings is recommended to prevent more varicosities from developing. There is usually minimal pain after sclerotherapy and mild analgesics such as acetaminophen or ibuprofen are adequate for pain control.)

After the nurse has completed teaching about sclerotherapy for a client with varicose veins, which client statement indicates that more teaching is needed? A. "I can eat and drink normally in the hours before the procedure." B. "I will still need to wear compression stockings after the procedure." C. "I can plan to take acetaminophen or ibuprofen for pain after the procedure." D. "I should return to the clinic immediately if there is any swelling at the procedure site."

b (These symptoms are associated with compromised arterial perfusion. An embolus of plaque and damage to the femoral artery wall are possible complications of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment would be conducted before notifying the primary health care provider, who will need to know whether pedal pulses are present. Taking the client's blood pressure and pulse is unnecessary, because the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. The nurse may need to teach the client about what is causing the symptoms after the diagnosis is made.)

Two hours after a cardiac catheterization that was accessed through the right femoral route, a client reports numbness and pain in the right foot. Which action will the nurse take first? a. Call the primary health care provider. b. Check the client's pedal pulses bilaterally. c. Take the client's blood pressure and pulse. d. Teach about postcatheterization embolus

b (Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.)

Which cytokine stimulates the liver to produce fibrinogen and protein C? a. Interleukin-1 b. Interleukin-6 c. Thrombopoietin d. Tumor necrosis factor

d (A client with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis. Elevating the client's foot on pillows can reduce the risk of edema. Asking the client with osteomyelitis to flex the affected extremity can result in flexion contracture. Encouraging the client with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; carefully handle the involved limb and avoid excessive manipulation, which may lead to a pathological fracture.)

Which nursing intervention prevents footdrop in a client with osteomyelitis? a. Elevating the foot with the use of pillows b. Consistently flexing the affected extremity c. Encouraging the client to change positions d. Neutral positioning of the foot with the use of a splint

a (Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. Spastic paralysis of both the upper and lower extremities is associated with an upper motor neuron disease or lesion. Hyperflexion of the upper extremities and hyperextension of the lower extremities is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities is associated with a lower motor neuron disease or lesion.)

A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. Which positioning behaviors would the nurse expect to observe? a. Hyperextension of both the upper and lower extremities b. Spastic paralysis of both the upper and lower extremities c. Hyperflexion of the upper extremities and hyperextension of the lower extremities d. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

c (When there is a fluid volume deficit, fluid moves from the intracellular and interstitial compartments to the intravascular compartment in an attempt to maintain blood volume. Cellular dehydration is manifested by poor (inelastic) tissue turgor, which is assessed by the rapidity with which skin returns to its original position after being pinched. Lethargy and fatigue, not restlessness, are expected with dehydration. With an intestinal obstruction, there is an absence of bowel movements; constipation is not a good indicator of dehydration in this situation. Hypotension, not hypertension, is associated with hypovolemia.)

A client develops an intestinal obstruction. A nasogastric tube is inserted and connected to low, continuous suction. The nurse monitors the client for fluid volume deficit. Which clinical finding would the nurse expect if the client becomes dehydrated? a. Restlessness b. Constipation c. Inelastic skin turgor d. Increased blood pressure

a (The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement. The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss. Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease. The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations.)

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, in which part of the brain would the nurse suspect the tumor is located? a. Cerebellum b. Parietal lobe c. Basal ganglia d. Occipital lobe

b (The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be concerned, your medication can be increased" negates the client's feelings and discourages communication.)

A client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which response would the nurse make? a. "Did you forget to take your medication?" b. "You are worried about having more seizures?" c. "You must be under a lot of stress right now." d. "Don't be concerned; your medication can be increased."

b (Positioning the client in the prone position for short periods helps prevent hip flexion contractures. Do not immobilize the client's residual limb, but do not keep the joint bent for prolonged periods. Begin exercises to prevent contractures as soon as possible. Positioning the client in the right side-lying position can cause trauma to the incision site and should be avoided. Do not elevate the client's residual limb for more than 48 hours because hip flexion contractures can result.)

A client returns from surgery, after a right below-the-knee amputation, with the residual limb straight, but elevated on a pillow to prevent edema. In which position would the nurse place the client after the first postoperative day? a. Any position, as long as the residual limb remains immobilized b. Turn client to the prone position for 15 to 20 minutes at least three times a day c. For short periods, position the client in the right side-lying position d. Maintain elevation of the residual limb for a total of 3 days

b (Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is the first, priority assessment. Venous access facilitates administration of parenteral medications and fluids that may be urgently needed, but it is not the first action. Removing the client's clothing should be done after the client's respiratory status is evaluated. Determining the extent of the burns, using the rule of nines, should be done after the client's respiratory status is evaluated.)

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? a. Remove the client's clothing. b. Evaluate whether the client has inhaled smoke. c. Insert a venous access device in an unaffected arm. d. Determine the extent of the burns, using the rule of nines.

a (Tinea pedis is a fungal infection with an itching sensation associated with pain. It is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering. Tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area. Tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.)

A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. The nurse would expect to teach the client about which condition? a. Tinea pedis b. Tinea cruris c. Tinea corporis d. Tinea unguium

d (Generally, upper respiratory infections are viral; therefore antibiotics would not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.)

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. Which response from the nurse would be the best? a. "I don't know; however, I will ask your health care provider for a prescription as soon as possible." b. "Antibiotics are used to treat viruses, and your cultures indicate the presence of a bacterial infection." c. "Antibiotics are ineffective for treating the bacteria that caused your upper respiratory infections." d. "Upper respiratory infections are generally caused by viruses and would not be treated with antibiotics."

a (Arterial blood flow is improved with exercise by fostering the development of collateral circulation. Meticulous care of minor skin breakdown is important for the person with diabetes, but it does not improve arterial blood flow. Elevating the legs above the heart reduces arterial blood flow; the legs should be kept dependent to facilitate tissue perfusion. Soaking the feet in hot water is contraindicated because it can burn the skin or cause drying; also, individuals with diabetes may have neuropathies, which alter the perception of temperature.)

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). Which measures would the nurse include to increase arterial blood flow to the extremities? a. Exercises that promote muscular activity b. Meticulous care of minor skin breakdown c. Elevation of the legs above the level of the heart d. Soaking the feet in hot water each day

b (Maintaining the sitting position for a prolonged period places excessive stress on the surgical area. Sleeping on a firm mattress to support the back maintains appropriate lordosis of the small of the back and provides support. Putting a pillow under the legs when sleeping on one's back relieves pressure on the back and promotes comfort in bed. Avoiding lifting heavy objects until the health care provider's approval prevents excessive pressure on the musculature and vertebral column.)

The nurse is preparing a client for discharge after a laminectomy. Which client statement indicates a need for additional instruction? a. "I should sleep on a firm mattress to support my back." b. "I should spend most of the day sitting in a straight-back chair." c. "I should put a pillow under my legs when sleeping on my back." d. "I should avoid lifting heavy objects until instructed by the health care provider."

b (A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given. There is no indication that a red blood cell count is needed; however, a white blood cell count would be beneficial. A urinalysis is not needed, because data gathered during the assessment indicate an incisional infection. At the early stage of the infection, there is no need to obtain a knee x-ray.)

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics? a. Red blood cell count b. Wound culture c. Knee x-ray d. Urinalysis

c (Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary health care provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.)

The nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. Which action would the nurse take in response to the client's comment? a. Tell the client to take a friend along for safety. b. Encourage participation in this activity, because it provides excellent range-of-motion exercise. c. Explain that the incision should not be immersed in water until it has healed. d. Let the client know that swimming can substitute for the prescribed physical therapy.

a (The initial action by the nurse would be assessment of the resources that the client is currently using or has available. A home health referral may be needed, but more information about the client's current resources is needed before asking the health care provider for a referral. Short-term placement in a long-term care facility is helpful for many clients to transition from hospital to home, but there is not enough information to determine whether this is a good option for this client. An assisted living facility is appropriate for many clients, but more assessment data are needed to decide whether this client would benefit from an assisted living facility.)

When a client with heart failure is to be discharged and tells the nurse that there are no family members who can help with care at home, which action would the nurse take first? a. Question the client about current support systems. b. Ask the health care provider for a home health referral. c. Suggest short-term placement in a long-term care facility. d. Recommend that the client consider an assisted living facility.

b (Avoiding caffeine and alcohol will prevent development of dry skin. Wearing splints will prevent damage to dry skin caused by scratching during deep sleep due to pruritus. Higher temperatures lead to increased perspiration and itching. Keeping the client's environment cooler will decrease the itching. Use of deodorant soap will make the skin dry, further, so the nurse needs to follow up to correct this misconception. Clients should avoid deodorant soap when experiencing dry skin.)

