NURS 502 FINALS REVIEW

Which structure indicated in the figure is the primary reproductive organ of the female? Click this link to find out the following image: https://bit.ly/3E45z9c

A Label A indicates the ovary, the primary reproductive organ of a female. Label B indicates the fallopian tubes, label C indicates the uterus, and label D indicates the symphysis pubis. The fallopian tubes, uterus, and vagina are the secondary reproductive organs of the female.

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected. A test for the human immunodeficiency virus (HIV) is performed and acute retroviral syndrome is diagnosed. Which clinical responses are associated most commonly with this syndrome? Select all that apply. A. Malaise B. Confusion C. Constipation D. Swollen lymph glands E. Oropharyngeal candidiasis

A & D Development of HIV-specific antibodies (seroconversion) is accompanied by a flu-like syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs 1 to 3 weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flu-like syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or an opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. A. Rye B. Oats C. Rice D. Corn E. Wheat

A, B, & E Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability? A. Cola drinks B. Gelatin C. Fiber D. Rice

A. Cola drinks The caffeine in cola is chemically irritating to the intestinal mucosa. Caffeine also promotes secretion of gastric juice. Gelatin is absorbed slowly and is not irritating. Rice does not irritate the bowel and need not be restricted. Fiber is increased in irritable bowel syndrome to provide bulk and regular bowel habits.

A client scheduled for a transurethral prostatectomy expresses concern about the effect the surgery will have on sexual ability. Which information should the nurse share with the client? A. May experience retrograde ejaculations B. May have a diminished sex drive C. Will have prolonged erections D. Will be impotent

A. May experience retrograde ejaculations Ejection of semen into the bladder instead of the urethra is common after a transurethral prostatectomy. The surgery should not interfere with the libido and will not cause prolonged erections. Impotence is not typical with this approach; it may occur with the retroperitoneal approach.

A health care provider prescribes cholestyramine, an anion exchange resin, to treat a client's persistent diarrhea. What vitamin does the nurse anticipate may become deficient because cholestyramine reduces the absorption of fat? A. Retinol (Vitamin A) B. Riboflavin (Vitamin B2) C. Thiamine (Vitamin B12) D. Pyridoxine (Vitamin B6)

A. Retinol (Vitamin A) Cholestyramine is a fat-binding agent; it binds with and interferes with all the fat-soluble vitamins (A, D, E, and K). Thiamine is not a fat-soluble vitamin and is unaffected. Riboflavin is not a fat-soluble vitamin and is unaffected. Vitamin B6 is not a fat-soluble vitamin and is unaffected.

The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take? A. Clamp the tube. B. Consider this an expected event. C. Instill the tube with iced normal saline. D. Notify the surgeon immediately.

B. Consider this an expected event. As a result of the trauma of surgery, some bleeding can be expected for four to five hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? A. Snack daily in the evenings B. Divide food into four to six meals a day C. Eat the last of three daily meals by 8:00 PM D. Suck a peppermint candy after each meal

B. Divide food into four to six meals a day The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.

A client who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. Which substance removal should the nurse share with the client? A. Blood B. Sodium C. Glucose D. Bacteria

B. Sodium Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. Red blood cells do not pass through the semipermeable membrane during hemodialysis. Glucose does not pass through the semipermeable membrane during hemodialysis. Bacteria do not pass through the semipermeable membrane during hemodialysis.

A nurse is caring for a client who had surgery for the formation of a continent urostomy. The nurse engages the client in early postoperative ambulation to prevent what complication? A. Wound infection B. Urinary retention C. Abdominal distention D. Incisional evisceration

C. Abdominal distention Bed rest weakens the perineal and abdominal muscles used in defecating; ambulation promotes peristalsis and improves muscle tone, thereby facilitating expulsion of flatus and promoting defecation. Early ambulation will not prevent a wound infection. There will be no urinary retention because the surgery involved removal of the bladder and the creation of a permanent urinary diversion. Early ambulation will not prevent incisional evisceration.

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable? A. Blue B. Gray C. Brick red D. Dark purple

C. Brick red A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

Which drug would be effective for the treatment of pituitary Cushing's syndrome? A. Mitotane B. Cabergoline C. Cyproheptadine D. Bromocriptine mesylate

C. Cyproheptadine Cyproheptadine is effective for the treatment of pituitary Cushing's syndrome. Mitotane is prescribed for the treatment of adrenal Cushing's syndrome. Cabergoline and bromocriptine mesylate are effective for the treatment of hyperpituitarism.

What characteristic of an adolescent girl suggests to the nurse that she has bulimia? A. History of gastritis B. Positive self-concept C. Excessively stained teeth D. Frequent re-swallowing of food

C. Excessively stained teeth Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food (rumination) and re-swallowing of food are not associated with bulimia; emptying of the stomach contents through the mouth (vomiting) is associated with bulimia.

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? A. Urge incontinence B. Stress incontinence C. Overflow incontinence D. Functional incontinence

C. Overflow incontinence Overflow incontinence [1] [2] [3] describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities).

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? A. Fruits B. Grains C. Red meat D. Vegetable oils

C. Red meat Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.

A client who is a heavy smoker has been prescribed a high-calorie, high-protein diet. The nurse should encourage the client to eat foods that are high in which vitamin? A. Niacin B. Thiamine C. Vitamin C (ascorbic acid) D. Vitamin B12

C. Vitamin C (ascorbic acid) Smoking accelerates oxidation of tissue vitamin C (ascorbic acid). As a result, smokers need an additional 35 mg/day. Niacin is not oxidized more rapidly in the smoker. Thiamine is not oxidized more rapidly in the smoker. Vitamin B12 is not oxidized more rapidly in the smoker.

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A. Antacids should be taken 1 hour before meals. B. These should be scheduled at 4-hour intervals. C. Antacid tablets are just as fast and effective as the liquid form. D. Antacids commonly interfere with the absorption of other drugs.

D. Antacids commonly interfere with the absorption of other drugs. Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin. Liquid antacids are faster acting and more effective than antacid tablets. Antacids should be taken 1 or 2 hours after meals and at bedtime. Antacid tablets may be taken more frequently than every 4 hours.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A. Fatigue B. Anorexia C. Yellow urine D. Clay-colored stools

D. Clay-colored stools Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When the client sets outcomes, what need is it important for him to understand? A. Plan to avoid people who drink. B. Accept that he is a fragile person. C. Develop new social drinking skills. D. Restructure his life without alcohol

D. Restructure his life without alcohol Clients must learn new lifestyles and coping skills[1] [2] to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.

The primary healthcare provider has prescribed an intravenous piggyback (IVPB) to be administered every 4 hours. The prescription is 1200 mg vancomycin, which must be added to 50 mL D5W after being diluted according the pharmacy's instructions. After the nurse dilutes the powdered medication with the correct amount of saline, the resulting solution contains 1 gram of drug per 3 mL. How much antibiotic solution should be added to the 50 mL of D5W? Record your answer using one decimal place. ___ mL

The prescribed dose is 1200 mg. The available concentration of drug is 1 g/3 mL. The prescribed dose should first be converted to the available concentration. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be added to 50 mL D5W. (Copy & paste image link on an extra tab for written solution: https://eaq.elsevier.com/Libraries/EAQ_NCLEX-RN_2-0/QB-k3dz/Q-2996-x4y1jski/9t8b/Drug+calculation+questions_gold_1_Q33.png)

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply. A. Tremors in both hands make it difficult for the client to hold a cup. B. The client's systolic blood pressure has dropped 6 points over the last 6 hours. C. The client was observed falling asleep while talking on the telephone to family. D. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. E. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.

A, D, & E Diaphoresis and tremors are physical characteristics of alcohol withdrawal. Agitation is a psychosocial characteristic of alcohol withdrawal. Systolic blood pressure would rise rather than fall if the client were experiencing alcohol withdrawal. Insomnia, rather than drowsiness, is a physical characteristic of alcohol withdrawal.

The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? A. Being physically immobile B. Sobbing for no apparent reason C. Reporting great difficulties falling asleep D. Startling easily to loud noises and being touched

A. Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress? A. Bland foods B. Regular diet C. Gluten-free foods D. Low-carbohydrate foods

A. Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

What intervention should the nurse implement when caring for a client 24-hours post-thyroidectomy? A. Check the sides of the operative site dressing and the back of neck. B. Support the head during mild range-of-motion (ROM) exercises. C. Encourage the client to ventilate feelings about the surgery. D. Advise the client that regular activities can be resumed immediately.

A. Check the sides of the operative site dressing and the back of neck. Bleeding may occur and blood will pool in the back of the neck due to gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods should be encouraged.

During group therapy, the working phase usually begins when the group displays what? A. Cohesiveness B. Confrontation C. Imitative behavior D. Corrective recapitulation

A. Cohesiveness When the group becomes united (cohesive), the clients can feel accepted, valued, and part of the group; this is the optimal time for the working phase to begin. Confrontation, imitative behavior, and corrective recapitulation all occur later in the working phase of group process, not in the beginning.

A financially struggling, large family is instructed by the home health nurse about ways to increase the dietary intake of calcium. Which suggestion should the nurse make? A. Collards or kale in one meal a day B. Fruit-flavored yogurt every other day C. Bread made with cornmeal each morning D. Eight ounces (240 mL) of milk with every meal

A. Collards or kale in one meal a day Leafy green vegetables are an excellent source of calcium, are inexpensive, and can be home-grown; collards and kale are high in calcium. Yogurt does contain calcium, but it is costly for a large, financially struggling family. Cornbread and other bread products provide limited sources of calcium unless specifically enriched, making them more expensive. Although milk contains calcium, serving milk at every meal exceeds the recommended amount of milk for adults and is costly.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? A. Depression B. Dependency C. Marital stress D. Identity confusion

A. Depression Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

Which hormone is released from the posterior pituitary gland? A. Oxytocin B. Prolactin C. Growth hormone D. Luteinizing hormone

A. Oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply.

Which hormone does the nurse state has both inhibiting and releasing action? A. Prolactin B. Somatostatin C. Somatotropin D. Gonadotropin

A. Prolactin Prolactin secreted by the hypothalamushas both inhibiting and releasing action. Somatostatin inhibits the secretion of growth hormone. Somatotropin and gonadotropin are releasing hormones.

After interacting with a client, a nurse finds that a 23-year-old client has never undergone a Papanicolaou (Pap) test. What should the nurse suggest to the client? A. Schedule a Pap test immediately B. Schedule a Pap test during menses C. Schedule a Pap test every five years D. Schedule a Pap test and human papillomavirus test

A. Schedule a Pap test immediately The Papanicolaou test (Pap test) is a cytologic study performed annually after the age of 21 years. The nurse should advise a 23-year-old client to undergo a Pap test immediately to rule out precancerous and cancerous cells within the client's cervix. Undergoing a Pap test during menses may interfere with laboratory analysis and results. A human papillomavirus test is performed every 5 years. Pap tests and human papillomavirus tests are recommended in clients between the ages of 30 and 65 years.

Which electrolyte deficiency triggers the secretion of renin? A. Sodium B. Calcium C. Chloride D. Potassium

A. Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

The nurse is reviewing a client's current medication therapy and suspects hematuria. Which medication is responsible for the client's condition? A. Warfarin B. Cimetidine C. Phenazopyridine D. Nitrofurantoin

A. Warfarin Warfarin is an anticoagulant. Anticoagulants may cause hematuria, which is the presence of blood in the urine. Cimetidine is an antihistamine. Antihistamines affect the normal contraction and relaxation of the urinary bladder. Phenazopyridine and nitrofurantoin cause urine discoloration.

A nurse is teaching a client about self-management techniques for smoking cessation. Which statement made by the client indicates the need for further teaching? A. "I should list the reasons why I should stop smoking." B. "I should visit all the places where I started smoking." C. "I should remove all ashtrays and lighters." D. "I should try replacing tobacco with sugarless mints and gum."

B. "I should visit all the places where I started smoking." Clients may be tempted to smoke if they visit the places where they started smoking. Listing the reasons to stop smoking may help the client to prevent smoking. Removing ashtrays and lighters from the environment may help the client to prevent smoking. When the client is tempted to smoke, sugarless mints and gums may act as good substitutes for tobacco smoking.

