Nursing 265 Week 6

Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number.

20.6 X 1000 = 6001200/600 = 2 Rationale The prescribed dose is 1200 mcg. The available medication is a tablet with 0.6 mg. First, convert the prescribed medication to units of the available medication. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate number of tablets to be administered. Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

A patient has a prescription to receive famotidine (Pepcid) 30 mg intravenous piggyback (IVPB) or intravenous push (IVP) q12hr. Available is a vial containing 10 mg/mL. How many milliliters should the nurse draw up to administer this dose?

3 mL Rationale Multiply 10 by x and multiply 30 × 1 to yield 10x = 30. Divide 30 by 10 to yield 3 mL.STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment. p. 903

Which organism is responsible for causing Lyme disease in clients?

Borrelia burgdorferi Rationale Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculushumanus var. corporis also causes pediculosis.

The nurse is educating a student nurse about enteral feedings that are administered through a nasogastric (NG) tube. What is appropriate for the nurse to include in the teaching about the nasogastric (NG) tube?

It is inserted through the nose into the stomach. Rationale A nasogastric tube is inserted through the nose and goes to the stomach via the throat. The tube does not go all the way to the jejunum. The insertion of a nasogastric tube is not a surgical intervention. p. 865

A nurse is caring for a client with a hiatal hernia. Which risk factor should the nurse assess for in this client?

Obesity Rationale Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Alcoholism may cause gastritis, an enlarged liver, or pancreatitis, but not a hiatal hernia. Inflammation of the bronchi will not weaken the diaphragm. Esophageal varices result from increased portal pressure; they do not cause a hiatal hernia.

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide?

Treat Helicobacter pylori infection." Rationale Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function. Antibiotics do not augment the immune response, potentiate the effect of antacids, or reduce hydrochloric acid secretion.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the drug is being used primarily for which of its properties?

Antiinflammatory Rationale The antiinflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. Aspirin does not preserve bone integrity. Flexion contractures are prevented by exercise, not aspirin. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

Which virus can cause encephalitis in adults and children?

West Nile virus Rationale The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.

Before beginning a transfusion of red blood cells (RBCs), which nursing action is the highest priority to avoid an error during the procedure?

Check the identifying information on the unit of blood against the patient's identification (ID) bracelet. Rationale The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should match exactly the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringers because it will cause red blood cell (RBC) hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, because this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. p. 649

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?

Esophageal pain may imitate the symptoms of a heart attack. Rationale Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. GERD does not predispose to heart disease. Exercise does not seem to exacerbate esophageal reflux problems unless the stomach is full when exercising. Exercising to maintain a healthy weight helps reduce esophageal reflux. Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is mostimportant for the nurse to include in the teaching plan for this client?

Meeting nutritional needs Rationale To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

Which drug can be administered via the intramuscular route to treat anaphylaxis?

Rationale Epinephrine is administered through the intramuscular route to treat anaphylaxis. Methdilazine is administered to treat allergic reactions and pruritus. Phenylephrine is administered orally, not intramuscularly, to treat anaphylaxis. Mycophenolate mofetil is administered intravenously as an immunosuppressant agent.

Which is the first medication approved to reduce the risk of human immunodeficiency virus (HIV) infection in unaffected individuals?

Rationale Truvada is the first medication approved to reduce the risk of HIV infection in unaffected individuals who are at a high risk of HIV infection. Abacavir is administered to treat HIV infection and is a reverse transcriptase inhibitor. Cromolyn is administered in the management of allergic rhinitis and asthma. Methdilazine, an antihistamine, is administered to treat the skin and provide relief from itching.

A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity?

disturbances in hearing Rationale Ringing in the ears occurs because of its effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity. Feelings of drowsiness are not side effects of aspirin; aspirin promotes comfort, which may permit rest. Aspirin may cause diarrhea, nausea, and vomiting, not intermittent constipation. A metallic taste in the mouth is not a side effect of salicylates such as aspirin.

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse?

Chart the dose as not given on the medical record and explain in the nursing progress notes. Rationale Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient and the patient should not be encouraged to take it today. The nurse should not have the family convince the patient to take the magnesium hydroxide. An incident report is not necessary in this instance. If the patient is having loose stools, he or she will likely not need the docusate sodium later during the day. p. 936

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations?

systemic responses of the body to a localized inflammatory process Rationale With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).

Which drug is prescribed for the client to treat severe nodulocystic acne?

Rationale Isotretinoin is used for nodulocystic acne and may provide lasting remission. Imiquimod is a topical immunomodulator used to treat plantar warts. Clindamycin is a topical antibiotic used to treat acne vulgaris to suppress new lesions and minimize scarring. Corticosteroids are contraindicated because use of corticosteroids may cause flare-ups in clients with acne.

Which child is at the highest risk for blunt trauma associated with the indirect entry (hematogenous stage) of microorganisms?

8 year old boy Rationale The indirect entry of microorganisms, which is the hematogenous stage of osteomyelitis, most frequently affects the growing bones of boys younger than 12 years of age. Therefore an 8-year-old boy would be at the highest risk for blunt trauma.

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?

For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Rationale 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. STUDY TIP: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved?