When teaching a client self-care measures to prevent dry skin, which client statement indicates misunderstanding of the content? a. "I will decrease intake of caffeine and alcohol." b. "I will use deodorant soap in place of alkaline soap." c. "I will wear splints at night to prevent scratching in a deep sleep." d. "I will adjust my thermostat to remain around 74°F to 78°F (23.3°C-25.5°C)."

a (Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis; these foods do not contain vitamin D unless fortified. If large amounts of magnesium are present, calcium absorption is impeded because magnesium and calcium absorption are competitive; vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.)

Which action by a 70-year-old female client would best limit further progression of osteoporosis? a. Taking supplemental calcium and vitamin D b. Increasing the consumption of eggs and cheese c. Taking supplemental magnesium and vitamin E d. Increasing the consumption of milk products

a (The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact or discouraging long visits from family members will unnecessarily isolate the client.)

Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? a. Use standard precautions. b. Employ airborne precautions. c. Plan interventions to limit direct contact. d. Discourage long visits from family members

b (Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Assessing lung sounds and performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the health care provider to the problem is necessary, but only after client safety is ensured)

Which action would the nurse take first for a client with myasthenia gravis who is experiencing increased dysphagia? a. Assess lung sounds. b. Raise the head of the bed. c. Perform tracheal suctioning. d. Call the health care provider

c (Muscles used for swallowing are innervated by the ninth (glossopharyngeal) and tenth (vagus) cranial nerves. Dyspnea is unrelated to cranial nerves; this is associated with neck edema and potential compromise of the airway. Edema of the neck will not influence the cranial nerves; some edema is expected because of the inflammatory process at the site of surgery. Alterations in blood pressure may occur but are not caused by cranial nerve dysfunction.)

Which assessment finding is associated with cranial nerve dysfunction after carotid endarterectomy? a. Labored breathing b. Edema of the neck c. Difficulty in swallowing d. Alteration in blood pressure

c (Punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.)

Which characteristic does the nurse associate with a punch biopsy? a. It is usually indicated for superficial or raised lesions. b. It is more uncomfortable than other biopsies while healing. c. It is performed using a circular cutting instrument 2 to 6 mm in diameter. d. It removes only the portion of the skin that rises above the surrounding tissue

c (In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In medication eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.)

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? a. Medication eruption b. Atopic dermatitis c. Contact dermatitis d. Nonspecific eczematous dermatitis

c (Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.)

Which criteria would the nurse consider when determining if an infection is a health care-associated infection? a. Originated primarily from an exogenous source b. Is associated with a medication-resistant microorganism c. Occurred in conjunction with treatment for an illness d. Still has the infection despite completing the prescribed therapy

d (AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+ T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.)

Which diagnostic criterion should the nurse use to explain acquired immunodeficiency syndrome (AIDS) to a client with immunodeficiency virus (HIV)? a. Contracts HIV-specific antibodies b. Develops an acute retroviral syndrome c. Is capable of transmitting the virus to others d. Has a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%)

c (Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Health care providers use this method to investigate the cause of an inflamed joint and in determining the client's response to anti-inflammatory medication therapy. Use of plethysmography is to record variations in volume and pressure of blood passing through tissues. Duplex venous Doppler records blood flow abnormalities to the lower extremities, which helps detect deep vein thrombosis. Somatosensory evoked potential use identifies subtle dysfunction of lower motor neuron and primary muscle disease.)

Which diagnostic study would the health care provider use to investigate the cause of an inflamed joint and determine a client's response to anti-inflammatory medication therapy? a. Duplex venous Doppler b. Plethysmography c. Thermography d. Somatosensory evoked potential

b (Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with a well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested as scaliness under the distal nail plate.)

Which fungal infection does the client refer to as jock itch? a. Tinea pedis b. Tinea cruris c. Tinea corporis d. Tinea unguium

c (To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.)

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. a. Switch positions every 4 hours. b. Use a heating pad for the first 24 hours. c. Apply for 30-minute time intervals. d. Place the ice pack directly to injury site. e. Take ibuprofen every 4 hours PRN.

b (Elevation of the residual limb helps prevent edema; however, slight elevation during the first 24 hours as continued elevation may lead to hip contractures. The knee joint is kept extended, not flexed during this time. The client usually is out of bed on the second postoperative day. Hemorrhage and infection are the two most common complications. The dressing usually is a pressure dressing, and the surgeon does not change the pressure dressing this soon postoperatively. Sometimes the pressure dressing has a cast in place to shape the residual leg for a prosthesis.)

Which nursing interventions would the nurse implement when providing postoperative care for a client who had a below-the-knee amputation? a. Maintain strict bed rest for 2 days postprocedure to reduce dependent edema b. Elevate residual leg slightly while keeping the knee joint straight for first 24 hours. c. Hemorrhage rarely occurs during the early postoperative period. d. The surgeon will change the dressing within 48 hours after the procedure

a, e (In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.)

Which statement is correct regarding negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct. a. A suction pump is used. b. Necrotizing infections are treated. c. Oxygen is administered under high pressure. d. A low-voltage current is applied to a wound area. e. Chronic ulcers are reduced by removing fluids from the wound.

d (A ligament is a dense, fibrous connective tissue that connects bone to bone, such as the tibia to the femur at the knee joint. Ligaments provide stability while permitting controlled movement at the joint. Fascia is a connective tissue that can withstand limited stretching; it provides strength to muscle tissues. Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that are located at bony prominences and joints to relieve pressure. A tendon is a dense, fibrous connective tissue that attaches muscle to bone.)

Which tissue connects the client's tibia to the femur at the knee joint? a. Fascia b. Bursae c. Tendons d. Ligaments

C (Asking if the client is concerned about dying is reflective and encourages further communication. A statement that the surgeon is experienced may be true, but is not specific to the client's statement and cuts off further communication. Telling the client that other people generally do well is nonspecific and provides false reassurance that is unlikely to decrease anxiety. Asking about whether the client would like sleep medication evades the client's concerns and cuts off more communication about the client's concerns.)

A 50-year-old client who has aortic stenosis and is scheduled for a valve replacement tells the nurse, "I gave my spouse all my financial records in case I don't make it." Which response by the nurse is best? A. "Your surgeon is very experienced." B. "People your age generally do very well." C. "Are you concerned that you may die during surgery?" D. "Would you like medication to help you sleep at night?"

b (Aging causes a lowering of the physiological coping reserve of various systems of the body. The pain threshold increases with aging. There are many etiologies for confusion (e.g., medication intolerance, altered metabolic state, unfamiliar surroundings). As individuals age they become more entrenched in ideas, environment, and objects that are familiar, and thus do not tolerate change well.)

A 90-year-old resident fell and fractured the proximal end of the right femur. The surgeon plans to reduce the fracture with an internal fixation device. Which general fact about the older adult would the nurse consider when caring for this client? a. Aging causes a lower pain threshold. b. Aging reduces the physiological coping defenses. c. Most confused states result from dementia. d. Older adults psychologically tolerate changes well.

b (In the antigen-antibody response, once the B cell is sensitized, it divides and forms a plasma cell, which produces antibodies against the sensitizing antigen. Inactivation or neutralization is the process of making an antigen harmless without destroying it. Memory cells produce antibodies after the next exposure to an antigen that is recognized by the body. Agglutination is the clumping of antigens linked with antibodies, forming immune complexes.)

Identify the role of plasma cells in the antigen-antibody response. a. Makes an antigen harmless without destroying it b. Produces antibodies against the sensitizing antigen c. Produces antibodies after an exposure to a known antigen d. Clumps antibody-antigens linkages together to form immune complexes

c (Shark cartilage is considered as an alternative or complementary therapy to prescribed medications for clients with HIV and AIDS. Lymphocyte transfusions and bone marrow transplants are used to improve immunity in clients with HIV and AIDS. Lemon juice and lemongrass may provide relief from oral thrush in some clients with HIV and AIDS. A high-calorie, high-protein diet is advised to clients with HIV and AIDS to improve their nutritional status.)

In the management of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), which role does shark cartilage play? a. Shark cartilage enhances immunity. b. Shark cartilage reduces oral thrush. c. Shark cartilage is a complementary therapy. d. Shark cartilage is a nutritional supplement.

a (Malaria is caused by the protozoan Plasmodium falciparum, which is carried by the female Anopheles mosquitoes. Avoiding untreated water, undercooked food, and overpopulated areas will not prevent protozoa from entering the bloodstream.)

Regarding the spread of malaria, which method would the nurse teach those clients traveling to Southeast Asia? a. Bites from female Anopheles mosquitoes b. Consuming untreated water c. Consuming undercooked food d. Visiting overpopulated areas

a, b, e (Dry skin is a response to hypothyroidism that is related to the associated decreased metabolic rate. Lethargy and sensitivity to cold are symptoms related to hypothyroidism that are associated with a decreased metabolic rate. Insomnia and tachycardia are related to hyperthyroidism, not hypothyroidism.)