The nurse is providing postoperative care 8 hours after a client had a total cystectomy and the formation of an ileal conduit. Which assessment finding should be reported immediately? A. Edematous stoma B. Dusky-colored stoma C. Absence of bowel sounds D. Pink-tinged urinary drainage

B. Dusky-colored stoma A dusky-colored stoma may denote a compromised blood supply to the stoma and impending necrosis. An edematous stoma and absence of bowel sounds are expected in the early postoperative period after this surgery. Pink-tinged urine may be present in the immediate postoperative period.

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known? A. Iliac area B. Epigastric area C. Hypogastric area D. Suprasternal area

B. Epigastric area The stomach is located within the sternal angle, known as the epigastric area. The iliac area is in the area of the iliac bones. The hypogastric area is the lowest middle abdominal area. The suprasternal area is the area above the sternum.

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward? A. Being understanding B. Establishing a patent airway C. Maintaining a drug-free environment D. Establishing a therapeutic relationship

B. Establishing a patent airway The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized. Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? A. Medical treatment is curative; surgery is not required. B. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. C. For most clients, surgery is recommended early in the course of treatment. D. Medical treatment is all that will be needed if the client can maintain emotional stability.

B. For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. That medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.

A nurse in the emergency department is assigned a recently admitted client. The nurse reviews the client's progress notes, obtains the vital signs, and performs a physical assessment. Which intervention should the nurse anticipate the primary healthcare provider will prescribe initially? Check this photo link for choices: https://bit.ly/3JzmSjL A. Pain medication B. Intravenous fluids C. Multiple antibiotics D. Packed red blood cell

B. Intravenous fluids The client probably is experiencing hypovolemic shock, as evidenced by the vital signs (elevated pulse and respirations and low blood pressure). Intravenous fluids will help correct the hypovolemia. Analgesics should not be administered until after the client is assessed fully, particularly for a head injury. Antibiotics may be prescribed eventually, but this is not the initial intervention. Packed red blood cells eventually may be administered, but this depends on an additional physical assessment and hematologic laboratory tests.

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? A. Monitor vital signs. B. Maintain an open airway. C. Maintain fluid and electrolytes. D. Monitor pupil response and equality.

B. Maintain an open airway. A patent airway is the priority because the airway may become occluded by the tongue in an unconscious client. Monitoring vital signs is not the priority, although it is an important nursing function. Monitoring pupil response and equality and maintaining fluid and electrolytes are not the priority, although they are important nursing functions.

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? A. Residual B. Paranoid C. Catatonic D. Disorganized

B. Paranoid Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? A. Irritability, polydipsia, and polyuria B. Polyuria, polydipsia, and polyphagia C. Nocturia, weight loss, and polydipsia D. Polyphagia, polyuria, and diaphoresis

B. Polyuria, polydipsia, and polyphagia Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? A. Projection B. Regression C. Repression D. Rationalization

B. Regression Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.

Three days before surgery for a permanent colostomy for cancer of the colon, a client is receptive of all procedures, responds pleasantly when approached, and does not question staff about what is being done. What is the most appropriate conclusion for the nurse to make based on these behaviors? A. The client has been fully informed about what to expect. B. The client is not verbalizing feelings about what will happen. C. The client cannot accept the illness and the need for surgery. D. The client feels reassured by frequent contact with health team members.

B. The client is not verbalizing feelings about what will happen. Both a diagnosis of cancer and a colostomy drastically alter self-image and body image. People react differently to this stress, often finding it difficult to express their concerns verbally; however, their actions may demonstrate awareness of the situation. Not enough information is available to support the conclusions that the client is fully informed about expectations, is not accepting of the illness and the need for surgery, or is feeling reassured by healthcare members.

The registered nurse is preparing to assess a client's renal system. Which statement by the nurse indicates effective technique? A. "I must first palpate the client if a tumor is suspected." B. "I must first listen for normal pulse at the client's wrist region." C. "I must first auscultate the client and then proceed to percussion and palpation." D. "I must first examine tender abdominal areas and then proceed to nontender areas."

C. "I must first auscultate the client and then proceed to percussion and palpation." Palpation and percussion can cause an increase in normal bowel sounds and hide abdominal vascular sounds. Therefore it is wise to perform auscultation prior to percussion and palpation during clinical assessment of the renal system. Palpation should be avoided if a client is suspected of having a tumor because it could harm the client. It is more important as part of clinical assessment of the renal system to listen for bruit by auscultating over the renal artery. Bruit indicates renal artery stenosis. The nontender areas should be examined prior to tender areas to avoid confusion regarding radiating pain from the tender area being percussed.

A client has been diagnosed with anemia. Which decreased hormone level may be the cause? A. Bradykinin B. Prostaglandin C. Erythropoietin D. Activated vitamin D

C. Erythropoietin Erythropoietin stimulates the production of red blood cells (RBCs) in the bone marrow. Deficiency of erythropoietin causes a decrease in RBCs, thereby resulting in anemia. Bradykinin increases blood flow and vascular permeability. Prostaglandins regulate kidney perfusion. Activated vitamin D promotes the absorption of calcium in the gastrointestinal (GI) tract.

A nurse is caring for a client with a diagnosis of benign prostatic hyperplasia (BPH). Which information about this condition is important for the nurse to consider when caring for this client? A. It is a congenital abnormality. B. A malignancy usually results. C. It predisposes to hydronephrosis. D. Prostate-specific antigen decreases.

C. It predisposes to hydronephrosis. Inability to empty the bladder as a result of pressure exerted by the enlarging prostate on the urethra causes a backup of urine into the ureters and finally the kidneys (hydronephrosis). BPH develops over the client's life span; it is not congenital. It is uncommon for BPH to become malignant. Prostate-specific antigen will increase.

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? A. Offering psychological support B. Monitoring the client's fluid balance C. Keeping the client's respiratory passages patent D. Providing a pad and pencil for writing messages

C. Keeping the client's respiratory passages patent A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response? A. Hypothyroidism is a gradual slowing of the body's function. B. A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. C. Less thyroid tissue is available to supply thyroid hormone after surgery. D. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

C. Less thyroid tissue is available to supply thyroid hormone after surgery. After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? A. Increase your intake of fat with each meal. B. Lie down after eating to help your digestion. C. Reduce your caloric intake to foster weight reduction. D. Drink several glasses of fluid during each of your meals.

C. Reduce your caloric intake to foster weight reduction. Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase pressure; fluid should be discouraged with meals.

When planning care for a client who has just completed withdrawal from multiple-drug abuse, what reality in relation to the client should the nurse take into consideration? A. Unable to give up drugs B. Unconcerned with reality C. Unable to delay gratification D. Unaware of the danger of drug addiction

C. Unable to delay gratification A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are concerned with reality, and their drug use is an attempt to blur the pains of reality. Intellectually these people may be aware of the dangers of drug addiction, but emotionally they cannot buy into the reality that it can happen to them.

A client who had a myocardial infarction requests assistance to have a bowel movement. What should the nurse do? A. Place the client on a bedpan. B. Help the client into the bathroom. C. Roll the client onto a fracture pan. D. Assist the client to a bedside commode

D. Assist the client to a bedside commode Defecation in the sitting position on a bedside commode uses less energy than walking to the bathroom or getting on and off a bedpan. Defecation is difficult on a bedpan and may cause straining and an increase in oxygen demands. Walking to the bathroom uses more energy than using a bedside commode. Although the use of a fracture pan takes less energy than using a regular bedpan, it takes more energy than using a commode.

The nurse reviews the kidney function blood studies of four clients. Which client may have kidney impairment? Check the following image in this link: https://bit.ly/3uz5kzX A. Client 1 B. Client 2 C. Client 3 D. Client 4

D. Client 4 A serum creatinine test is a great tool for determining kidney function. Blood urea nitrogen (BUN) tests measure the effectiveness of urea nitrogen. The normal range of serum creatinine lies between 0.6 and 1.2 mg/dL (53.04-106.08 mmol/L). The normal range of BUN lies between 10 and 20 mg/dL (3.57-7.14 mmol/L). Client 4's levels indicate kidney impairment. The serum creatinine and BUN are within normal limits for clients 1, 2, and 3.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do? A. Shave the client's abdomen. B. Medicate the client for pain. C. Encourage the client to drink fluids. D. Instruct the client to empty the bladder.

D. Instruct the client to empty the bladder. Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. Shaving the client's abdomen and medicating the client for pain are not necessary. Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate? A. Echolalia B. Neologisms C. Flight of ideas D. Loosening of associations

D. Loosening of associations Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

The primary healthcare provider confirms that the client has myopia. Which type of test did the nurse perform to help the primary healthcare provider reach this conclusion? A. Perimetry B. Jaeger card C. Ishihara chart D. Snellen eye chart

D. Snellen eye chart Myopia indicates nearsightedness. This is a condition in which a client cannot see distant images clearly, and the Snellen eye chart is used to measure distance vision. Perimetry is the computerized test performed to determine the degree of peripheral vision. The Rosenbaum Pocket Vision screener or a Jaeger card is the eye chart used to determine near vision. An Ishihara chart is used to determine a client's ability to see colors.

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, what prescription does the nurse anticipate? A. High-fat diet B. Supplemental cod liver oil C. Total parenteral nutrition (TPN) D. Water-soluble forms of vitamins A and E

D. Water-soluble forms of vitamins A and E Vitamins A, D, E, and K are known as fat-soluble vitaminsbecause bile salts and other fat-related compounds aid their absorption. A high-fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.

A nurse is caring for a client after a total knee replacement who is requesting hydrocodone/acetaminophen in addition to the patient-controlled analgesia (PCA). The client reports having taken two hydrocodone/acetaminophen tablets every 4 hours for several weeks before surgery. If each tablet contains 500 mg of acetaminophen, how much acetaminophen had the client been ingesting per day? Record your answer using a whole number with no punctuation. ___ mg

Two tablets every 4 hours over 24 hours equals a total of 12 tablets daily. Because each tablet has 500 mg, then 500 × 12 = 6000 mg. This is more than the recommended maximum dose of 4000 mg/24 hr for short-term use.

A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply. A. Increased heart rate B. Increased temperature C. Decreased respirations D. Increased pulse deficit E. Decreased blood pressure

A & B Thyroid storm is severe hyperthyroidism; excessive amounts of thyroxine increase the metabolic rate, thereby causing an increased heart rate (tachycardia). Because of the increased metabolic rate associated with thyroid storm, body temperature will increase. Because of the increased metabolic rate associated with thyroid storm, the respiratory rate increases (tachypnea) to meet the body's oxygen needs. Pulse deficit, the difference between apical and peripheral pulse rates, is not indicative of thyroid storm. The blood pressure will increase to meet the oxygen demand caused by the increased metabolic rate during thyroid storm.

What are the primary causes of adrenal insufficiency? Select all that apply. A. Hemorrhage B. Tuberculosis C. Pituitary tumors D. Postpartum pituitary necrosis E. Acquired immune deficiency syndrome

A, B, E The primary causes of adrenal insufficiency are hemorrhage, tuberculosis, and acquired immune deficiency syndrome. Pituitary tumors and postpartum pituitary necrosis are the secondary cases of adrenal insufficiency.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement? A. "I should wash my hands frequently." B. "I should launder my clothes separately." C. "I should put used tissues in the garbage." D. "I should wear a mask when leaving the house."

A. "I should wash my hands frequently." Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "Launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Putting used tissue in the garbage is important, but handwashing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A. Monthly injections of cyanocobalamin B. Regular daily use of a stool softener C. Weekly injections of iron dextran D. Daily replacement therapy of pancreatic enzymes

A. Monthly injections of cyanocobalamin Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? A. Use lemon juice to season meat. B. Put condiments on food to add flavor. C. Include canned vegetables in meal preparation. D. Drink carbonated beverages instead of decaffeinated coffee.

A. Use lemon juice to season meat. Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? A. Wait until a family member is also present. B. Assess the client's barriers to learning self-injection techniques. C. Begin with simple written instructions describing the technique. D. Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.

