NUR 114 Test 4

NORMAL side effect are swollen/bleeding gums

...

A patient is experiencing status epilepticus. The nurse prepares to give which drug of choice for the treatment of this condition? 1. Diazepam (Valium) 2. Midazolam (Versed) 3. Valproic acid (Depakote) 4. Carbamazepine (Tegretol)

1

The nurse has given medication instructions to a patient receiving phenytoin (Dilantin). Which statement by the patient indicates that the patient has an adequate understanding of the instructions? 1. "I will need to take extra care of my teeth and gums while on this medication." 2. "I can go out for a beer while on this medication."

1.

During a routine appointment, a patient with a history of seizures is found to have a phenytoin (Dilantin) level of 23 mcg/mL. What concern will the nurse have, if any? The patient is at risk for seizures because the drug level is not at a therapeutic level. The patient's seizures should be under control because this is a therapeutic drug level. The patient's seizures should be under control if she is also taking a second antiepileptic drug. The drug level is at a toxic level, and the dosage needs to be reduced.

4.

Phenytoin (Dilantin) has a narrow therapeutic index. The nurse recognizes that this characteristic means that a.the safe and the toxic plasma levels of the drug are very close to each other. b.phenytoin has a low chance of being effective. c.there is no difference between safe and toxic plasma levels. d.a very small dosage can result in the desired therapeutic effect.

A

Which precautions will the nurse institute to ensure the safety of a client with epilepsy who has been hospitalized? (Select all that apply.) a. Have suction equipment at the bedside b. Place a padded tongue blade at bedside c. Permit only clear oral fluids d. Keep bed rails up at all times e. Maintain the client on strict bedrest f. Ensure that the client has IV access

A,D,F

A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. Have you been experiencing any constipation? b. Are you eating a diet high in fiber and fluids? c. Do you have a history of high blood pressure? d. What vitamins and supplements are you taking?

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

ANS: C

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? A. Complete blood count B. Culture and sensitivity C. Prostate-specific antigen D. Cystoscopy

ANS: C The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

B

The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurses priority action? a. Restrain the clients extremities. b. Turn the clients head to the side. c. Take the clients blood pressure. d. Place an airway into the clients mouth.

B

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patients arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

C

child has seizure for more than 5 MINS🡪

CALL 911

Status epileptics med

Lorazepam

Why do we keep the foley cath

allows for healing of the sutures without worry of urine leaking from bladder into wrong spaces.

carbamazepine (Tegretol)—side effects—safety🡪

help when getting out of the bed

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care? a. You may experience nausea and vomiting for the first few weeks. b. Carbonated beverages can help decrease acid reflux from anastomosis sites. c. Take a stool softener to promote softer stools for ease of defecation. d. You may return to your normal workout schedule, including weight lifting.

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. Eat low-fiber and low-residual foods. b. White rice and bread are easier to digest. c. Add vegetables such as broccoli and cauliflower to your new diet. d. Foods high in animal fat help to protect the intestinal mucosa.

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

ANS: C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia Results from inadequate healing of an incision e. Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.

ANS: A Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the clients bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

A patient will be taking a 2-week course of combination therapy with omeprazole (Prilosec) and another drug for a peptic ulcer caused by Helicobacter pylori. The nurse expects a drug from which class to be ordered with the omeprazole? A. Antibiotic B. Nonsteroidal anti-inflammatory drug C. Antacid D. Antiemetic

ANS: A The antibiotic clarithromycin is active against H. pylori and is used in combination with omeprazole to eradicate the bacteria. First-line therapy against H. pylori includes a 10- to 14-day course of a proton pump inhibitor such as omeprazole, plus the antibiotics clarithromycin and either amoxicillin or metronidazole, or a combination of a proton pump inhibitor, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole. Many different combinations are used.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the clients gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the clients job risks.

ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? A. Alpha-fetoprotein (AFP) B. Prostate-specific antigen (PSA) C. Prostate acid phosphatase (PAP) D. C-reactive protein (CRP)

ANS: A AFP is a glycoprotein that is elevated in testicular cancer. PSA and PAP testing is used in the screening of prostate cancer. CRP is diagnostic for inflammatory conditions.

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? Cloudy urine Urinary hesitancy Post-void dribbling Weak urinary stream

ANS: A Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a. The treatment reduces testosterone and prevents bone fractures. b. The medications prevent erectile dysfunction and increase libido. c. There is less gynecomastia and osteoporosis with this drug regimen. d. These medications both inhibit tumor progression by blocking androgens.

ANS: A Lupron, an LH-RH agonist, stimulates the pituitary gland to release luteinizing hormone (LH) to the point that the gland is depleted of LH and testosterone production is lessened. This may decrease the prostate cancer since it is hormone dependent. Lupron can cause osteoporosis, which results in the need for Aredia to prevent bone loss. Erectile dysfunction, decreased libido, and gynecomastia are side effects of the LH-RH medications. Antiandrogen drugs inhibit tumor progression by blocking androgens at the site of the prostate.

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.