The nurse is teaching a client who had a thyroidectomy to observe for symptoms of surgically induced hypothyroidism. Which symptoms would be included in the teaching plan? Select all that apply. One, some, or all responses may be correct. a. Dry skin b. Lethargy c. Insomnia d. Tachycardia e. Sensitivity to cold

c (Apply direct lateral pressure to the nose for 10 minutes and apply ice or cool compresses to the nose and face if possible. Tilting the head back will cause the blood to be swallowed, which can result in vomiting and aspiration. Packing the bleeding nostril with tissue may cause further damage if done too firmly; some of the tissue may be left in the nose, causing an additional problem. Gauze or nasal tampons are used for packing. Blowing the nose can prevent clotting, which can result in prolonged bleeding.)

When a client develops epistaxis, which action would the nurse take? a. Tilt the head backward. b. Pack the nose with tissue. c. Apply direct lateral pressure to the nose. d. Instruct the client to blow the nose gently.

c (X-ray is one of the radiological diagnostic tests also used as therapy in some disease conditions. Desquamation is a serious side effect caused by x-rays. Vesicles, papules, and plaque-like lesions are serious effects caused by medication-induced photosensivity.)

Which is a serious side effect of x-rays? a. Vesicles b. Papular c. Desquamation d. Plaque-like lesions

c (Clients in advanced stages of muscular dystrophy are immobile. A client who sustained respiratory distress should be frequently repositioned to prevent the development of pneumonia. The client is also at risk of developing pressure injuries, which can be avoided by frequent repositioning of the client. Renal calculi can be prevented in this client by increasing fluid intake and decreasing dietary calcium. Urinary infection can be avoided by fluid intake to flush the renal system and measures to decrease urinary retention. Disorientation is a neurological complication that can be prevented by maintaining a proper sleep-wake schedule in accordance with day-night patterns and reorientation of the client to person, place, time, and control of sensory stimulation.)

While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent which complication? a. Renal calculi b. Disorientation c. Pressure injuries d. Urinary infection

b (A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help reduce pain by reducing the transmission and perception of pain impulses.)

While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above heart level. Which statement provides the reason behind this nursing intervention? a. To promote bone density b. To prevent further edema c. To reduce pain perception d. To increase muscle strength

a (The wrist joint is an example of a condyloid joint. It is a joint between the radial and carpals. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball and socket joint. The sacroiliac joint is an example of a gliding joint.)

Which joint is an example of a condyloid joint? a. Wrist joint b. Elbow joint c. Shoulder joint d. Sacroiliac joint

a (Passive range-of-motion exercises prevent the development of deformities (e.g., contractures) and do not require any energy expenditure by the client. Instituting range-of-motion exercises is an independent nursing function. The client will be unable to perform active exercises and weight-lifting. Isotonic exercises are active movement, which the client is unable to do.)

A client's cerebrovascular accident results in right hemiplegia. Which exercises would the nurse incorporate into the plan of care while the client is on bed rest? a. Passive range-of-motion exercises b. Active exercises of the extremities c. Light weight-lifting exercises of the right side d. Isotonic exercises that will capitalize on returning muscle function

c (Clients should be allowed to maintain some control, depending on their ability to perform a given task. Involve the client by allowing him or her to measure intake and output after assessment of abilities. The client's ability to perform simple mathematical equations may not be indicative of his or her ability to measure intake and output. Determining the client's reason for wanting to learn is immaterial. The client's experience with other medical procedures may not affect his or her ability to measure intake and output.)

After surgery, a client asks the nurse to help with measuring intake and output. How would the nurse respond? a. Determine the client's ability to perform simple mathematical equations. b. Identify the client's reason for wanting to measure intake and output. c. Assess the client's ability to measure intake and output. d. Evaluate the client's experience with other medical procedures.

d (Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunological irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.)

Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis? a. Urticaria b. Psoriasis c. Acne vulgaris d. Atopic dermatitis

d (An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.)

Which type of biopsy is required for removal of entire lesions on the skin? a. Punch biopsy b. Shave biopsy c. Incisional biopsy d. Excisional biopsy

a (Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.)

The nurse provides education to a client who is learning how to self-administer gastrostomy tube feedings and would include which instruction? a. Administering water after the feeding is completed b. Maintaining the supine position during the feeding c. Heating the feeding solution to slightly above body temperature d. Determining tube placement by instilling water before the feeding

a (SS is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of SS.)

Which characteristic is common in clients with Sjögren syndrome (SS)? a. Dry eyes b. Muscle cramping c. Urinary tract infection d. Elevated blood pressure

c (Granulation tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.)

Which event occurs in the proliferative phase of wound healing? a. Thinning of scar tissue b. Strengthening of collagen c. Formation of granulation tissue d. Increase in capillary permeability

a (Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.)

Which example is associated with third spacing in a burn injury? a. Blister formation b. Edema formation c. Fluid mobilization d. Fluid accumulation

b (Poor posture may affect the nerves innervating the neck, thereby causing pain in the neck. Headache may be associated with neck pain, but it does not precipitate neck pain. Low body weight and sedentary lifestyle may cause osteoporosis.)

Which factor may cause neck pain in a client? a. Headache b. Poor posture c. Low body weight d. Sedentary lifestyle

b (The diagnosis depends on the identification of characteristic histological features of an excised lymph node. A bone scan is a diagnostic device to assess bony metastasis of cancers. CT scans identify the extent of the disease in the abdominal and thoracic cavities. The 131I uptake study is not indicated for Hodgkin disease; it is used for radiotherapy or diagnosis of thyroid diseases.)

A client has a tentative diagnosis of Hodgkin disease. How would the nurse expect the diagnosis to be confirmed? a. Bone scan b. Lymph node biopsy c. Computed tomography (CT) scan d. Radioactive iodine (131I) uptake study

a (Voicing fears often reduces the associated anxiety. Socialization, when feelings need exploration, is not therapeutic. Although the client's request about visitors should be granted, simply accepting the client's wishes is not by itself therapeutic. Darkening the client's room avoids the problem and is not therapeutic.)

A client is admitted to the hospital with jaundiced skin and acute abdominal pain. Which is a therapeutic nursing response when the client refuses all visitors? a. Listen to the client's fears. b. Encourage the client to socialize. c. Place a sign on the door indicating visitor restrictions. d. Darken the client's room by pulling the drapes.

c (Hypertension is a cardiovascular complication found in clients with Cushing syndrome due to increased metabolic demands and catecholamines. Chest pain is seen in clients with hyperthyroidism and hypothyroidism. Tachycardia and atrial fibrillation are manifestations of dysrhythmias, which are associated with hypothyroidism or hyperthyroidism, parathyroidism, and pheochromocytoma.)

A client is diagnosed with Cushing syndrome. The nurse would monitor the client for which cardiovascular complication? a. Chest pain b. Tachycardia c. Hypertension d. Atrial fibrillation

b (Vitiligo is manifested by the presence of large patchy areas of pigment loss. This is mainly caused by primary hypofunction of the adrenal gland. Presence of edema at extremities indicates fluid and electrolyte imbalances mainly observed in a client with thyroid problems. Presence of reddish-purple stretch marks on the abdomen and "buffalo hump" between shoulders on the back of the neck often indicates excessive adrenocortical secretions.)

A client is diagnosed with primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed? a. Edema at extremities b. Uneven patches of pigment loss c. Reddish-purple stretch marks on the abdomen d. "Buffalo hump" between shoulders on the back

b, c, d (A boardlike abdomen is associated with the inflammatory process in the peritoneum. Abdominal tenderness is caused by the local inflammatory process and resulting bowel distention and irritation of the peritoneum. A decrease or absence of bowel sounds occurs in response to bowel distention caused by gas and shifting of fluid into the bowel. Jaundice is not a sign of peritonitis; it is caused by a disturbance in bilirubin metabolism. A rapid decrease in coagulation ability is associated with acute liver failure, not peritonitis.)

A client was admitted to the hospital with blunt trauma to the abdomen. The client was treated for a lacerated liver and abdominal hemorrhage. During the recovery period, the nurse would monitor the client for which indications of peritonitis? Select all that apply. One, some, or all responses may be correct. a. Jaundice b. Boardlike abdomen c. Abdominal tenderness d. Decreased bowel sounds e. Rapid decrease in coagulation ability

d (Clients with Cushing syndrome or those receiving cortical hormones must limit their intake of sodium and increase their intake of potassium, because the kidneys are retaining sodium and excreting potassium. Limiting sodium will not cause weight gain. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.)