B. Assess the client's barriers to learning self-injection techniques. 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. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern to the nurse? A. Glasgow Coma Scale (GCS) score of 8 B. Bleeding from the ears C. Pupils reactive to light D. Depressed fontanel

B. Bleeding from the ears Bleeding from the ears occurs with basal skull fractures; this assessment assists with diagnosing the location of the injury. A Glasgow Coma Scale of 8 indicates the client is unconscious, which is already specified in the scenario; therefore, it is not as concerning as the bleeding from the ears. A reactive pupil is a positive response; pupils should react to light. A depressed fontanel occurs in an infant in the presence of dehydration.

Which disease is caused by the deficiency of antidiuretic hormone? A. Acromegaly B. Diabetes insipidus C. Cushing's syndrome D. Syndrome of inappropriate antidiuretic hormone

B. Diabetes insipidus Diabetes insipidus is caused by the deficiency of antidiuretic hormone. Acromegaly and Cushing's syndrome are not associated with antidiuretic hormone; excessive production of growth hormone results in acromegaly and excessive production of adrenocorticotropic hormone causes Cushing's syndrome. Syndrome of inappropriate antidiuretic hormone occurs due to increased production of antidiuretic hormone.

What nursing intervention is anticipated for a client with Guillain-Barré syndrome? A. Providing a straw to stimulate the facial muscles B. Maintaining ventilator settings to support respiration C. Encouraging aerobic exercises to avoid muscle atrophy D. Administering antibiotic medication to prevent pneumonia

B. Maintaining ventilator settings to support respiration Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin is prescribed. What is an important nursing action associated with this drug? A. Administer the digoxin 1 hour after the client's morning insulin B. Monitor the client for atrial fibrillation and first-degree heart block C. Administer the medication with 8 ounces (240 mL) of orange juice D. Withhold the medication if the apical pulse rate is greater than 60 beats/min

B. Monitor the client for atrial fibrillation and first-degree heart block The speed of conduction is decreased when digoxin is given, and this can result in premature beats, atrial fibrillation, and first-degree heart block. Digoxin does not deplete potassium and therefore orange juice does not need to be given; orange juice is high in calories and needs to be calculated in the diet. Insulin and digoxin can be given at the same time. The purpose of the drug is to reduce a rapid heart rate and therefore should be administered; it should be withheld when the client's heart rate decreases below a parameter set by the healthcare provider (e.g., 60 beats/min).

Which gland does the nurse state is an exocrine gland? A. Thyroid gland B. Salivary gland C. Pituitary gland D. Parathyroid gland

B. Salivary gland Exocrine glands are glands with ducts that produce enzymes but not hormones. These glands secrete enzymes into ducts. The salivary gland secreting saliva is an example of an exocrine gland. Endocrine glands are ductless glands that produce hormones that are secreted into the blood. Thyroid, pituitary, and parathyroid glands are examples of endocrine glands.

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? A. Auscultate for breath sounds. B. Suction the client's oropharynx. C. Administer and continue to monitor oxygen via nasal cannula. D. Place the client in the orthopneic position.

B. Suction the client's oropharynx. A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway. Oxygen administration will be useless if the airway is not patent. Placing the client in the orthopneic position is unsafe for a client with Guillain-Barré syndrome. The client will be unable to maintain this position. Muscle weakness involves the lower extremities, progressing to the upper extremities and diaphragm.

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is mostindicative of increasing intracranial pressure? A. Polyuria B. Tachypnea C. Increased restlessness D. Intermittent tachycardia

C. Increased restlessness Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? A. Responds to any stimulus B. Responds to physical contact C. Unresponsiveness to the environment D. Interacts with children rather than adults

C. Unresponsiveness to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact; they also have impaired interpersonal relationships regardless of the age of the other person.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? A. Weigh the client daily. B. Restrict the client's oral fluid intake. C. Measure the client's urine specific gravity. D. Observe the client for increasing confusion.

D. Observe the client for increasing confusion. An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

Which instructions given to a client with renal calculi would be most beneficial? Select all that apply. A. "Drink plenty of water." B. "Have spinach soup every day." C. "Substitute lemon juice for tea." D. "Include high amounts of protein in the diet." E. "Consume foods rich in omega-3-fatty acids."

A & C Renal calculi is the formation of kidney stones. Drinking plenty of water will keep the body hydrated and prevent further formation of stones. Tea contains caffeine, a diuretic, which causes dehydration. Therefore the client must be advised to replace tea with lemon juice. Spinach is rich in oxalates. Consuming spinach soup may aggravate the problem, due to the formation of oxalate crystals. Excessive consumption of proteins may precipitate uric acid stones. Therefore the use of proteins should not be encouraged. Foods rich in omega-3-fatty acids are beneficial in maintaining good health. However, the use of omega-3-fatty acids, specifically in the treatment, mitigation, or prevention of kidney stones, is not justified.

A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply. A. Meditation B. Mental imagery C. Token economy D. Operant conditioning E. Deep-breathing exercises

A, B, E Meditation lowers heart and blood pressure rates, decreases levels of adrenal corticosteroids, improves mental alertness, and increases a sense of calmness and peace. Imagery is the internal experience of memories, dreams, fantasies, and visions that serves as a bridge connecting the body, mind, and spirit; its distractive ability decreases adrenal corticosteroids, promotes muscle relaxation, and increases a sense of calmness and peace. Deep breathing increases oxygenation and releases tension in the muscles of the neck, shoulders, and torso. Token economy is a behavioral theory that acknowledges acceptable behavior with a reward (token) that can be redeemed for something that has a perceived value (e.g., a desirable activity). Operant conditioning, a behavioral therapy, is the learning of a particular type of behavior followed by a reward.

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. A. Respiratory depression B. Distention of the bladder C. Decreased blood pressure D. Fine tremor of the fingers E. High-pitched gurgling bowel sounds

A, C, E Anticholinergic effects of pyridostigmine can cause life-threatening respiratory depression, bronchospasm, laryngospasm, and respiratory arrest. Anticholinergic effects of pyridostigmine can cause hypotension, tachycardia, bradycardia, dysrhythmias, and cardiac arrest. Pyridostigmine is an anticholinergic that increases the peristaltic activity of the intestines. The result is hyperactive bowel sounds. Bladder distention is not associated with pyridostigmine. Although pyridostigmine can cause uncoordination, it does not cause fine tremors of the hands.

A nurse is assessing a client with diabetes insipidus. Which signs indicative of diabetes insipidus should the nurse identify when assessing the client? Select all that apply. A. Excessive thirst B. Increased blood glucose C. Dry mucous membranes D. Increased blood pressure E. Decreased serum osmolarity F. Decreased urine specific gravity

A, C, F As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Diabetes mellitus affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective? A. "I should call the clinic if my eye begins to hurt." B. "I am so glad that I can take a shower tomorrow." C. "There will be bright flashes of light for a few days." D. "My vision should show some improvement by tomorrow."

A. "I should call the clinic if my eye begins to hurt." Pain after a cataract extraction and intraocular lens implant may indicate infection, increased intraocular pressure, or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.

A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching? A. "I wanted another child, and now pregnancy is not an option for me." B. "I must allow extra time for irrigating my colostomy when traveling." C. "It is good to know that I can swim every day after my incision heals." D. "I'm glad I won't have to have special clothing and I can wear what I have."

A. "I wanted another child, and now pregnancy is not an option for me." Pregnancy is possible; it should be determined whether the client is referring to physiologic capability or emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or intestine. There are no adaptations or restrictions on the types of clothing.

The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease? A. 25% B. 50% C. 75% D. 100%

A. 25% Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. Other options, such as 50%, 75%, and 100%, are not plausible. However, the children do have a 50% chance of being carriers.

What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux? A. Avoid walking swiftly by the client. B. Keep the client in the prone position. C. Discontinue oral hygiene temporarily. D. Massage both sides of the face frequently.

A. Avoid walking swiftly by the client. The nurse should avoid walking swiftly past the client because drafts or even slight air currents can initiate pain [1] [2]. The client may assume any position of comfort, but pressure on the face while in the prone position may trigger an attack. Although the procedure for oral hygiene may be modified, it is not discontinued. Massaging may trigger an attack and should be avoided.

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? A. Encourage the client to rest for short periods. B. Continue the bath while supporting the client's arms. C. Gradually increase the client's activity level each day. D. Administer a dose of pyridostigmine bromide.

A. Encourage the client to rest for short periods. Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins. Continuing the bath while supporting the client's arms and gradually increasing the client's activity level each day will aggravate the fatigue; activity and rest should be delicately balanced to prevent fatigue. Administering a dose of pyridostigmine bromide cannot be done without a healthcare provider's prescription; rest usually will alleviate the fatigue.

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. The teaching on postoperative care provided by the nurse should cover what topic? A. Gastric suction B. Oxygen therapy C. Fluid restriction D. Urinary catheter

A. Gastric suction After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions that allow healing at the site of anastomosis. Oxygen is not required unless the client experiences a complication necessitating its administration. An IV to meet fluid needs and replace gastric losses is given to the average client. A urinary catheter may or may not be necessary.

A client with migraine headaches is admitted for an electroencephalogram (EEG). Which statement made by the client assures the nurse that preprocedure teaching has been effective? A. I will need to avoid caffeine. B. I will have a headache after the test. C. I will need to avoid milk until the test is completed. D. I will be able to take my sleeping pill before the test.

A. I will need to avoid caffeine. Caffeine products usually are avoided before an EEG because of their effect on brain activity. A headache is not a complication after an EEG. It is not necessary to avoid milk or other calcium-rich foods. Antianxiety and sleep medications usually are discontinued before the EEG because of their effect on brain activity.

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? A. Ketoacidosis B. Somogyi phenomenon C. Hypoglycemic reaction D. Hyperosmolar nonketotic coma

A. Ketoacidosis Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

For which clinical indication should a nurse observe a child in whom autism is suspected? A. Lack of eye contact B. Crying for attention C. Catatonia-like rigidity D. Engaging in parallel play

A. Lack of eye contact Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor the client's vital signs. B. Increase the client's fluid intake. C. Improve the client's nutritional status. D. Determine the client's reasons for drinking.

A. Monitor the client's vital signs. A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take? A. Obtain vital signs B. Clamp the NG tube C. Instill 30 mL of iced normal saline into the NG tube D. Record the observations and continue monitoring the client

A. Obtain vital signs Large amounts of blood or excessive bloody drainage 12 hours postoperatively indicate that the client is hemorrhaging. Vital signs should be taken. Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. The primary healthcare provider must prescribe instilling 30 mL of iced normal saline into the nasogastric tube. Continuing to monitor the drainage and record the observations is an unsafe intervention at this time; action must be taken to address and stop the hemorrhaging.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? A. Prepare the client for surgery. B. Administer oxygen per nasal catheter. C. Place in the supine position, with legs elevated. D. Ask the client if there have been any black stools.

A. Prepare the client for surgery. These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the client in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation.

A client admitted to the emergency department has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client? A. Starvation B. Alcoholism C. Bone healing D. Positive nitrogen balance

A. Starvation In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones. There is no fat in alcohol; fat oxidation does not occur. Bone healing does not require the use of great amounts of fat; calcium is deposited to form callus. A positive nitrogen balance does not require the use of great amounts of fat.

A client has laparoscopic surgery to remove a calculus from the common bile duct. What postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished? A. Stools become brown B. Liver tenderness is relieved C. Colic is absent after ingestion of fats D. Serum bilirubin level returns to the expected range

A. Stools become brown The return of brown color to the stool indicates that bile is entering the duodenum and being converted to urobilinogen by bacteria. Liver tenderness is unrelated to bile flow. The absence of biliary colic is related to the removal of the calculus, not the flow of bile. The serum bilirubin level is not affected.

The urinalysis report of a client reveals cloudy urine. What does a nurse infer from the client's report? A. The client has a urinary infection. B. The client has a biliary obstruction. C. The client has diabetic ketoacidosis. D. The client has been on a starvation diet.