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. Which response by the nurse is accurate? a. "The client will gain excessive weight if sodium is limited." b. "An inadequate intake of potassium contributed to the disease." c. "This type of diet increases emotional stability." d. "Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium."

c (Deficiency of glucocorticoids causes hypoglycemia in the client with Addison disease. Clinical manifestations of hypoglycemia include nervousness; weakness; dizziness; cool, moist skin; hunger; and tremors. Hypokalemia is evidenced by nausea, vomiting, muscle weakness, and dysrhythmias. Weakness with dizziness on arising is postural hypotension, not hypertension. An increased extracellular fluid volume is evidenced by edema, increased blood pressure, and crackles)

A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. Which physiological response would the nurse suspect is the probable cause of these symptoms? a. A lack of potassium b. Postural hypertension c. A hypoglycemic reaction d. Increased extracellular fluid volume

b (Bordetella pertussis causes whooping cough . Pertussis is a respiratory tract infection beginning with the common cold and progresses to whooping cough. The client also develops coughing episodes lasting for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis)

A client's respiratory tract infection, which started with a common cold, has progressed to whooping cough. The client reports "coughing fits" lasting for several minutes. Which organism is responsible for the client's condition? a. Bacillus anthracis b. Bordetella pertussis c. Streptococcus pneumoniae d. Mycobacterium tuberculosis

b (The response "Tell me why you want to refuse the procedure" is open ended and attempts to explore why the client is refusing the procedure; it promotes communication. The response "Why did you sign the consent?" is accusatory; the client has the right to withdraw consent at any time. The response "You are obviously afraid about something concerning the procedure" is a conclusion without appropriate data; it puts the client on the defensive. The response "Although the procedure is very important, I understand why you changed your mind" is a conclusion without appropriate data; it may raise the client's anxiety level.)

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which response by the nurse is therapeutic? a. "Why did you sign the consent?" b. "Tell me why you want to refuse the procedure." c. "You are obviously afraid about something concerning the procedure." d. "Although the procedure is very important, I understand why you changed your mind."

c (Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculus humanus var. corporis also causes pediculosis.)

Which organism is responsible for causing Lyme disease in clients? a. Phthirus pubis b. Sarcoptes scabiei c. Borrelia burgdorferi d. Pediculus humanus var. corporis

c (Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.)

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture? a. Establishing a schedule for pain medication b. Maintaining a fixed schedule of daily activities c. Modifying the home environment to prevent accidents d. Understanding that a more sedentary lifestyle is necessary

c (All states have laws about obligatory reporting of child abuse to local authorities. This responsibility is delegated by the state to an appropriate local agency such as Child Protective Services. A staff member of the agency investigates allegations of child abuse, and recommendations are made to protect the child's welfare. The clinic treats the client medically, but other agencies handle child abuse and other social problems. The hospital probably will not admit the child unless an immediate medical incident requires it. The Bureau of the Handicapped is concerned with equipment and supplies required for the individual with a disability.)

During a home visit, the nurse discovers that a child in the household who has a disability has been experiencing seizures. The child's parent appears indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. Where would the nurse direct a referral? a. Outpatient clinic b. Hospital pediatric unit c. Child Protective Services d. Bureau of the Handicapped

a (Phthirus pubis is responsible for dermatitis related to sexually transmitted infections. Candida albicans may lead to vulvovaginitis. Campylobacter jejuni may cause proctitis. Ureaplasma urealyticum may cause salpingitis, infertility, reproductive loss, and ectopic pregnancies.)

Which organism is responsible for causing dermatitis related to a sexually transmitted infection (STI)? a. Phthirus pubis b. Candida albicans c. Campylobacter jejuni d. Ureaplasma urealyticum

c (Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.)

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans

c (Clients without a pituitary gland (hypophysectomy) should avoid bending at the waist because this position increases intracranial pressures. Drinking lots of water and eating high-fiber foods reduce the risk of constipation, so this should not cause increased intracranial pressure. The client should bend the knees to lower the body, which reduces the risk of increased intracranial pressures.)

The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20 mm Hg. Which action made by the client is responsible for the reported ICP? a. Drinking lots of water b. Eating high-fiber foods c. Bending over at the waist d. Bending knees when lowering body

b (The tuberculin PPD is injected intradermally; it is the most accurate skin test for tuberculosis (TB) because of the testing material and the intradermal method used. No other skin test is appropriate as a follow-up; further tests are now warranted, including a chest x-ray film. The test result is positive, not negative; thus further testing is necessary. The Tine test is less accurate than the tuberculin PPD and is not used as a follow-up test. More than 10 mm of induration is a positive test result, not a doubtful test result.)

The nurse identifies 12 mm of induration at the site of a client's tuberculin purified protein derivative (PPD) test. Which rational would the nurse use to explain this test? a. The test result is negative and would not require any follow-up. b. The result indicates a need for further tests and a chest x-ray. c. The skin test is a screening method and you now need a Tine test. d. This skin test is inconclusive and requires repeat testing in 6 weeks.

a (A client with injuries due to a fall must avoid having throw or scattered rugs at home to reduce the incidence of falls. The registered nurse (RN) would encourage the client to drink 3000 mL of water per day to promote optimal bladder and bowel function. The client would eat six small meals with foods rich in fiber, such as fruits and vegetables, to prevent constipation. The RN has to encourage the client to perform exercise above and below the cast daily for a speedy recovery.)

The registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for additional instruction? a. "I should walk on soft scatter rugs at home." b. "I should drink 3000 mL of water every day." c. "I should eat fruits and vegetables six times a day." d. "I should exercise the joints above and below the cast daily."

b, d (A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.)

What information from a client's history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct. a. Hemorrhoids b. Increased age c. High-fiber diet d. Ulcerative colitis e. Low hemoglobin level

a, b, d (With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.)

When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects which assessment findings? Select all that apply. One, some, or all responses may be correct. a. Dependent edema b. Swollen hands and fingers c. Collapsed neck veins d. Right upper quadrant discomfort e. Oliguria

c (Because it is unclear what the anticoagulant needs are for this client, the nurse would contact the health care provider for clarification. The nurse would not tell the client that no anticoagulant was needed without further clarification. Daily aspirin use is not adequate to prevent venous thrombosis in clients at high risk, such as those who have had orthopedic surgery. The nurse would not place the responsibility for clarification about anticoagulant use on the client, because it is a nursing responsibility to clarify discharge medications and instructions.)

Which action would the nurse take after noting that a client who has been on anticoagulant therapy after hip surgery is being discharged with no anticoagulant prescription? a. Explain to the client that anticoagulant therapy will no longer be needed. b. Suggest that the client take aspirin daily to prevent venous thrombosis. c. Contact the health care provider to clarify whether anticoagulant therapy is needed. d. Instruct the client to call the health care provider to ask about anticoagulant medications.

b (Multiple sclerosis is a central nervous system-specific autoimmune disease. Rheumatic fever is related to the heart. Myasthenia gravis is a muscle-related autoimmune disease. Goodpasture syndrome is a kidney-related autoimmune disease.)

Which autoimmune disease is directly related to the client's central nervous system? a. Rheumatic fever b. Multiple sclerosis c. Myasthenia gravis d. Goodpasture syndrome

d (According to the muscle-strength scale, a score of 3 indicates active movement against gravity only and not against resistance. A score of 4 indicates active movement against gravity and some resistance. A score of 2 indicates active movement of a body part with elimination of gravity. A score of 5 indicates active movement against full resistance without evident fatigue.)

Which client action would the nurse score as 3 on the muscle-strength scale? a. Active movement against gravity and some resistance b. Active movement of body part with elimination of gravity c. Active movement against full resistance without evident fatigue d. Active movement against gravity only and not against resistance

c (Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.)

Which clinical finding occurs due to thinning of the subcutaneous layer? a. Decreased tone and elasticity b. Decreased sensory perception c. Increased risk for hypothermia d. Increased susceptibility to dry skin

b (FES is clinically manifested by dyspnea because of low levels of arterial oxygen. Nausea and orthopnea are not seen in FES. However, tachypnea, headache, and lethargy are seen in clients with FES. Paresthesia occurs with compartment syndrome.)

Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia

a, d (Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi. The symptoms of the chronic persistent stage are arthritis and chronic fatigue. Dyspnea and dizziness are the symptoms of the early disseminated stage. Erythema migrans is observed in the localized stage.)

Which clinical manifestations indicate the chronic persistent stage of Lyme disease? Select all that apply. One, some, or all responses may be correct. a. Arthritis b. Dyspnea c. Dizziness d. Chronic fatigue e. Erythema migrans

a (Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.)

Which component of skin maintains optimal barrier function? a. Keratin b. Melanin c. Collagen d. Adipose tissue

c (Cushing syndrome occurs because of chronic exposure to excess corticosteroids. Weight gain and purplish-blue striae are the clinical manifestations of Cushing syndrome. Anemia, weight gain, and cold dry skin are the common manifestations of hypothyroidism. Weight loss and fatigue are the manifestations observed in Addison disease. Severe, pounding headache, tachycardia, and profuse sweating are the clinical manifestations observed in pheochromocytoma.)

Which condition would the nurse anticipate in a client who complains of weight gain and has purplish-blue striae on the abdomen? a. Hypothyroidism b. Addison disease c. Cushing syndrome d. Pheochromocytoma

a (Mifepristone is an antiprogesterone that blocks the progesterone receptors and acts as an abortifacient. Metyrapone, cyproheptadine, and aminoglutethimide are used to treat hyperfunctioning of the adrenal glands (Cushing disease/syndrome).)