A. The client has a urinary infection. The urine becomes cloudy when an infection is present due to the presence of leukocytes. Therefore the nurse concludes that the client has a urinary infection. In cases of biliary obstruction, the urine contains bilirubin. The presence of ketones in the urine indicates diabetic ketoacidosis or prolonged starvation.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? A. There is less chance of aspiration. B. This procedure does not require a pump. C. Self-administration of the feeding is possible. D. More tube feeding mixture can be given each time.

A. There is less chance of aspiration. When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. A. Limiting contact with the abuser B. Determining a safe place to go in an emergency C. Memorizing the domestic violence hotline number D. Obtaining a bank loan to finance leaving the abuser E. Arranging for a family member to assist her in leaving

B & C It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

A client is admitted to the hospital with a diagnosis of severe chronic kidney disease. Which assessment findings should the nurse expect the client to exhibit? Select all that apply. A. Polyuria B. Paresthesias C. Hypertension D. Metabolic alkalosis E. Widening pulse pressure

B & C Paresthesias [1] [2] occur as a result of excess nitrogenous wastes, altered fluid and electrolytes, and altered regulatory functions. Nonfunctioning kidneys cause fluid retention that may result in hypervolemia and hypertension. Polyuria occurs because of extensive nephron damage and may occur in the early stage of kidney disease but not in the severe stage. Metabolic acidosis, not alkalosis, results from the inability to excrete hydrogen ions and retain bicarbonate. Widening pulse pressure occurs with increased intracranial pressure, not with kidney dysfunction.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply. A. Cyanosis B. Backache C. Shivering D. Bradycardia E. Hypertension

B & C Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. Shivering occurs as part of the inflammatory response associated with a transfusion reaction. Cyanosis is not commonly associated with a transfusion reaction. Tachycardia, not bradycardia, is associated with a transfusion reaction. Hypotension, not hypertension, is associated with a transfusion reaction.

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? A. "Urinary control may be permanently lost to some degree." B. "An indwelling urinary catheter is required for at least a day." C. "Your ability to perform sexually will be impaired permanently." D. "Burning on urination will last while the cystostomy tube is in place."

B. "An indwelling urinary catheter is required for at least a day." An indwelling urethral catheter is used, because surgical trauma can cause edema and urinary retention, leading to additional complications, such as bleeding. Urinary control is not lost in most cases; loss of control usually is temporary if it does occur. Sexually ability usually is not affected; sexual ability is maintained if the client was able to perform before surgery. A cystostomy tube is not used if a client has a transurethral resection; however, it is used if a suprapubic resection is done.

The nurse is teaching self-management techniques to a client newly diagnosed with polycystic kidney disease. Which statement of the client indicates a need for further teaching? A. "I should monitor my bowel movements." B. "I should weigh myself once a week." C. "I should record my blood pressure daily." D. "I should notify my healthcare provider if I have fever."

B. "I should weigh myself once a week." Polycystic kidney disease is characterized by a sudden weight gain due to enlarged kidneys. Therefore the client should weigh himself or herself every day at the same time of day and with the same amount of clothing on. Bowel movements should be monitored to prevent constipation. The client should regularly record his or her blood pressure to prevent hypertension. The client should notify the healthcare provider if he or she has fever.

A client is treated with a radium implant for cancer of the cervix. Which information is important for the nurse to teach the client when giving discharge instructions? A. "Limit daily fluid intake." B. "Return for follow-up care." C. "Continue a low-residue diet." D. "Take daily mineral supplements."

B. "Return for follow-up care." Before discharge it is important for the nurse to instruct the client to return for follow-up care at specified intervals. Fluids are not reduced unless cardiac or renal pathology is present. When the implant is in place, a low-residue diet is indicated to prevent pressure from a distended colon; when the radium implant is removed, the client can return to a regular diet. If the diet is adequate, mineral supplements are unnecessary.

A client with a small nodule of the thyroid gland is to have a subtotal thyroidectomy. The client asks the nurse for clarification about what this surgery involves. What information should the nurse include in a response to the question? A. The entire thyroid gland is removed. B. A small part of the gland is left intact. C. One parathyroid gland is removed also. D. A portion of the thyroid is removed with the parathyroids.

B. A small part of the gland is left intact. A small portion of the gland is left in the hope that it will provide enough hormone for adequate function. The entire gland is not removed. The parathyroids are not removed.

A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. What should the nurse assess for in this client? A. Melena B. Anal itching C. Constipation D. Ribbon-shaped stools

B. Anal itching Anal itching and irritation can occur from having anal intercourse with a person infected with gonorrhea. Frank rectal bleeding, not upper gastrointestinal bleeding (melena), occurs. Painful defecation, not constipation, occurs. The shape of formed stool does not change; however, defection can be painful.

A nurse is auscultating a client's heart. Where should the nurse listen to hear S1 the loudest? A. Base of the heart B. Apex of the heart C. Left lateral border D. Right lateral border

B. Apex of the heart The first heart sound is produced by closure of the mitral and tricuspid valves; it is best heard at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.

During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response? A. Nihilistic delusion B. Delusions of persecution C. Delusions of control D. Delusions of grandeur

B. Delusions of persecution Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? A. Reaction formation; this is related to the client's recent altered body image B. Denial; the client is having difficulty accepting reality C. Impotency resulting from the surgery; sexual counseling may be indicated D. Suicidal thoughts; consultation with a psychiatrist should be prescribed

B. Denial; the client is having difficulty accepting reality As long as no one else confirms the presence of the stoma and the client does not adhere to a prescribed regimen, the client's denial is supported. There is no evidence to document that reaction formation is being used. There are no data to support the conclusion that the client has an inability to function sexually. There is no evidence that suicidal thoughts are present or will be acted upon.

A client with a history of chronic kidney disease is hospitalized. Which assessment findings will alert the nurse to kidney insufficiency? A. Facial flushing B. Edema and pruritus C. Dribbling after voiding and dysuria D. Diminished force and caliber of stream

B. Edema and pruritus The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. Pallor, not flushing, occurs with chronic kidney disease as a result of anemia. Dribbling after voiding is a urinary pattern that is not caused by chronic kidney disease; this may occur with prostate problems. Diminished force and caliber of stream occur with an enlarged prostate, not kidney disease.

The family member of a client with newly diagnosed Guillain-Barré syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do? A. Notify the healthcare provider. B. Go with the family member to assess the client. C. Send the nursing assistive personnel to take vital signs. D. Assure the family member this is a normal response for this disease.

B. Go with the family member to assess the client. The initial response for the nurse is to assess the client to ensure a patent airway. Guillain-Barré syndrome will exhibit ascending paralysis and can impede respiratory function. The healthcare provider will be notified after the nurse has assessed the client. The nurse needs to personally assess the client since this is a change in condition; the nurse should not send the nursing assistive personnel to assess the client. This is not a normal response to this disease, so it is not correct to assure the family member of this.

A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

B. Grade 2 According to the phlebitis scale, grade 2 presents as pain at the access site with erythema or edema. Grade 1 presents as erythema with or without pain. Grade 3 presents as pain at the access site with erythema or edema, streak formation, and palpable cord. Grade 4 presents as pain at the access site with erythema or edema, streak formation, palpable cord more than one inch long, and purulent drainage.

As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" What does the nurse conclude provoked the client's aggressive behavior? A. Voices are directing his behavior. B. He felt confined when the nurse walked into the room. C. He was afraid of doing harm to the nurse if the nurse came closer. D. He thought that the nurse was similar to someone who had frightened him in the past.

B. He felt confined when the nurse walked into the room. Clients acutely ill with schizophrenia frequently do not trust others; feeling trapped may be frightening, causing them to lash out. There is no indication that voices are speaking to the client in this instance. Clients acutely ill with schizophrenia usually are more concerned with what is happening to them and are not able to be concerned about others. Although the nurse may have reminded the client of a threatening person from his past, it is not the primary motivation for this behavior.

The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? A. High concentrations of oxygen cause alveoli to rupture. B. High concentrations of oxygen eliminate the respiratory drive. C. The client does not need any more than 1 L/min. D. The oxygen at 1 L/min should be enough to diminish the anxiety.

B. High concentrations of oxygen eliminate the respiratory drive. Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. Too much oxygen will knock out the stimulus to breathe. High concentrations of oxygen will not cause a rupture. The client actually could need more oxygen; however, if a higher concentration is given, it will knock out the respiratory drive. The oxygen is being given because of the shortness of breath.

A client who was admitted to the psychiatric unit because of a major depressive disorder is exhibiting increasingly withdrawn behavior. The nurse understands that eventually the client will experience what feelings? A. Hedonia B. Isolation C. Paranoia D. Ambivalence

B. Isolation In an attempt to control anxiety, the client continues to retreat from people and the activities within the environment; this will eventually precipitate feelings of loneliness and isolation. Depressed clients exhibit a decreased interest in pleasurable activities (anhedonia) rather than an excessive interest in pleasurable activities (hedonia). Paranoia may be a cause, not a result, of withdrawal. Ambivalence, or experiencing conflicting emotions at the same time, is not precipitated by depression.

The nurse is providing postoperative care for a client who had an extensive surgical revision of the head of the pancreas. To decrease the risk of hemorrhage at the operative site, what action should the nurse take? A. Keep the client in the supine position. B. Maintain patency of the nasogastric tube. C. Replace fat-soluble vitamins as necessary. D. Administer prescribed tube feedings to the client slowly.

B. Maintain patency of the nasogastric tube. A patent nasogastric tube prevents distention and compression in the surgical area. The supine position will place too much tension on the abdominal wall. A low-Fowler position is preferred; movement should be encouraged. Replacement of vitamins is a dependent function; vitamins must be prescribed by the healthcare provider. Tube feedings are contraindicated because peristalsis is absent for one to three days after surgery and because the feeding will place pressure on the suture line.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? A. Prepare for blood transfusions. B. Notify the surgeon immediately. C. Make the client nothing by mouth (NPO). D. Administer the prescribed preoperative sedative.

B. Notify the surgeon immediately. Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, which action should the nurse take? A. Apply an abdominal binder. B. Place a support under the scrotum. C. Teach the client to cough several times an hour. D. Encourage the client to eat a high-carbohydrate diet.

B. Place a support under the scrotum. After inguinal hernia repair, the scrotum commonly becomes edematous and painful; drainage is facilitated by elevating the scrotum on rolled linen or using a scrotal support and/or ice application. An abdominal binder will not support the operative site; the incision is too low. Coughing increases intraabdominal pressure and should be avoided because it strains the operative site. Obesity is a factor in the development of hernias; high-carbohydrate diets should be discouraged.

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? A. Irrigate the T-tube as necessary B. Protect the abdominal skin from bile drainage C. Have the client wear a binder when out of bed D. Empty the T-tube drainage bag every two hours

B. Protect the abdominal skin from bile drainage The enzymatic activity of bile can cause excoriation and skin breakdown; the skin should be protected. A T-tube is not irrigated. A binder will not protect the skin, although it may support abdominal musculature. Drainage is emptied when the bag is full or at routine intervals (usually every 8 to 12 hours).

A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective? A. "After meals I will take a 10-minute walk." B. "After meals I will drink 8 oz (240 mL) of water." C. "After meals I will rest in a sitting position for one hour." D. "After meals I will lie down in bed for at least 20 minutes."

C. "After meals I will rest in a sitting position for one hour." Gravity (sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus. Exercise immediately after eating may prolong the digestive process. Water should not be taken with or immediately after meals because it overdistends the stomach. Lying down in bed for at least 20 minutes is not an appropriate action because it promotes the reflux of gastric contents into the esophagus.

A client with cancer of the bladder is admitted to the hospital for diagnostic tests to determine the extent of the disease. While the nurse is caring for the client, the client asks, "If they remove my bladder, how will I be able to urinate?" Which is the best response by the nurse? A. "You can still function normally without a bladder." B. "I am sure this is very upsetting to you, but it will be over soon." C. "I know you're upset, but there are alternatives to removing your bladder." D. "The tests will help to determine whether your bladder has to be removed."

C. "I know you're upset, but there are alternatives to removing your bladder." The response "I know you're upset, but there are alternatives to removing your bladder" offers the best combination of factual information and emotional support. The response "You can still function normally without a bladder" disregards the client's feelings; it is inaccurate information, because if the bladder is removed, bladder function will not be normal. Although the response "I am sure this is very upsetting to you, but it will be over soon" identifies the client's feelings, further communication is cut off by the second part of the response. The response "The tests will help to determine whether your bladder has to be removed" is factual but does not answer the question or offer emotional support; it may increase anxiety.

The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? A. "I'm sure you will be able to do it." B. "Maybe a family member can do it for you." C. "You seem to be nervous about going home." D. "Perhaps you can stay in the hospital another day."

C. "You seem to be nervous about going home." Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help to reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? A. Edema B. Diarrhea C. Amenorrhea D. Hypertension

C. Amenorrhea Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration.

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first? A. Obtain the client's vital signs. B. Review the client's intake and output. C. Assess that the tubing attached to the collection bag is patent. D. Explain that the balloon inflated in the bladder causes this feeling.

C. Assess that the tubing attached to the collection bag is patent. The drainage tubing may be obstructed. Retained fluid raises bladder pressure, causing discomfort similar to the urge to void. The client's vital signs are not related to the complaint. Although the nurse may review the client's intake and output, it is not the priority. Whether urine is draining from the tubing at this point in time is significant. Although it is true that the balloon inflated in the bladder causes this feeling, the patency of the gravity system should be ascertained before determining the cause of the complaint.

Two days after abdominal surgery a client experiences extensive flatus. The nurse administers the Harris flush (Harris drip). Which finding indicates a therapeutic effect? A. Client has a bowel movement. B. Client's returns are finally clear. C. Client's abdomen is less distended. D. Client is able to retain a half liter of fluid.

C. Client's abdomen is less distended. The Harris flush removes accumulated gas in the intestine, which reduces distention of the abdomen. Stimulating evacuation is not the purpose of a Harris flush; a bowel movement indicates that an enema, not a Harris flush, was effective. The returns of a Harris flush usually contain small amounts of fecal material; the technique is not used for cleansing the bowel. The fluid is not retained; small amounts are instilled slowly and then permitted to return slowly, taking gas with it.

The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? A. Lability B. Passivity C. Curiosity D. Withdrawal

C. Curiosity Intellectual deterioration associated with dementia decreases interest in the environment. Diffuse impairment of brain tissue function results in fluctuations in the extremes of emotions; lability of mood is common with dementia. Clients with dementia usually fluctuate between aggressive acting out and passive acceptance. In clients with dementia, intellectual deterioration can result in behavior that mimics withdrawal.

A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? A. Loss of faith in God B. Visual hallucinations C. Decreased social interaction D. Feelings about the future are absent

C. Decreased social interaction Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders. Depressed clients are commonly negative and pessimistic, especially regarding their future.

A nurse is caring for a client exhibiting compulsive behaviors. The nurse concludes that the compulsive behavior usually incorporates the use of which defense mechanism? A. Projection B. Regression C. Displacement D. Rationalization

C. Displacement Displacement is the unconscious redirection of an emotion from a threatening source to a nonthreatening source. Projection is the attribution of one's unacceptable feelings and thoughts to someone else. Regression is the return to an earlier, more comfortable level of behavior; it is a retreat from the present. Rationalization is the attempt to make unacceptable behavior or feelings acceptable by justifying the reasons for them.

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? A. Ability to chew and speak distinctly B. Capacity to smile and close the eyelids C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

C. Effectiveness of respiratory exchange and ability to swallow Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should the nurse include in the education? A. Weight loss B. Subnormal temperature C. Elevated blood pressure D. Increased urinary output

C. Elevated blood pressure Hypertension is a clinical manifestation of kidney transplant. Weight gain, not loss, occurs with a rejection of the kidney [1] [2] because of fluid retention. The client will have an elevated temperature exceeding 100° F (37.8 ° C) with kidney rejection. Urine output will be decreased or absent, depending on the degree of kidney rejection.

A nurse reviews the plan of care for a geriatric client with less than adequate nutritional intake. The nurse should question which prescription? A. Have client sit in a chair for meals to prevent aspiration of food/liquid into the lungs. B. Provide six small feedings in 24 hours whenever requested by the client. C. Give one can of diet supplement at 8:00 AM with breakfast and 4:00 PM prior to evening meal. D. Encourage the client's family members to bring food from home, especially their favorite dishes.

C. Give one can of diet supplement at 8:00 AM with breakfast and 4:00 PM prior to evening meal. Supplements given before meals will make a client less hungry at meal times; supplements should be given after meals. Sitting in an upright position facilitates passage of food to the stomach. Small, frequent meals are less overwhelming and generally more appealing for the nutritionally-challenged client. Clients are more likely to eat food familiar to them than institutional food.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? A. Ripe bananas B. Milk products C. Green vegetables D. Creamed potatoes

C. Green vegetables Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? A. Inept B. Eccentric C. Impulsive D. Dependent

C. Impulsive Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? A. Increased serum glucose B. Deficient renal perfusion C. Inadequate antidiuretic hormone (ADH) secretion D. Excess amounts of intravenous (IV) fluid

C. Inadequate antidiuretic hormone (ADH) secretion Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production. While excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? A. Decreased cardiac output B. Decreased stroke volume of the heart C. Increased contractile force of the myocardium D. Increased electrical conduction through the atrioventricular (AV) node

C. Increased contractile force of the myocardium Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output. The positive inotropic effect of digoxin increases, not decreases, cardiac output. Digoxin increases the strength of myocardial contractions (positive inotropic effect) and slows the heart rate (negative chronotropic effect); these effects increase the stroke volume of the heart. Digoxin decreases the refractory period of the AV node and decreases conduction through the sinoatrial (SA) and AV nodes.

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? A. It equals the expected urinary output for the next 24 hours. B. It will prevent the development of pneumonia and a high fever. C. It will compensate for both insensible and expected output over the next 24 hours. D. It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

C. It will compensate for both insensible and expected output over the next 24 hours. Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

Which test is used to specifically detect intracranial aneurysms in clients? A. Diffusion imaging B. Magnetic resonance imaging C. Magnetic resonance angiography D. Magnetic resonance spectroscopy

C. Magnetic resonance angiography Magnetic resonance angiography is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations. Magnetic resonance spectroscopy is indicated in epilepsy, Alzheimer disease, and stroke to assess abnormalities in the brain's biochemical processes. Diffusion imaging is indicated for evaluation of ischemia in the brain to determine the location and severity of a stroke. Magnetic resonance imaging is taking multiple sets of images to determine normal and abnormal anatomy.

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? A. Hypernatremia B. Hyperchloremia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.

A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma? A. Dry, pale pink, and even with the skin B. Moist, skin-colored, and flush with the skin C. Moist, red, and raised above the skin surface D. Dry, purple, and depressed below the skin surface

C. Moist, red, and raised above the skin surface The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface to allow drainage to go into the appliance rather than onto the skin. The stoma should be moist, not dry. Pale pink may indicate limited circulation to the stoma. Although some stomas can be flush with the skin, a raised stoma is more common. Although the stoma should be moist, a skin-colored stoma indicates limited circulation to the stoma. A purple color indicates compromised circulation.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? A. Ideas of grandeur B. Confusing illusions C. Persecutory delusions D.Auditory hallucinations

C. Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? A. Delusions B. Hallucinations C. Posttraumatic stress disorder (PTSD) D. Obsessive-compulsive disorder (OCD

C. Posttraumatic stress disorder (PTSD) PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level.

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? A. Write down conversations to facilitate the recall of information. B. Monopolize conversations about the anxiety being experienced. C. Redirect the conversation with the nurse to physical symptoms. D. Start a conversation asking the nurse to recommend palliative care.

C. Redirect the conversation with the nurse to physical symptoms. Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? A. Sinus tachycardia B. Normal sinus rhythm C. Sinus rhythm with premature atrial contractions (PACs) D. Sinus bradycardia with premature ventricular contractions (PVCs)

C. Sinus rhythm with premature atrial contractions (PACs) A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.

The nurse assists an elderly client in squirting warm water over the perineum. Which outcome indicates effective nursing care? A. The client will not have nocturia. B. The client will not have a bladder infection. C. The client will not have a tendency to retain urine. D. The client will not have urinary stress incontinence.

C. The client will not have a tendency to retain urine. The renal system undergoes age-related changes in elderly clients. A tendency to retain urine is a physiologic change that can result in urine stasis. Assisting the client in squirting warm water over the perineum will help to initiate voiding in the client. Thus when the client does not have a tendency to retain urine, this finding is an effective outcome. Discouraging excessive fluid intake for two to four hours before the client goes to bed reduces nocturia. Providing thorough perineal care after each voiding will help to prevent bladder infections. Responding quickly to the client's indication of the need to void will help to reduce urinary stress incontinence.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? A. Diuresis, irritability, and fever B. Lethargy, cold skin, and hypertension C. Thirst, cool skin, and orthostatic hypotension D. Bounding pulse, restlessness, and slurred speech

C. Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

What is the primary purpose of conducting a cystoscopy in a client with decreased and difficult urination? A. To ascertain the size of the kidneys B. To ascertain the protein content in urine C. To ascertain the presence of urethral wall abnormality D. To ascertain the total amount of catecholamines excreted

C. To ascertain the presence of urethral wall abnormality Cystoscopy is a procedure in which a cystoscope is used to visualize and examine the inner walls of the urinary bladder and ureter. The cystoscope is introduced into the client's ureter to detect the presence of urethral wall abnormalities or occlusions. Radiography or ultrasonography of the kidneys will enable visualization of the kidneys and therefore kidney size can be ascertained. A 24-hour urine test is performed to analyze the levels of various components in the urine and is recommended to ascertain the protein content in urine. The total amount of catecholamines excreted in urine can also be measured through 24-hour urine sample testing.

In what situation should a nurse anticipate that a client will experience a phobic reaction? A. When seeking attention from others B. When thinking about the feared object C. When coming into contact with the feared object D. When being exposed to an unfamiliar environment

C. When coming into contact with the feared object With phobias, the individual transfers anxiety to a safer inanimate object or situation. Therefore the anxiety and resulting feelings will be precipitated only when the client is in direct contact with the object or situation. Phobias are severe anxiety reactions, not attention-seeking actions. It is not thinking about the feared object that causes anxiety; it is the possibility of having to come into contact with it. It is the presence of the phobic object or situation that triggers the anxiety, not the unfamiliarity of the environment.

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply. A. Polyuria B. Insomnia C. Bradycardia D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness

D, E, F As fluid is retained, the body weight will increase. One liter of fluid weighs 2.2 pounds (1 kilogram). Excess ADH causes water retention, which leads to dilutional hyponatremia. Dilution of blood and hyponatremia cause a decreased level of consciousness. Water retention and decreased urinary output occur because of ADH excess. Urine output decreases to less than 20 mL/hour. This client will be lethargic, confused, or comatose, depending on the degree of hyponatremia. Tachycardia, not bradycardia, occurs in response to fluid volume excess associated with increased ADH.

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective? A. "I should massage my feet and legs with oil or lotion." B. "I should apply heat intermittently to my feet and legs." C. "I should eat foods high in protein and carbohydrate kilocalories." D. "I should control my blood glucose with diet, exercise, and medication."

D. "I should control my blood glucose with diet, exercise, and medication." Controlling the diabetes decreases the risk of infection; this is the best prevention. Oil or lotion that is not completely absorbed may provide a warm, moist environment for bacterial growth. Coexisting neuropathy may result in injury from heat application. Protein, carbohydrates, and fats must be in an appropriate balance; high carbohydrate intake can provide too many calories.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? A. It stimulates plasma cells directly. B. A delayed titer of antibodies is generated. C. It provides immediate active immunity. D. A passive immunity is produced.

D. A passive immunity is produced. Tetanus antitoxin stimulates the body to create protective antibodies to the tetanus toxin. It helps provide these antibodies, which confer immediate passive immunity that lasts about seven to 14 days. Passive immunization is the administration of immunoglobulin prepared from individuals known to have high levels of antibodies to the infectious agent in question. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity.