Which drug acts as an abortifacient in female clients? a. Mifepristone b. Metyrapone c. Cyproheptadine d. Aminoglutethimide

a, b, c, d, e (There are multiple potential hazards in the home clients should be educated about to avoid injury. Area rugs and multiple electrical cords on the floor pose a fall risk. A clogged, dirty fireplace could lead to carbon monoxide poisoning. Polypharmacy can cause mental status changes, confusion, and orthostatic blood pressure changes; these can increase the client's fall risk. If the nurse observes a wheeled walker with uneven legs, the physical therapist would be notified as they can follow-up to evaluate the mobility aid's safety.)

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. One, some, or all responses may be correct. a. Area rugs on the floor b. Clogged, dirty fireplace c. Multiple electrical cords d. Multiple prescribed medications e. Wheeled walker with uneven legs

a, b, c, d, e (According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.)

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. a. Monitoring vital signs b. Cutting off the clothing c. Inserting a urinary catheter d. Removing the client's jewelry e. Establishing an intravenous line

b, c, d (Skin turgor is inspected for signs of dehydration and for rashes or lesions. The client is questioned about any current or previous skin disorders. When the nurse does a physical examination of a preoperative client, examining the neck for distended neck veins or palpating the chest for heaves or lifts falls under the cardiovascular system.)

Which items would the nurse include in assessment of the integumentary system for a preoperative client? Select all that apply. One, some, or all responses may be correct. a. Inspect the neck for distended veins. b. Assess the skin turgor for signs of dehydration. c. Examine the skin for rashes or lesions. d. Question the client about any skin disorders. e. Palpate the chest for heaves or lifts.

c (Chondrosarcoma occurs most commonly in cartilage in the arm, leg, and pelvic bones of older adults in the age group of 50 to 70 years old. Endochroma occurs in clients in the age group of 10 to 20 years old. Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old.)

Which type of bone tumor occurs most commonly in elderly clients? a. Endochroma b. Osteosarcoma c. Chondrosarcoma d. Osteochondroma

d (The reality of a situation is not the important issue at this time, but the client's feelings or perceptions about the change are the most important determinant of the client's ability to cope. The extent of change is not relevant; what is relevant is whether the client perceives the change as enormous or less important. Although suddenness of the change may influence a person's coping ability, this is not the primary factor influencing a client's coping mechanisms with body image changes. Although obviousness of the change may influence a person's coping ability, this is not the primary factor influencing coping mechanisms with body image changes.)

Which key factor assists the nurse in assessing how a client will cope with the body image change after an above-the-knee amputation? a. Extent of the change b. Suddenness of the change c. Obviousness of the change d. Personal perception of the change

c (Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.)

Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? a. Increased blood urea nitrogen (BUN) and hypotension b. Hyperkalemia and poor skin turgor c. Hyponatremia and decreased urine output d. Polyuria and increased specific gravity of urine

c (Addison disease is the lack of mineralocorticoids, which causes hyponatremia, hypovolemia, and hyperkalemia. Dietary modification and administration of cortical hormones are aimed at correcting these electrolyte imbalances, which can be life threatening. There is no disturbance in the eosinophil count. Lymphoid tissue does not change. Although glucocorticoids are involved in metabolic activities, including carbohydrate metabolism, the primary aim of therapy is to restore electrolyte imbalance.)

Which outcome is the main focus of treatment for a client with Addison disease? a. Decrease in eosinophils b. Increase in lymphoid tissue c. Restoration of electrolyte balance d. Improvement of carbohydrate metabolism

c (Abduction reduces stress on anatomic structures and maintains the head of the femur in the acetabulum. External rotation places stress on the acetabulum and the head of the femur. Hip flexion may dislodge the head of the femur from the acetabulum. Functional alignment places stress on the bone, soft tissue, and nail plate; it can cause damage and dislocation of the head of the femur.)

Which position would the nurse use for placement of the affected extremity of a client who is recovering from an open reduction and internal fixation (ORIF) of a fractured hip? a. External rotation b. Slight hip flexion c. Moderate abduction d. Anatomic body alignment

a (A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.)

Which radiographic test is used to view the entire skeleton? a. Bone scan b. Gallium and thallium scan c. Computed tomography (CT) d. Magnetic resonance imaging (MRI) scan

c (Because of its inverse relationship with calcium, when serum calcium levels increase, serum phosphorus levels decrease (greater than 3 mg/dL; greater than 0.17 mmol/L). Serum calcium levels will increase because of the action of elevated levels of serum parathormone; serum calcium levels usually exceed 10 mg/dL (2.50 mmol/L). Serum chloride levels will increase, not decrease, with hyperparathyroidism. Parathyroid hormone, produced in the parathyroid gland, will increase with hyperparathyroidism.)

Which serum blood level would the nurse expect to be decreased in a client with a diagnosis of hyperparathyroidism? a. Calcium b. Chloride c. Phosphorus d. Parathyroid hormone

a (Syphilis is an STI caused by Treponema pallidum. Neisseria gonorrhoeae causes gonorrhea. Haemophilus ducreyi and Klebsiella granulomatis cause genital warts. Herpes simplex virus, Trichomonas vaginalis, and Candida albicans may cause vulvovaginitis.)

Which sexually transmitted infection (STI) is caused by Treponema pallidum? a. Syphilis b. Gonorrhea c. Genital warts d. Vulvovaginitis

a (A wheal is a firm, edematous, irregularly shaped skin lesion, formed as an inflammatory response to an allergen or insect bite. A plaque is a circumscribed, elevated, superficial lesion, like psoriasis. A vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.)

Which skin lesion presents as a firm, edematous, irregularly shaped lesion on a client who reports an insect bite? a. Wheal b. Plaque c. Vesicle d. Pustule

d (Natural killer cells attack nonselectively on nonself cells, especially body cells that have undergone mutation and become malignant. Plasma cells secrete immunoglobulins in response to the presence of a specific antigen. Cytotoxic T cells attack selectively and destroy nonself cells, including virally infected cells. Helper T cells enhance immune activity through secretion of cytokines and lymphokines to control or limit specific immune responses.)

Which statement indicates the function of natural killer cells within the immune system? a. Secrete immunoglobulins in response to the presence of a specific antigen b. Exhibit heightened selectivity and destroy nonself cells, including virally infected cells c. Enhance immune activity through secretion of cytokines and lymphokines d. Attack nonselectively on nonself cells, especially mutated and malignant cells

b (Clients with influenza will be placed on droplet precautions because the infection can be spread by talking or sneezing. HIV-positive clients will be instructed to use barrier protection with any kind of sexual contact to prevent spread of the virus. Clients with TB will be placed on airborne transmission precautions. Clients with MRSA would require contact precautions.)

Which infection would the nurse identify as requiring a client to be placed on droplet precautions? a. Human immunodeficiency virus (HIV) b. Influenza c. Tuberculosis (TB) d. Methicillin-resistant Staphylococcus aureus (MRSA)

d (When serum calcium levels lower, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which promotes bone resorption. Estrogens stimulate osteoblastic (bone-building) activity and inhibit PTH. Calcitonin inhibits bone resorption and increases the renal excretion of calcium and phosphorus as needed to maintain balance in the body. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length.)

Which hormone promotes bone resorption in a client and potentially leads to decreased bone densities? a. Estrogen b. Calcitonin c. Growth hormone d. Parathyroid hormone (PTH)

A (Eggs do not contain roughage and will not prevent constipation. Beans contain both soluble and insoluble fibers that promote intestinal peristalsis, preventing constipation. Raw fruits and steamed vegetables contain roughage that promotes intestinal peristalsis, preventing constipation.)

The nurse gives the client with a history of constipation a list of foods to help prevent it. Which statement made by the client indicates that further teaching is needed? A. "I should eat eggs." B. "I should eat beans." C. "I should eat fresh fruits." D. "I should eat steamed vegetables."

d (Because diminished circulation leads to inadequate healing, early treatment of injuries is essential. Toenails should not be too short and should be trimmed straight across. Bathwater should be checked with a bath thermometer; toes of persons with peripheral artery disease (PAD) may be less sensitive to temperature change, and a burn may occur. These clients develop trophic skin changes; the drying action of alcohol will contribute to dryness and skin breakdown.)

The nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which directions will the nurse include in the teaching plan? a. Trimming toenails so that they are short and rounded b. Checking bathwater temperature by putting the toes in first c. Using alcohol to rub hands, feet, legs, and arms at least two times a day d. Seeking professional treatment for any minor injuries to the extremities

a (Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly or complete sequential movement. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have a speech problem.)