A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action? A. Sitting quietly with the client B. Encouraging the client to play video games C. Introducing the client to several other clients D. Assigning a staff member to supervise the client

D. Assigning a staff member to supervise the client Assigning a staff member to supervise the client will enable the staff member to respond quickly to any escalation in the client's mood or behavior. Sitting quietly with the client may put the nurse at risk, because it may actually make the client more anxious and precipitate violence. The client is too anxious to concentrate on a game or to interact with other people.

What response will a nurse monitor for when assessing a client for side effects of long-term cortisone therapy? A. Hypoglycemia B. Severe anorexia C. Anaphylactic shock D. Behavioral changes

D. Behavioral changes Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not responses to long-term glucocorticoid therapy.

A nurse taking calls at a local crisis center hotline receives a telephone call from a suicidal adolescent. The nurse can safely terminate the call when the client does what? A. Wishes to terminate the conversation B. Has responded to the nurse's initial assessment of suicide risk C. Begins repeating the same information that has already been discussed D. Can state a preventive plan of action for dealing with self-destructive behaviors

D. Can state a preventive plan of action for dealing with self-destructive behaviors The client should be able to state specific behaviors that can be used to decrease self-destructive thoughts and actions; the client must be empowered. Terminating the conversation is ineffective because the client may end the conversation and remain suicidal. The nurse may gather data through the suicide risk assessment tool, but the client may not have attained catharsis; therefore the dialogue should be continued until a contract has been set or self-destructive behaviors have diminished. Repeating the same information that has already been discussed is an indication that the nurse should help the client focus on life and not on suicide; the client has not yet attained catharsis.

The nurse assesses a male client with a preliminary diagnosis of cancer of the urinary bladder. Which clinical manifestation will indicate to the nurse the cancer is in the early stage? A. Dysuria B. Retention C. Hesitancy D. Hematuria

D. Hematuria Hematuria is the most common early sign of cancer of the urinary system, probably because of the urinary system's rich vascular network. Dysuria is not specific for bladder cancer. Retention and hesitancy are not specific for bladder cancer; usually they are associated with an enlarged prostate in the male.

A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma? A. Allergic B. Emotional C. Extrinsic D. Intrinsic

D. Intrinsic Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered to be extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold, dust, etc.

Which is a clinical manifestation of a cluster headache? A. Vertigo B. Neck rigidity C. Phonophobia D. Ipsilateral tearing of the eye

D. Ipsilateral tearing of the eye Ipsilateral tearing of the eye, or tearing on the same side as the headache, is a clinical manifestation of cluster headaches. Neck rigidity, vertigo, and phonophobia are manifestations of migraine headaches.

Which type of nerve helps the client's pupil constrict? A. Motor B. Sensory C. Sympathetic D. Parasympathetic-motor

D. Parasympathetic-motor The parasympathetic-motor nerves located in the midbrain help in pupil constriction. The motor nerves help in eye movement. The sensory nerves help in sensory perception. The sympathetic nerves help in involuntary functions of the body.

A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? A. Gait training in the physical therapy department daily B. Isometric exercises every two hours while awake C. Active range-of-motion exercises at least every four hours D. Passive range-of-motion exercises at least every eight hours

D. Passive range-of-motion exercises at least every eight hours Passive range-of-motion exercises at least every eight hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every four hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.

Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? A. Amoxicillin B. Ciprofloxacin C. Nitrofurantoin D. Phenazopyridine

D. Phenazopyridine Phenazopyridine is a topical anesthetic that is used to treat pain or burning sensation associated with urination. It also imparts a characteristic orange or red color to urine. Amoxicillin is a penicillin form that could cause pseudomembranous colitis as a complication; it is not associated with reddish-orange colored urine. Ciprofloxacin is a quinolone antibiotic used for treating UTIs and can cause serious cardiac dysrhythmias and sunburns. It is not, however, responsible for reddish-orange colored urine. Nitrofurantoin is an antimicrobial medication prescribed for UTIs. This drug may affect the kidneys but is not associated with reddish-orange colored urine.

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? A. Projection B. Sublimation C. Compensation D. Rationalization

D. Rationalization Rationalization is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. Projection is the denial of emotionally unacceptable feelings and the attribution of the traits to another person. Sublimation is the substitution of a socially acceptable behavior for an unacceptable feeling or drive. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

A nurse is caring for a client who underwent a cervical biopsy. The nurse finds that the client has a body temperature of 100° F, increased abdominal pain, and increased drainage that is foul-smelling. Which action is priority? A. Administer analgesics to the client B. Place the client in the lithotomy position C. Ask the client to douche the perineal area D. Report the client's condition to the primary healthcare provider

D. Report the client's condition to the primary healthcare provider A client who underwent a cervical biopsy may have a body temperature of 100° F, increased abdominal pain, and foul-smelling drainage due to infection. The nurse should report these findings regarding the client's condition to the primary healthcare provider to prevent sepsis. Analgesics may reduce the pain in the client, but not the other symptoms. Placing the client in the lithotomy position will not provide adequate comfort. The client should not douche the genital area for about two weeks after a cervical biopsy.

During an examination of a client with kidney dysfunction, the nurse finds the presence of glucose in the urine. Which nursing intervention is beneficial for this client? A. Administering oral fluids B. Noting the finding down as normal C. Administering hypoglycemic medication D. Reporting this finding to the primary healthcare provider

D. Reporting this finding to the primary healthcare provider The presence of glucose in the urine is an abnormal finding that requires further assessment. Therefore, the nurse should report this finding to the primary healthcare provider. The nurse should not administer oral fluids or hypoglycemic medication without instructions from the primary healthcare provider.

During administration of an enema, a client reports having intestinal cramps. What should the nurse do? A. Discontinue the procedure. B. Instill the fluid at a slower rate. C. Lower the height of the container. D. Stop the fluid until the cramps subside

D. Stop the fluid until the cramps subside Administration of additional fluid when a client reports experiencing abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not reduce it entirely.

A client reports the passage of urine while coughing. What condition does the nurse suspect of the client? A. Enuresis B. Pneumaturia C. Urinary retention D. Stress incontinence

D. Stress incontinence Involuntary urination upon increased pressure is called stress incontinence. The pressure on the urinary bladder increases while sneezing and coughing. Involuntary urination at night is called enuresis. Urination with the presence of gas in it is called pneumaturia. Urinary retention is the inability to urinate despite a full bladder.

A nurse is teaching a group of recently hired staff members about defense mechanisms. An example given is Scarlett O'Hara, in the movie Gone with the Wind, who said, "I'll think about that tomorrow." What defense mechanism does this statement reflect? A. Denial B. Splitting C. Repression D. Suppression

D. Suppression Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. Denial is an unconscious attempt to escape from unpleasant or unacceptable realities by ignoring their existence. Splitting is the inability to integrate the positive and negative aspects of oneself or others into a cohesive whole; this is common in people with borderline personality disorders. Repression is the unconscious denial of an uncomfortable or unwanted situation or feeling.

The nurse is assessing a client with mumps and orchitis. Which organ will be affected? A. Seminal vesicles B. Prostate Gland C. Epididymis D. Testes

D. Testes Mumps is a viral infection that may cause orchitis in males. Painful inflammation and swelling of the testes.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? A. Dehydration B. Skin breakdown C. Electrolyte imbalances D. Urinary tract infection

D. Urinary tract infection Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.

A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1. Wash the hands 2. Verify the solution to be administered 3. Aspirate the contents of the stomach 4. Instill the prescribed solution 5. Document the client's response to the procedure

1, 2, 3, 4, 5 The hands should be washed to prevent contamination of the formula and the delivery system. Because numerous formulas may be used to correct specific nutritional problems, the nurse should verify that the formula to be administered is the one prescribed. The stomach contents should be aspirated to observe the fluid removed and to ascertain the feeding tube's location in the stomach. If the tube is correctly positioned, the solution is administered. The amount of formula given, the length of time involved, and the client's response to the procedure are recorded.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse would monitor the client for which complications? Select all that apply. A. Hyperglycemia B. Infection C. Hepatitis D. Anorexia E. Dysrhythmias

A & B Hyperglycemia related to the high concentration of dextrose in TPN is a common complication of this therapy and must be monitored for by the nurse. Another common complication is related to the central venous access that is needed for infusion of TPN. Catheter-related infection is frequently seen and must be monitored for by the nurse. Hepatitis is usually not associated with total parenteral nutrition. Anorexia often is present before the medical decision is made to begin total parenteral nutrition. Dysrhythmias are not related to total parenteral nutrition, but may be a sign of hyperkalemia or hypokalemia.

A client with hyperthyroidism is being treated with propylthiouracil (PTU). What instruction should the nurse plan to include in the teaching plan regarding this drug? Select all that apply. A. "Avoid abrupt discontinuation of the medication." B. "Monitor your weight, pulse, and mood routinely." C. "You can expect an immediate response to this medication." D. "Also take an iodine replacement to aid metabolism of the drug." E. "Report side effects, such as sore throat, fever, joint pain, or oral lesions."

A, B, E Abrupt discontinuation of the medication may result in thyroid crisis. PTU blocks the synthesis of T3 (triiodothyronine) and T4 (thyroxine). The therapeutic effect of the drug should result in increased weight, decreased pulse, and stability of mood. Sore throat, joint pain, fever, or oral lesions may indicate infection caused by drug-induced blood dyscrasias, such as leukopenia and agranulocytosis. The response to this drug may take up to 3 weeks. Over-the-counter medications and seafood containing iodine should be avoided.

A client with the diagnosis of osteogenic sarcoma has a metastasis to the lung. Which client statement about the concept of metastasis indicates that the nurse needs to follow up? A. "I'm upset to know that the tumor may metastasize to my bones." B. "I didn't realize that I could have a metastasis without having pain." C. "I can have metastases to other parts of my body besides the lung." D. "I need to talk with my doctor about the possibility of more metastases."

A. "I'm upset to know that the tumor may metastasize to my bones." When the client tells the nurse, "I'm upset to know that the tumor may metastasize to my bones," the client must be corrected by the nurse because this is a misconception about osteogenic sarcoma. Osteogenic sarcoma is a primary malignant bone tumor. It has a high mortality rate because it often is diagnosed after it has metastasized to the lung. All the other statements are correct and do not need follow-up. Pain may or may not be associated with a primary site or sites of metastases. Pain that does occur may range from mild and occasional to constant and severe. "I can have metastases to other parts of my body besides the lung" is a true statement and further teaching is not necessary. Because the tumor may continue to metastasize, planning for the future (e.g., medical treatment, palliative interventions) should be discussed with the client, family, healthcare provider, and other support systems.

During a health symposium a nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood? A. "Meats and cream-based foods need to be refrigerated." B. "Once most food is cooked, it does not need to be refrigerated." C. "Poultry should be stuffed and then refrigerated before cooking." D. "Cooked food should be cooled before being put into the refrigerator."

A. "Meats and cream-based foods need to be refrigerated." A cold environment limits growth of microorganisms. All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. Stuffing and then refrigerating poultry promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. Cooling foods before refrigeration promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse? A. "Tell me more about what you are thinking." B. "Products are available to limit this problem." C. "This is a problem, but the surgery is necessary." D. "Most people who have this surgery share this same concern."

A. "Tell me more about what you are thinking." The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client's concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client's concerns.

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "What prompts your drinking episodes?" C. "Do you also eat when you drink?" D. "Why do you mix the vodka with orange juice?"

A. "When was your last drink of vodka?" The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? A. Add extra salt to food B. Consume high-potassium foods C. Omit protein foods at each meal D. Restrict the daily intake of fluids to 1 L

A. Add extra salt to food Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease.

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? A. Encouraging expression of concerns B. Administering antibiotics as prescribed C. Teaching the importance of getting rest D. Explaining that everything will be all right

A. Encouraging expression of concerns Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? A. Enhances the quality of the client's life B. Reduces the likelihood of a respiratory infection C. Prevents the malabsorption syndrome from occurring D. Cures the cachexia that results from bone cancer and chemotherapy

A. Enhances the quality of the client's life Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. Palliative care focuses on reducing symptoms and increasing quality; it does not focus on finding a cure. Nutritional interventions cannot prevent the occurrence of respiratory infections; this requires mobilization of respiratory secretions to prevent stasis. Malabsorption cannot be prevented with teaching; malabsorption may or may not occur depending upon the disease process and functioning of the client's gastrointestinal tract.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate level

A. Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair

A. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? A. Inhales deeply through the mouthpiece, relaxes, and then exhales. B. Inhales deeply, seals the lips around the mouthpiece, and exhales. C. Uses the incentive spirometer for 10 consecutive breaths per hour. D. Coughs several times before inhaling deeply through the mouthpiece.

A. Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? A. Lactase B. Sucrase C. Maltase D. Amylase

A. Lactase Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? A. Left Sims B. Back lying C. Knee chest D. Mid-Fowler

A. Left Sims To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? A. Listen to the client's fears B. Encourage the client to socialize C. Grant the client's request about visitors D. Darken the client's room by pulling the drapes

A. Listen to the client's fears 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 with human immunodeficiency virus (HIV) infection is diagnosed with tuberculosis. Before starting antitubercular pharmacotherapy, what essential test results should the nurse review? A. Liver function studies B. Pulmonary function studies C. Electrocardiogram and echocardiogram D. White blood cell counts and sedimentation rate

A. Liver function studies Antitubercular drugs, such as isoniazid (INH) and rifampin (RIF), are hepatotoxic; liver function should be assessed before initiation of pharmacologic therapy. Pulmonary function studies, electrocardiogram, and echocardiogram might be done; the results of these tests are not crucial for the nurse to review before administering antitubercular drugs. White blood cell counts and sedimentation will not provide information relative to starting antitubercular therapy or to its side effects.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? A. Low fat B. Low carbohydrate C. Soft-textured and bland D. High protein and kilocalories

A. Low fat The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? A. Monitor for nonverbal cues of pain B. Check the pressure dressing for bleeding C. Assist the client to ambulate around his room D. Irrigate the client's nasogastric tube with sterile water

A. Monitor for nonverbal cues of pain Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor vital signs B. Increase fluid intake C. Obtain a foam mattress D. Improve nutritional status

A. Monitor vital signs The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client to be on the alert? A. Urgency or frequency of urination B. An increase of ketones in the urine C. The inability to maintain an erection D. Pain radiating to the external genitalia

A. Urgency or frequency of urination Urgency or frequency of urination occur with a urinary tract infection [1] [2] because of bladder irritability; burning on urination and fever are additional signs of a UTI. Increase of ketones is associated with diabetes mellitus, starvation, or dehydration. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus, not infection.

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's best response? A. "Notify the respiratory therapist." B. "Empty the fluid from the tubing." C. "Decrease the amount of humidity." D. "Document the output on the record."

B. "Empty the fluid from the tubing." Emptying the fluid from the tubing is necessary to prevent fluid from entering the trachea; some systems have receptacles attached to the tubing to collect fluid; others have to be temporarily disconnected while fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Decreasing the amount of humidity is unsafe; humidity is necessary to preserve moistness of the respiratory tract and to liquefy secretions. The amount of condensation is irrelevant to intake and output.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? A. "My blood type is A positive." B. "I smoke one pack of cigarettes a day." C. "I have been overweight most of my life." D. "My blood pressure has been high lately."

B. "I smoke one pack of cigarettes a day." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? A. "I will ask the primary healthcare provider to clarify the diagnostic procedure." B. "Tell me more about the conversation you had with your healthcare provider." C. "The procedure will be fast so that you will experience minimal discomfort." D. "Your perception of the diagnostic test is incorrect."

B. "Tell me more about the conversation you had with your healthcare provider." The response "Tell me more about the conversation you had with your healthcare provider" is the best response. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding of the procedure. Instructing the client to ask the healthcare provider to clarify the procedure is not the priority; at this point, the nurse should collect more data and then may have to refer. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive.

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? A. Platelet count B. Amylase level C. Red blood cell count D. Erythrocyte sedimentation rate

B. Amylase level In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times over baseline; serum amylase usually returns to expected adult levels within three days after treatment begins. The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? A. Ginger ale B. Apple juice C. Orange juice D. Cola beverages

B. Apple juice Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

The practitioner prescribes a regular diet, gait training, elastic stockings, and benztropine mesylate for a client. The client experiences orthostatic hypotension, a side effect of benztropine mesylate. What should the nurse anticipate as the priority nursing action? A. Postpone gait training B. Apply elastic stockings C. Withhold the next dose D. Increase the fluid intake

B. Apply elastic stockings Elastic stockings help decrease venous pooling of blood and help maintain systemic blood pressure when the client stands up. Orthostatic hypotension occurs on rising to an upright position. Gait training should not be postponed; safety measures, such as permitting adequate time for the blood pressure to adjust to the client moving to the sitting or standing position, should be implemented. An alteration in dosage may be prescribed, but sudden withdrawal is dangerous and unwarranted. Increasing fluid intake may increase the intravascular fluid volume temporarily but will not affect reflexes involved in orthostatic hypotension.

A client has surgery for an incarcerated hernia. The healthcare provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? A. Reduce dietary roughage. B. Avoid lifting heavy items. C. Increase dietary potassium intake. D. Keep the head of the bed elevated.

B. Avoid lifting heavy items. Avoiding lifting helps prevent increased intraabdominal pressure that may disrupt the surgical repair. Roughage helps prevent constipation, thus avoiding straining and increased intraabdominal pressure. There is no indication for potassium supplements. The client can assume any position of comfort.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? A. Tympany B. Borborygmi C. Abdominal bruit D. Pleural friction rub

B. Borborygmi Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? A. Checking for the last bowel movement B. Checking for residual stomach contents C. Checking to determine time of last medication for nausea D. Checking to make sure the head of bed is elevated at least 15 degrees

B. Checking for residual stomach contents Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? A. Drink a glass of milk before retiring. B. Elevate the head of the bed on blocks. C. Eliminate carbohydrates from the diet. D. Take antacids, such as sodium bicarbonate.

B. Elevate the head of the bed on blocks. Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.

A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery? A. Describing the specific surgical procedure B. Ensuring the bowel preparation is initiated C. Encouraging the client to socialize with other clients D. Providing the client's food preferences for the evening meal

B. Ensuring the bowel preparation is initiated It is essential that the gastrointestinal tract be cleansed for surgery; proper visualization and prevention of peritonitis depend on the intestine being as clean of feces as possible. A specific and detailed description may cause anxiety and is unnecessary unless the client asks for this information. Encouraging the client to socialize with others is not the priority; however, therapeutic communication between the nurse and the client should be encouraged. Generally with gastrointestinal surgery, clear liquids are prescribed at least 24 to 48 hours before surgery and then nothing by mouth after midnight the night before surgery.

A client is admitted to the hospital with severe renal colic caused by a ureteral calculus. Later that evening the client's urinary output is much less than the intake. When it is confirmed that the bladder is not distended, what should the nurse suspect developed? A. Oliguria B. Hydroureter C. Renal shutdown D. Urethral obstruction

B. Hydroureter Calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the ureter, causing hydroureter. There is insufficient information to come to the conclusion of oliguria, even though output is less than intake; oliguria is present when the output is less than 400 mL in a 24-hour period. Calculi do not cause renal shutdown directly; they may obstruct the urinary tract and cause damage indirectly as a result of pressure from urine buildup. If the urethra is obstructed, the bladder will be distended.

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client? A. Crackles B. Hypovolemia C. Gastric reflux D. Jugular vein distention

B. Hypovolemia Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention. Crackles indicate an accumulation of fluid in the alveoli associated with hypervolemia, not hypovolemia. Gastric reflux occurs with gastroesophageal reflux disease (GERD), not with pancreatitis. Jugular vein distention indicates hypervolemia, not hypovolemia.

Before a femoral arteriogram is started, what should the nurse teach the client regarding the procedure? A. Radioactive dye will be injected into the femoral vein B. Local anesthesia will be used to decrease pain at the site C. Contrast media will be injected into a small vessel of the foot D. Medication will be administered intravenously to induce sleep

B. Local anesthesia will be used to decrease pain at the site Teaching the client that local anesthesia will be used to decrease any pain at the site reassures the client and allays fears of pain. The contrast medium used is not radioactive. The femoral artery is used for contrast media. The client will be awake during the procedure.

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)

B. Second degree AV block Mobitz I (Wenckebach) Also called Mobitz I or Wenckebach heart block, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. Which information should the nurse share with the client? A. Choose only familiar sexual positions. B. Select familiar settings for sexual activity. C. Return to regular sexual activity in four to six weeks. D. Depending upon your preference, take a hot or cold shower after intercourse.

B. Select familiar settings for sexual activity. An unfamiliar environment increases stress, which increases cardiac workload. It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. It is generally safe to resume sexual activity 7 to 10 days after an uncomplicated MI. However, some physicians believe that the client should decide when ready to resume sex. Hot or cold showers should be avoided just before and after intercourse.

A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established with what laboratory test? A. Urinalysis B. Stool culture C. Febrile agglutinin test D. Complete blood count

B. Stool culture The Salmonella bacilli can be visualized via microscopic examination of stool. Although a urinalysis might be done, it is not definitive for the diagnosis of salmonellosis. Although a febrile agglutinin test might be done, it is not definitive for the diagnosis of salmonellosis. Although a complete blood count might be done, it is not definitive for the diagnosis of salmonellosis.

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion? A. The client leans forward while coughing. B. The client smokes four cigarettes per day. C. The client avoids showering and swimming. D. The client uses a non-oil-based ointment to lubricate the stoma.

B. The client smokes four cigarettes per day. Smoking can increase the risk for developing other cancers such as lung cancer and can decrease the rate of healing from laryngeal surgeries. Leaning forward while coughing promotes healing. Avoiding showering and swimming helps to prevent water from entering the airways through the stoma. Using a non-oil-based ointment to lubricate the stoma may aid in quick healing.

Following a laryngectomy a client experiences frequent coughing episodes and copious production of secretions. How should the nurse explain this to the client? A. The irritation of the stoma as a result of the tracheostomy tube that is in place B. The reaction of the mucous membranes to air that is dry and cool C. An upper respiratory inflammation caused by allergies D. An insufficient coughing and deep breathing regimen

B. The reaction of the mucous membranes to air that is dry and cool Air is moisturized and warmed as it passes through the nasopharynx. With a laryngectomy this area is bypassed, and the tracheobronchial tree compensates by producing copious amounts of secretions. Irritation of the stoma by the tracheostomy tube will produce local irritation and a local response. Upper respiratory inflammation because of allergies is not a response to allergies but to the stress of the air that is entering the tracheobronchial tract. The air is no longer warmed or humidified by passing through the nose. Insufficient coughing and deep breathing do not create a response of coughing.

During a cardiovascular assessment, a nurse auscultates a client's heart and hears these sounds. How does the nurse document these sounds on the client's assessment report? A. Cardiac murmurs B. Third heart sound (S3) C. Second heart sound (S2) D. Pericardial friction rubs

B. Third heart sound (S3) The third heart sound (S3) is a low-intensity vibration of the ventricular walls; it sounds like a gallop. It is associated with decreased compliance of the ventricles during filling. Cardiac murmurs are turbulent sounds that occur between normal heart sounds. The second heart sound (S2) is a short, high-pitched sound heard at the base of the heart at the end of ventricular systole. Pericardial friction rubs are high-pitched, scratchy sounds that may be transient or intermittent. They are associated with pericarditis.

A client is receiving intravenous mannitol after sustaining a critical head injury. What assessment will the nurse perform that is specific to the safe administration of the medication? A. Body weight daily B. Urine output hourly C. Vital signs every 2 hours D. Level of consciousness every 8 hours

B. Urine output hourly Mannitol, an osmotic diuretic, increases the intravascular volume that must be excreted by the kidneys. The client's urine output should be monitored hourly to determine the client's response to therapy. Although with mannitol there is an increase in urinary excretion that is reflected in a decrease in body weight (1 L of fluid is equal to 2.2 pounds [1 kg]), a daily assessment of the client's weight is too infrequent to assess the client's response to therapy. Urine output can be monitored hourly and is a more frequent, accurate, and efficient assessment than is a daily weight. Vital signs should be monitored every hour considering the severity of the client's injury and the administration of mannitol. Although the level of consciousness should be monitored with a head injury, assessments every 8 hours are too infrequent to monitor the client's response to therapy.