The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding? a. Anomia b. Apraxia c. Dysarthria d. Dysphagia

d (The spheroidal joint is a ball and socket joint that provides flexion, extension, adduction, abduction, and circumduction in the shoulders and hips. The pivotal joint provides rotation in the atlas and axis, and at the proximal radioulnar joint. The saddle joint, which is at the carpometacarpal joint of the thumb, provides flexion, extension, abduction, adduction, and circumduction of the thumb-finger. The condyloid joint is a wrist joint between the radial and carpals; it provides flexion, extension, abduction, adduction, and circumduction.)

Which type of joint is present in the client's shoulders? a. Pivotal b. Saddle c. Condyloid d. Spheroidal

c (Medication-induced diabetic insipidus is usually caused by demeclocycline, which can interfere with the response of the kidneys to antidiuretic hormone. Demeclocycline does not cause endocrine disorders, such as acromegaly, diabetes mellitus, and Cushing syndrome.)

Which type of medication-induced hormonal imbalance is likely to be observed in a client undergoing treatment with demeclocycline? a. Acromegaly b. Diabetes mellitus c. Diabetes insipidus d. Cushing syndrome

b (Thyroxine increases the rate of protein synthesis in all the body tissues. Estrogen stimulates bone-building, which is known as osteoblastic activity. Parathormone promotes osteoclastic activity in a state of hypocalcemia. Vitamin D and its metabolites are produced in the body and transported in the blood to promote the absorption of calcium and phosphorus from the small intestine.)

Which hormone increases the rate of protein synthesis? a. Estrogen b. Thyroxine c. Parathormone d. Vitamin D

c (SLE is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I, or immediate hypersensitive reaction. Cytotoxic, or type II, hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions caused by delayed, or type IV, hypersensitivity reactions.)

Identify the type of hypersensitivity reaction associated with systemic lupus erythematosus (SLE). a. Type I b. Type II c. Type III d. Type IV

c (Inflammation associated with gonorrhea may lead to destruction of the epididymis in males and tubal mucosal destruction in females, causing sterility. Many gonococci have become penicillin resistant and difficult to treat. Gonorrhea is a common sexually transmitted infection. Neisseria gonorrhoeae will invade internal structures, particularly the epididymis in males and the fallopian tubes in females.)

In addition to being highly infectious, which additional fact would the nurse teach the client with gonorrhea? a. Easily cured b. Occurs very rarely c. Can produce sterility d. Limited to the external genitalia

a (Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore, it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.)

Which treatment is beneficial for a client with muscle spasm? a. Thermotherapy b. Muscle massage c. Frequent position changes d. Muscle-strengthening exercise regimen

b (Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrum from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.)

Which type of immunity will clients acquire through immunizations with live or killed vaccines? a. Natural active immunity b. Artificial active immunity c. Natural passive immunity d. Artificial passive immunity

d (The gliding joint is present in between the tarsal bones. The pivot joint is present in the proximal radioulnar joint. The hinge joint is present in the elbows and knees. The saddle joint is present in between the carpometacarpal joints of the thumb.)

Which type of joint is present in between the client's tarsal bones? a. Pivot b. Hinge c. Saddle d. Gliding

d (Epstein-Barr virus is responsible for mononucleosis and possibly Burkitt lymphoma. Parvovirus and rotavirus cause gastroenteritis. Coronavirus causes upper respiratory tract infections.)

Which virus is responsible for causing infectious mononucleosis in clients? a. Parvovirus b. Coronavirus c. Rotavirus d. Epstein-Barr virus

d (Nasal hypophysectomy is a surgical procedure performed to treat hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up, the appearance of light yellow color at the edge of otherwise clear nasal discharge in the dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign" and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal because the client breathes through the mouth because of the nasal packing. Neck rigidity could be an indication of infection, such as meningitis after the surgery. A fall in blood pressure upon standing is called orthostatic hypotension and is a side effect of bromocriptine.)

A client has undergone nasal hypophysectomy surgery. During postoperative care, the nurse would monitor the client for which indication of cerebrospinal fluid leakage? a. Dry mouth b. Rigidity of neck muscles c. Fall in blood pressure upon standing d. A yellow edge around nasal discharge

d (The response "You sound unhappy. Have you tried to talk to your spouse?" identifies the client's feelings and accepts them but also points out the responsibility of the client to take action. Although the response "You don't get along with your spouse" identifies one of the client's concerns, the identification of the underlying feeling is more therapeutic. The response "I'm sorry. What can I do to make you feel better?" makes the nurse responsible for changing the situation, which is not appropriate or therapeutic. The response "It may be temporary because your spouse also needs time to adjust" denies the client's feelings and provides false reassurance.)

A client with recently diagnosed diabetes states, "I feel bad. My spouse and I do not get along. It seems as though my spouse doesn't care about my diabetes." Which response by the nurse is appropriate? a. "You don't get along with your spouse." b. "I'm sorry. What can I do to make you feel better?" c. "It may be temporary because your spouse also needs time to adjust." d. "You sound unhappy. Have you tried to talk to your spouse?"

b (Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity. Wearing socks should be encouraged because it keeps the feet warm, increasing arterial dilation and perfusion. Increasing fluid intake decreases the viscosity of blood, possibly preventing thrombus formation, and should be encouraged. Clients with peripheral arterial disease can use alcohol in moderation.)

After the nurse completes teaching for a client with foot pain who has peripheral arterial disease, which client statement indicates that further teaching is needed? a. "I will wear socks." b. "I will elevate my foot." c. "I will increase fluid intake." d. "I will drink a moderate amount of alcohol."

c (Soreness is to be expected. A progression to a soft diet will provide nutrients needed for healing and energy and will stimulate the return of bowel activity. Analgesics as prescribed will reduce soreness during meals. Reordering the full-fluid diet is not within the legal role of the nurse. Soreness is to be expected; this is not an emergency necessitating medical action. The soreness is not because of drying; when the client is at home, humidified air might help reduce the soreness, but it will not help the client eat the soft diet. Gargling involves hyperextension of the neck, which may put tension on the suture line.)

On the first postoperative day after a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports a sore throat when swallowing. Which intervention would the nurse take for this client a. Reorder the full-fluid diet. b. Notify the primary health care provider. c. Administer analgesics as prescribed before meals. d. Provide saline gargles to moisten the mucous membranes.

c (When ingested food rapidly enters the jejunum without having gone through the usual mixing and digestive process, the hypertonic bolus causes rapid movement of extracellular fluid into the bowel; this rapid shift decreases the circulating blood volume. Decreased peripheral vascular resistance, visceral pooling of blood, and reactive hypoglycemia also are implicated. Additionally, the distended jejunum increases intestinal peristalsis and motility. Backward flow of gastric contents into the esophagus, or gastric reflux, causes heartburn, dysphagia, water brash, acid regurgitation, or belching (eructation). Reflux gastritis is a chronic inflammation of the lining of the stomach caused by reflux of duodenal contents; epigastric pain, nausea, vomiting, and hematemesis are common clinical manifestations. Abdominal peritonitis is an inflammation of the peritoneal membrane; rigidity of abdominal muscles, abdominal pain, low-grade fever, malaise, absent bowel sounds, and shallow respirations are common clinical manifestations.)

Six weeks after discharge, a client with a jejunoileal bypass for morbid obesity returns to an outpatient clinic reporting palpitations, abdominal cramps, diarrhea, and dizziness 30 minutes after meals. Which complication would the nurse consider that the client is most likely experiencing? a. Gastric reflux b. Reflux gastritis c. Dumping syndrome d. Abdominal peritonitis

a (A T-tube maintains patency of the common bile duct until inflammation subsides. When the duct is patent and bile enters the gastrointestinal tract, the color of stool is brown. Ankle pumping prevents venous stasis if a client is not able to ambulate. Absence of bile affects the ability to digest fats, not carbohydrates. A T-tube drains by gravity; it is not a self-contained suction device like a Hemovac, so compression is not necessary.)

The nurse is caring for a client with a T-tube after an open cholecystectomy. Which specific action would the nurse include in the plan of care? a. Monitor stool color. b. Teach ankle pumping exercises. c. Restrict intake of refined carbohydrates. d. Compress the drainage container after emptying.

b (Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause bleeding in the GI tract; clients with a history of GI bleeding should not take NSAIDs. Digoxin is an antidysrhythmic used to slow and strengthen heart rate; it would not contribute to GI bleeding. Atorvastatin is a cholesterol-reducing medication and is not contraindicated with GI bleeding. Famotidine is a histamine (H2) blocker to reduce acid secretion in the stomach; it would not cause GI bleeding.)

The nurse is reviewing a list of current medications with a client who has developed gastrointestinal (GI) bleeding. Which prescription would the nurse discuss with the primary health care provider? a. Digoxin b. Ibuprofen c. Famotidine d. Atorvastatin

b (Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.)