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? A. Vitamins B. Whole bran C. Cod liver oil D. Amino acids

B. Whole bran Whole bran provides bulk that promotes intestinal motility and a regular bowel movement. Vitamins are not related to normalizing bowel function. Cod liver oil is not related to regulating bowel function. Amino acids are not related to regulating bowel function.

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply. A. Keep the oxygen source higher than the client's airway. B. Adjust the liter flow according to the oxygen saturation. C. Prevent the client's blanket from covering the adaptor's orifices. D. Ensure that the bag does not deflate completely during inspiration. E. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

C & E The adaptor's orifices allow room air to combine with the oxygen to provide a specific oxygen concentration. A Venturi mask uses one of several adaptors, which are usually color-coded, to deliver the prescribed FiO2. The oxygen source does not need to be higher than the client's airway because its flow does not depend on gravity. The liter flow is adjusted according to the flow rate that corresponds to the percent of oxygen prescribed; this usually is identified on the base of each adaptor. A Venturi mask does not have a bag like a rebreather mask.

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? A. "Before I start the procedure, I will don sterile gloves." B. "Before I start the procedure, I will obtain my body weight." C. "Before I start the procedure, I will measure the residual volume." D. "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."

C. "Before I start the procedure, I will measure the residual volume." Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely.

A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? A. "Why did you sign the consent form originally?" B. "I can understand why you changed your mind." C. "Can you tell me your reasons for refusing the procedure?" D. "You must be afraid about something concerning the procedure."

C. "Can you tell me your reasons for refusing the procedure?" The response "Can you tell me your reasons for refusing the procedure?" attempts to explore why the client is refusing the procedure; the question promotes communication. The response "Why did you sign the consent form originally?" is accusatory; the client has the right to withdraw consent at any time. The response "I can understand why you changed your mind" is a conclusion without appropriate data; it may also increase the client's anxiety level. "You must be afraid about something concerning the procedure" is a conclusion without appropriate data; it also puts the client on the defensive.

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that this drug has which property? A. Sedative B. Hypnotic C. Analgesic D. Antibiotic

C. Analgesic Acetylsalicylic acid (aspirin) acts as an analgesic by inhibiting production of inflammatory mediators. Acetylsalicylic acid does not act as a sedative to calm individuals. Acetylsalicylic acid does not act as a hypnotic to induce sleep. Acetylsalicylic acid does not destroy or control microorganisms.

A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? A. Pancreatitis B. Thrombophlebitis C. Bacterial meningitis D. Acute cholecystitis

C. Bacterial meningitis The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis? A. Rectal examination B. Serum phosphatase level C. Biopsy of prostatic tissue D. Massage of prostatic fluid

C. Biopsy of prostatic tissue A definitive diagnosis of the cellular changes associated with benign prostatic hyperplasia [1][2] (BPH) is made by biopsy, with subsequent microscopic evaluation. Palpation of the prostate gland through rectal examination is not a definitive diagnosis; this only reveals size and configuration of the prostate. The serum phosphatase level will provide information for prostatic cancer; a definitive diagnosis cannot be made with this test for BPH. A sample of prostatic fluid helps to diagnosis prostatitis.

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder? A. General blanching of skin B. Easy fatigue of extremities C. Burning pain after exposure to cold D. Presence of Homans sign when ambulating

C. Burning pain after exposure to cold Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation. As a result of impaired circulation, burning pain and intermittent claudication occur. General blanching of the skin, easy fatigue of extremities, and presence of Homans sign when ambulating are not related to thromboangiitis obliterans.

When caring for a client who has hyponatremia, the nurse would monitor for which symptom? A. Increased urine output B. Deep rapid respirations C. Change in level of consciousness D. Distended neck veins

C. Change in level of consciousness A normal sodium level is between 135 and 145 mEq/L (135 and 145 mmol/L) of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular over-hydration which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output.

A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain? A. Keep the left foot cool B. Cross legs with the left one on top C. Comply with the prescribed exercise program D. Keep the foot elevated at a 30-degree angle

C. Comply with the prescribed exercise program An exercise/rest program helps develop collateral circulation, which improves well-being and enables clients to increase their ability to walk longer distances. A cool environment favors constriction of peripheral blood vessels and further decreases arterial flow. Crossing the legs increases local pressure, which tends to occlude blood vessels. Elevation slows inflow of arterial blood, leading to further oxygen deprivation and pain.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? A. Exercise to improve circulation B. Eat bland foods and avoid spices C. Consume a high-fiber diet and drink adequate water D. Use laxatives to avoid constipation and the Valsalva maneuver

C. Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococcus (VRE). After notifying the primary healthcare provider, which action should the nurse take to decrease the risk of transmission to others? A. Insert a Foley catheter. B. Initiate droplet precautions. C. Move the client to a private room. D. Use a high-efficiency particulate air (HEPA) respirator when entering the room.

C. Move the client to a private room. Clients with VRE should be moved to a private room to decrease transmission to others. VRE has been identified in the urine, not respiratory secretions. Contact isolation should be implemented. A Foley catheter should not be inserted because it will predispose the client to develop an additional infection. A HEPA respirator is not required when entering the room.

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? A. Clamp the nasogastric tube. B. Irrigate the tube gently with normal saline. C. Record the observation and continue to monitor the drainage from the tube. D. Reduce the pressure of the suction and record observations of the drainage characteristics.

C. Record the observation and continue to monitor the drainage from the tube. Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A. Low-residue, bland diet B. Fluid intake below 500 mL C. Small, frequent feeding schedule D. Low-protein, high-carbohydrate diet

C. Small, frequent feeding schedule Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.

A client says, "I take baking soda in water when I get heartburn." The nurse suggests an antacid containing aluminum and magnesium hydroxide instead of baking soda. What is the advantage these antacids have over baking soda? A. They contain little, if any, sodium. B. Absorption by the stomach mucosa is markedly enhanced. C. There is no direct effect on the systemic acid-base balance when taken as directed. D. Fewer side effects, such as diarrhea or constipation, are experienced when they are used properly.

C. There is no direct effect on the systemic acid-base balance when taken as directed. Nonsystemic antacids are not readily absorbed, so they do not alter the acid-base balance. Sodium bicarbonate is absorbed and can alter the acid-base balance. These preparations do contain sodium. Nonsystemic antacids are insoluble and not readily absorbed. Diarrhea and constipation are side effects of nonsystemic antacids.

Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? A. "I must eat foods high in calories." B. "I should avoid alcoholic beverages." C. "I will eat more often but in smaller amounts." D. "I can eat foods high in fat now that the acute stage is over."

D. "I can eat foods high in fat now that the acute stage is over." The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and is appropriate.

A nurse prepares to administer intravenous (IV) albumin to a client with ascites. What effect does the nurse anticipate? A. Ascites and blood ammonia levels will decrease. B. Decreased capillary perfusion and blood pressure. C. Venous stasis and blood urea nitrogen level will increase. D. As extravascular fluid decreases, the hematocrit will decrease.

D. As extravascular fluid decreases, the hematocrit will decrease. Serum albumin is administered to maintain blood volume and normal oncotic (osmotic) pressure; it does this by pulling fluid from the interstitial spaces into the intravascular compartment. Serum albumin does affect blood ammonia levels; fluid accumulated in the abdominal cavity is removed via a paracentesis. The administration of albumin results in a shift of fluid from the interstitial to the intravascular compartment, which probably will increase the blood pressure. Albumin administration does not affect venous stasis or the blood urea nitrogen level.

A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric tube is inserted. The healthcare provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? A. Instill normal saline. B. Assess breath sounds. C. Auscultate for bowel sounds. D. Check the tube for placement.

D. Check the tube for placement. Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? A. Offer soft-textured foods to reduce the digestive burden B. Offer low-cholesterol foods to avoid further formation of gallstones C. Increase protein intake to promote tissue healing and improve energy reserves D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition? A. Dependent edema B. Spoon-shaped nails C. Loose, decayed teeth D. Delayed wound healing

D. Delayed wound healing Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? A. Increased fiber intake B. Bacterial contamination C. Inappropriate positioning D. High osmolarity of the feedings

D. High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period? A. Limiting fluid intake for several days B. Withholding fluids for 72 hours C. Having the client change the colostomy bag D. Keeping the client's skin around the stoma clean

D. Keeping the client's skin around the stoma clean If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection. Although oral fluids are withheld until peristalsis returns, it is essential that parenteral fluids be administered to replace the losses incurred by surgery. The client is often unable to accept the altered body image and must be given time to adjust before participating actively in self-care.

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? A. Stroke volume B. Venous pressure C. Coronary artery patency D. Left ventricular functioning

D. Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart. The patency of the coronary arteries usually is evaluated by cardiac catheterization.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? A. Presence of distention B. Extent of weight gained C. Amount of high-fiber food consumed D. Length of time this problem has existed

D. Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? A. Tingling of the fingertips and toes B. Dry and sticky mucous membranes C. Abdominal cramping and irritability D. Muscle weakness and cardiac dysrhythmias

D. Muscle weakness and cardiac dysrhythmias Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia or hyperkalemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure? A. Right atrial pressure B. Cardiac output by thermodilution C. Pulmonary artery diastolic pressure D. Pulmonary capillary wedge pressure

D. Pulmonary capillary wedge pressure Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility. Right atrial pressure measures only the function of the right side of the heart and indirectly its ability to receive blood. Cardiac output by thermodilution does not measure intracardiac pressures. Pulmonary artery diastolic pressure may not be as accurate an indicator of left ventricular pressure if chronic obstructive pulmonary disease or pulmonary hypertension exists.

A client with a history of hypertension comes to the emergency department with double vision and a blood pressure of 260/120 mm Hg. The healthcare provider prescribes a sodium nitroprusside infusion. The nurse recalls that sodium nitroprusside decreases blood pressure by what mechanism? A. Decreasing the heart rate B. Increasing cardiac output C. Increasing peripheral resistance D. Relaxing arterial smooth muscles

D. Relaxing arterial smooth muscles This drug decreases blood pressure by relaxing venous and arteriolar smooth muscles and is used for immediate reduction of blood pressure. This drug may increase the heart rate as a response to vasodilation. It decreases cardiac workload by decreasing preload and afterload. It decreases peripheral resistance by dilating peripheral blood vessels.

A client with osteomyelitis is receiving antibiotic therapy through a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics was administered, and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. What should the nurse conclude that this finding probably indicates? A. The dose should be increased. B. The dose is in excess of the client's needs. C. There was an adequate administration of the antibiotic. D. There was a problem with the obtaining of blood specimens.

D. There was a problem with the obtaining of blood specimens. Peak levels will always be higher than trough levels; therefore, this result indicates that there has been some mix-up while drawing the samples. Increasing the dose would be an appropriate action if the trough level was too low. Concluding that the dose is in excess of the client's needs would be appropriate if the trough level was too high; however, the trough level still should never exceed the peak level. There is not enough information provided to determine whether there was adequate antibiotic administration.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider? A. Passage of pink-tinged urine B. Pink drainage on the dressing C. Intake of 1750 mL in 24 hours D. Urine output of 20 to 30 mL/hr

D. Urine output of 20 to 30 mL/hr Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage on the dressing may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The healthcare provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? A. Protein enzymes B. Energy carbohydrates C. Vitamins and minerals D. Water and electrolytes

D. Water and electrolytes Fluid and electrolytes are lost through intestinal decompression; on a daily basis about 20% of the total body water is secreted into and almost completely reabsorbed by the gastrointestinal (GI) tract. Because the client is kept nothing by mouth (NPO), there is no stimulus to cause enzymes to be secreted into the GI tract. Intravenous dextrose supplies some carbohydrates as a source of energy; carbohydrates will not be drawn from storage by intestinal decompression. Because the client is being kept NPO, vitamins and minerals are not entering the GI tract and therefore are not lost.