The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step? a. Wait until a family member is present. b. Assess barriers to learning colostomy care. c. Provide simple written instructions concerning the care. d. Wait until the client has accepted the change in body image.

b, d (A fever of 100°F (37.8°C) or higher for 2 days is a sign of an infection that should be reported to the health care provider. Redness, tenderness, swelling, heat, and drainage are physical responses associated with an infection or a problem with healing. The puncture sites should be washed gently with mild soap and warm water. Tape strips should be allowed to fall off; they should not be pulled off because they reinforce closure of the incision. Using a heating pad for 20 minutes hourly is recommended to relieve discomfort in the right, not left, shoulder because of phrenic nerve irritation because of retention of carbon dioxide gas insufflated into the abdomen during surgery.)

A client had a laparoscopic cholecystectomy. Postoperatively, the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What would the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. One, some, or all responses may be correct. a. Wash the puncture sites with strong soap and hot water daily. b. Call the health care provider for a fever of 100°F (37.8°C) or higher more for 2 days. c. Remove the tape strips over the puncture sites 1 week after surgery. d. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage. e. Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the left shoulder.

D (Laryngeal nerve injury can cause laryngeal spasms, resulting in airway obstruction. Parathyroid damage results in hypocalcemia, not hypercalcemia. Thyroid storm (thyroid crisis) is characterized by the release of excessive levels of thyroid hormone, which increases the metabolic rate. An increase in the metabolic rate increases vital signs, resulting in hypertension, not hypotension, and tachycardia, not bradycardia. Tetany is caused by a decrease in parathormone, a parathyroid hormone, not a thyroid hormone.)

A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? A. Hypercalcemia may result from parathyroid damage. B. Hypotension and bradycardia may result from thyroid storm. C. Tetany may result from underdosage of thyroid hormone replacement. D. Hoarseness and airway obstruction may result from laryngeal nerve damage

a (Occasional PACs (premature atrial contractions) are benign and will not affect cardiac output, but the nurse will continue to monitor the client for increased numbers of PACs or other dysrhythmias. Activation of the Rapid Response Team is inappropriate, because there is no indication that the client is unstable. No defibrillator is needed for this benign atrial dysrhythmia. Lidocaine is specific for ventricular, not atrial, irritability.)

A client on a telemetry unit demonstrates a sinus rhythm with an occasional premature atrial contraction (PAC). Which action would the nurse take? a. Continue to monitor the client. b. Ensure that a defibrillator is available close by. c. Activate the Rapid Response Team. d. Give lidocaine intravenously as per protocol.

b (Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. It is correct that the patient should not lie on the arm with the fistula. Redness and swelling are signs of infection, which is a complication of cannulization.)

A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? a. "I must touch the shunt several times a day to feel for the bruit." b. "I have to take his blood pressure every day in the arm with the fistula." c. "He will have to be very careful at night not to lie on the arm with the fistula." d. "We really should check the fistula every day for signs of redness and swelling."

a (Growth hormone level of 7 ng/ml indicates an abnormality. An abnormal increase in shoe size and backache are indicative of hypersecretion of growth hormone. Suppression testing should be performed because high glucose levels are known to suppress the release of growth hormone. After administering 100 g of oral glucose, if the client's levels of growth hormone fail to fall to less than 5 ng/mL, an abnormality in the secretion of growth hormone is considered. Growth hormone level of 3 ng/mL after oral glucose intake is a normal result. Urine output of 3 L and specific gravity of 1.006 are normal results. The client is said to have diabetes insipidus if the urine output in 24 hours is greater than 4 L and has low specific gravity of less than 1.005.)

A client reports backache and abnormal increase in shoe size. The primary health care provider prescribes 100 g of oral glucose, and blood and urine samples are collected for testing. Which finding in the client indicates an abnormality? a. Growth hormone level is 7 ng/mL b. Growth hormone level is 3 ng/mL c. Urine produced in 24 hours is 3 L d. Urine produced has a specific gravity of 1.006

b, e (Risk factors for varicose veins include work that involves prolonged standing (such as standing at a cash register for many hours) and a family history of venous insufficiency or varicose veins. A BMI of 23 is normal, and varicose veins are more common in clients who are obese. Smoking is a risk factor for arterial disease but not for varicose veins or venous insufficiency. High-impact exercises may lead to varicose veins, but swimming would not increase venous pressure and would likely improve venous return.)

A client who is scheduled for endovenous ablation of the saphenous vein asks the nurse, "How did I get varicose veins?" Which factors in the client's history will the nurse discuss? Select all that apply. One, some, or all responses may be correct. a. Has body mass index (BMI) of 23 b. Works as cashier in a grocery store c. Smokes 1 pack per day of cigarettes d. Swims 1 mile several times per week e. Reports family history of venous insufficiency

d (A level more than 200 mg/dL (5 mmol/L) is considered elevated. This client's total cholesterol is mildly elevated and the initial intervention would be making changes in diet and activity level. The client's cholesterol is not elevated enough to require medication as an initial intervention. The client's cholesterol is elevated and action is advised to lower total cholesterol level and cardiac risk. A low level is less than 140 mg/dL (2.0 mmol/L). Medical attention should be sought, because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.)

A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How would the nurse respond? a. "Your cholesterol is high, and you may need medication." b. "This is within the acceptable range, and no action is required." c. "Your level is low; you should eat more foods that" d. "Your cholesterol is elevated slightly. A diet low in saturated fats should be followed."

d (Aspirin interferes with the gastric mucosa's natural protection from pepsin and hydrochloric acid, worsening the gastritis. The client should avoid lying down after eating; sitting up for 1 hour after meals uses gravity to minimize esophageal reflux. Antacids usually are prescribed after meals. Small, frequent, bland feedings are preferred, not foods that are high in carbohydrates.)

A client with chronic gastritis is being treated with medication and diet. Which would the nurse teach the client when discussing the therapeutic regimen? a. Lie down after eating when possible. b. Take an antacid preparation with meals. c. Limit high-carbohydrate foods in the diet. d. Avoid using analgesics that contain aspirin.

2700 ml (One liter of fluid equals 1000 mL; each liter of fluid is equal to 1 kg of weight.82.1 kg - 79.4 kg = 2.7 kg = 2700 mL.)

A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How many milliliters of fluid has the client retained?

d (Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased Pco2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased Pco2 value indicates compensatory hypoventilation. Increased pH and decreased Pco2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased Pco2 values reflect hypoventilation and respiratory acidosis.)

Which arterial blood gas report is indicative of diabetic ketoacidosis? a. Pco2: 49, HCO3: 32, pH: 7.50 b. Pco2: 26, HCO3: 20, pH: 7.52 c. Pco2: 54, HCO3: 28, pH: 7.30 d. Pco2: 28, HCO3: 18, pH: 7.28

a (Actively participating in care enhances feelings of self-worth and autonomy. Expectations for others do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.)

Which behavior by a client who has had an ST-segment-elevation myocardial infarction indicates that the nurse's actions to improve client autonomy have been successful? a. Active participation in providing self-care b. Verbalizing realistic expectations of caregivers c. Discussing necessary lifestyle changes with family members d. Listing the indicators of recovery after a myocardial infarction

a, b, e (Parathyroid hormone increases bone breakdown, which increases serum calcium levels. Parathyroid hormone increases net release of calcium and phosphorus from bone into the extracellular fluid. It increases sodium and phosphorus excretion by the kidneys, not in the bone, and increases absorption of calcium and phosphorus in the gastrointestinal tract by using activated vitamin D. However, this increased absorption of calcium and phosphorus is not related to the bone.)

Which effect does the parathyroid hormone have on bones? Select all that apply. One, some, or all responses may be correct. a. Increased bone breakdown b. Increased serum calcium levels c. Increased sodium and phosphorus excretion d. Increased absorption of calcium and phosphorus e. Increased net release of calcium and phosphorus

a (In first degree AV block, a P wave precedes every QRS complex, but the PR interval is prolonged. Second degree heart block refers to AV conduction that is intermittently blocked. Some P waves are conducted and some are not. When no P waves are visible, rhythms such as junctional dysrhythmias or atrial fibrillation are suspected. Third degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles.)

Which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree atrioventricular (AV) block? a. Every P wave is conducted to the ventricles. b. Some P waves are conducted to the ventricles. c. There are no P waves visible on the rhythm strip. d. None of the P waves are conducted to the ventricles.

a (The treatment of ventricular tachycardia depends on whether the client has a pulse and is symptomatic with the dysrhythmia. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an Ambu bag would occur only if the client was not breathing. The client with pulseless ventricular tachycardia may be defibrillated, but the nurse first needs to check for a pulse.)

When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first? a. Check for a pulse. b. Start cardiac compressions. c. Prepare to defibrillate the client. d. Administer oxygen via an Ambu bag.

b (Having a client sit on the edge of the bed for a few minutes will allow the neurocirculatory reflexes to adjust to the force of gravity when an upright position is assumed. Although morphine sulfate administration may lower blood pressure, the nurse would not withhold analgesia from a postoperative client, especially before activity. Calcium channel blockers may also lower blood pressure, but the nurse would not withhold a prescribed medication. Early ambulation postoperatively is recommended to avoid postoperative complications such as venous thromboembolism and deconditioning.)

When getting a postoperative client out of bed, which action will the nurse take to avoid postural hypotension? a. Avoid giving the prescribed PRN morphine sulfate before getting the client up. b. Have the client sit on the edge of the bed for a few minutes before standing up. c. Withhold the prescribed calcium channel blocker until the client is already up. d. Educate the client about the reasons to avoid getting up soon after surgery.

d (Vitamin B12 is essential for appropriate maturation of red blood cells; therefore, relieving the deficiency is expected to improve hemoglobin and hematocrit levels. B12 deficiency causes pernicious anemia. Changes in electrolyte levels, impaired skin integrity, and peripheral edema are not clinical manifestations of B12 deficiency and would not be useful in determining effectiveness of therapy.)

To determine whether therapy for vitamin B12 deficiency is effective, which action will the nurse take? a. Monitor electrolyte levels. b. Assess skin integrity. c. Check for peripheral edema. d. Review hemoglobin and hematocrit levels.

c (Because blood in the femoral artery is at a high pressure and the catheter used for stenting is large, there is a high risk for hemorrhage and hematoma formation at the site of the catheter insertion. Frequent monitoring of the insertion site and vital sign checks are used to detect bleeding rapidly so that a hematoma does not occur. Infection is possible after insertion of the catheter through the femoral artery, but is not a common problem. Urinary retention and discomfort can occur because of the diuretic effect of the contrast dye used during cardiac catheterization and difficulty with voiding when clients are on bed rest postprocedure, but it is not a life-threatening complication. Orthostatic hypotension can occur because of the effect of several hours of bed rest and the diuretic effect of the contrast dye used during cardiac catheterization, but it is not as life threatening as hemorrhage and hematoma formation.)

When planning care for a client who has just returned to the nursing unit after placement of a coronary artery stent that was accomplished via access through the femoral artery, which complication is a priority for the nurse to prevent? a. Infection b. Urinary retention c. Hematoma formation d. Orthostatic hypotension

d (The usual dose of digoxin is 0.125 mg to 0.25 mg daily. A dose of 2.5 mg is excessive, and the prescription should be questioned. Two tablets would equal 0.25 mg, which may be the correct prescription, but this will need to be clarified with the primary health care provider. Twenty tablets would equal 2.5 mg, but this would be a toxic dose of digoxin. Clarifying why the digoxin is prescribed would not be useful, because the dose is inappropriate for any diagnosis.)

When preparing to give medications to a client, the nurse notes a prescription for digoxin 2.5 mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which action would the nurse take? a. Give two tablets. b. Administer 20 tablets. c. Clarify why the client is taking digoxin. d. Consult with the primary health care provider.

d (Changing position slowly when going from lying to sitting to standing gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Lying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.)

When teaching a client who has a new prescription for antihypertensive medication, which suggestion will the nurse make to minimize orthostatic hypotension? a. Wear support hose continuously. b. Lie down for 30 minutes after taking medication. c. Avoid tasks that require high-energy expenditure. d. Change position slowly when going from lying to standing.

a (A respiratory rate of 10 breaths/minute is abnormal and indicates oversedation with hydromorphone, which should be treated immediately with naloxone administration. Pain level would be assessed, but it is not as high a priority as reversing the opiate-induced respiratory depression. Documentation of findings also needs to be done, but this can be done after naloxone administration. The rapid response team may also be activated, but the nurse would not wait for the rapid response team to give the naloxone)

When the nurse obtains vital signs of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client who is receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which nursing action would be the priority? a. Give naloxone intravenously per protocol. b. Assess the client's pain level on a 10-point scale. c. Document the vital signs in the client record. d. Notify the hospital rapid response team.

c (Active participation in learning self-care indicates emotional acceptance of the need for surgery and planning for the future after surgery. Explaining the goals of the procedure may indicate intellectual readiness but not necessarily emotional readiness. A client who displays no signs of grief with a loss like amputation may be in denial. The client need not be dependent permanently; verbalizing acceptance of permanent dependency needs indicates the need for more teaching and emotional support.)

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery? a. Explains the goals of the procedure b. Displays few signs of anticipatory grief c. Participates in learning perioperative care d. Verbalizes acceptance of permanent dependency needs

b (Pulse rate and blood pressure are monitored to detect tachycardia and hypotension, which may indicate postprocedure bleeding. Maintaining the semi-Fowler position is contraindicated; flexion of the groin may compromise the clot at the femoral insertion site. A fever may indicate a bacterial invasion, but this will not be evident during the first few hours after catheterization. Encouraging frequent coughing and deep breathing is not necessary; the client did not have general anesthesia and will soon be ambulatory.)

Which action is included in nursing care for a client who just had a cardiac catheterization? a. Maintain the semi-Fowler position. b. Monitor the pulse and blood pressure. c. Take the temperature hourly until it stabilizes. d. Encourage frequent coughing and deep breathing.

c (Medication patches that interfere with electrode placement must be removed before application of AED pads because the patches may conduct electricity and interfere with defibrillation or cause burns on the chest. The AED pads would be attached after removing the medication patches. The analyze button would be pushed once the patches were attached. Bystanders would be instructed to "stand clear" after the rhythm had been analyzed and before pushing the "shock" button.)

Which action would the nurse take first when using an automated external defibrillator (AED) for a pulseless and unresponsive client? a. Attach the AED pads. b. Push the "analyze" button. c. Remove any medication patches. d. Tell bystanders to "stand clear."

c (Mobility via ambulation will reduce venous stasis and edema as well as promote arterial perfusion and healing. Bed rest is contraindicated because it promotes the development of thrombophlebitis and pulmonary emboli. Having the client sit in a chair constricts circulation through the graft and increases graft thrombosis risk. Keeping the knee in a flexed position also restricts blood flow through the graft and increases the risk for thrombosis.)

Which action would the nurse take when caring for a client on the first postoperative day after a femoral-popliteal bypass graft? a. Keep the client on bed rest. b. Have the client sit in a chair. c. Assist the client with ambulation. d. Position the client with the knees flexed.

a, d, e (Venous thrombosis is a possible complication after surgery because of venous stasis during the procedure and decreased activity after surgery. Symptoms include swelling distal to the thrombosis, and pain and warmth over the area of the thrombosis. Skin breakdown may occur with chronic venous insufficiency, but not with acute venous thrombosis. Pruritus may also occur with chronic venous disease but is not seen with venous thrombosis.)

Which findings in a client who has had major abdominal surgery indicate a possible venous thrombosis of the leg? Select all that apply. One, some, or all responses may be correct. a. Edema of the ankle b. Skin breakdown over the shin c. Pruritus on the side of the calf d. Tender area in the posterior lower leg e. Warmth along the course of the involved vessel

b, c (Food sources highest in iron are liver and beef, dried fruits (such as prunes), legumes, dark green leafy vegetables (which would include spinach), whole-grain and enriched bread and cereals, and beans. Carrots are not a high source of iron. Asparagus is not high in iron. Brussels sprouts are not high in iron.)

Which foods will the nurse include when suggesting dietary sources of iron to a client with anemia? Select all that apply. One, some, or all responses may be correct. a. Raw carrots b. Boiled spinach c. Dried prunes d. Brussel sprouts e. Asparagus spears

a (Carbonated beverages generally are high in sodium and should be avoided. Steak sauce is high in sodium and should be avoided. Many dairy products contain sodium and should be avoided. Artificial sweeteners do not contain sodium and do not have to be restricted.)

Which information would the nurse include when teaching a client how to reduce the dietary intake of sodium? a. Avoid carbonated beverages. b. Use steak sauce for flavoring foods. c. Increase the intake of dairy products. d. Restrict the use of artificial sweeteners.

d (Knowledge of the signs and symptoms for hypoglycemia or hyperglycemia is critical to the client's health and well-being and essential for survival. Although performing foot care is important, it should be done daily. The client has type 2 diabetes, which is usually controlled by oral hypoglycemic, not insulin. Self-serum glucose monitoring is more accurate than sugar and acetone urine measurements to identify serum glucose levels.)

Which is an appropriate teaching goal for a client who is newly diagnosed as having type 2 diabetes? a. To perform foot care weekly b. To administer insulin as prescribed c. To test urine for both sugar and acetone d. To identify symptoms of hypoglycemia or hyperglycemia

a (Research indicates that rapid defibrillation is the most successful intervention when resuscitating a client who has cardiac arrest due to ventricular fibrillation. Guidelines recommend defibrillation as the initial action. IV access for emergency medication is needed, but would be done after defibrillation. Bag-mask ventilation is necessary, but would be done after defibrillation. High-quality chest compressions are needed if defibrillation is unsuccessful in restoring a more normal rhythm.)

Which is the priority intervention for the unconscious client in ventricular fibrillation? a. Defibrillation b. Starting intravenous (IV) access c. Bag-mask ventilation d. High-quality chest compressions