Histamine Rationale Histamine is one of the mediators of injury involving IgE-mediated injury that may cause pruritus. Cytokines are the mediators of injury in delayed hypersensitivity reaction. Neutrophils are involved in immune complex-mediated hypersensitivity reactions. Macrophages in tissues are involved in cytotoxic reactions.

An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. What condition does he have?

Acne vulgaris Rationale Acne vulgaris is a common skin problem that adolescents experience. It is an inflammatory manifestation to the proliferation of Propionibacterium acnes. A varicocele is a collection of elongated and twisted superficial veins near the spermatic cord, superior to the testicle. Comedones are noninflammatory lesions.

Which type of brain tumor can originate from cells that form the myelin sheath around nerves?

Acoustic neuroma Rationale Acoustic neuromas can originate from cells that form the myelin sheath around the nerves. Meningiomas originate from the meninges; they can be a benign or malignant. Astrocytomas can originate from supportive tissues, glial cells, and astrocytes. Ependymomas can originate from the ependymal epithelium. It can range from benign to highly malignant.

Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching?

"I can eat foods high in fat now that the acute stage is over." Rationale 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 patient experiences abnormal weight loss, hair loss, sensitivity to cold, irregular menstruation, dry and yellowish skin, and constipation. The patient reports being extremely conscious about weight and appearance. The nurse recognizes that the assessment findings are indicative of which disorder?

Anorexia nervosa is a serious mental illness. It shows symptoms like weight loss, hair loss, sensitivity to cold, irregular menstruation, dry and yellowish skin, and constipation. It occurs more frequently in women. Hypophosphatemia is commonly associated with refeeding syndrome. Refeeding syndrome is characterized by fluid retention and electrolyte imbalances. Megaloblastic anemia is associated with deficiency of cobalamin.Text Reference - p. 903

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

Comfort Rationale Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible. Surgery is used to correct deformities and facilitate movement, which is not the priority. Concentration and motivation are difficult when a client is in severe pain.

A 28-year-old female patient inquires about options for contraception. The nurse recognizes that if the patient takes an estrogen-based oral contraceptive, her risk for venous thromboembolism (VTE) doubles based on what statement that is made by the patient?

I smoke 1 ½ packs of cigarettes a day." Rationale Women of childbearing age who take estrogen-based oral contraceptives or postmenopausal women on oral hormone therapy (HT) are at increased risk for VTE. Women who use oral contraceptives and tobacco double their risk. Smoking causes hypercoagulability by increasing plasma fibrinogen and homocysteine levels and activating the intrinsic coagulation pathway. Occupations in which a patient is mobile, hot tub use, and previous childbirth do not indicate increased risk of VTE. p. 817

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

Incontinence and inability to move independently. Rationale 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.

Which drug is used to treat acne vulgaris in adolescents but is contraindicated in pregnancy due to its teratogenic effects?

Isotretinoin Rationale Isotretinoin passes through the placental barrier and exhibits teratogenic effects, so it is contraindicated in pregnancy. Tretinoin is not harmful when used topically. Adapalene and benzoyl peroxide are safe drugs for topical use during pregnancy.

Which predisposing condition may be present in a client with pitting edema?

Kidney disease Rationale Kidney disease may be a predisposing condition associated with pitting edema. Shock may be associated with a decreased temperature. Hypothyroidism may be a predisposing condition of non-pitting edema, which occurs due to an endocrine imbalance. Severe dehydration may be associated with decreased elasticity of the dermis.

A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury?

Migration of leukocytes to the site of injury Rationale Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of "granulation" tissue and migration of fibroblasts occurs in the proliferative phase.

The nurse is caring for a patient who had a surgery for an arteriovenous fistula (AVF) in preparation for hemodialysis. What precautionary step should the nurse follow when caring for this patient?

Never take blood pressure measurements in the extremity. Rationale The nurse should inform the patient to never take blood pressure measurements, insert IV lines, or perform venipuncture in the extremity with vascular access. These special precautions are taken to prevent infection and clotting of the vascular access site. Maturation may take six weeks to months. Arteriovenous fistula (AVF) should be placed at least three months before initiating hemodialysis. p. 1088

Which disorder would the nurse state is related to the tonsils?

Pharyngitis Rationale Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

A client has sensorineural hearing loss. Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

Prolonged exposure to noise Rationale Sensorineural hearing loss occurs due to damage to the auditory nerve in the inner ear. Prolonged exposure to noise can cause damage to the cochlea. Cerumen in the ear can cause obstruction in the ear and lead to a conductive hearing loss. Foreign bodies can cause infection and inflammation in the ear, thereby leading to a conductive hearing loss. Perforation of the tympanic membrane leads to an increased risk of ear infections, which can cause conductive hearing loss.

Which benign condition shows silver scaly plaques on the skin?

Psoriasis Rationale A silver scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Non-inflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

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

What is the color of a client's wound caused by skin tears?

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

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every six hours. What should the nurse explain as the best way to prevent oral infection while taking this medication?

Rinse the mouth with water after the second puff of medication. Rationale Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection. The mouth should be rinsed after the second puff, not before each puff. Hard candy or breath mints will not prevent oral infection.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

Several minutes after the start of a transfusion of packed red blood cells, the patient reports itching. Hives begin to develop on the patient's chest and abdomen. Which immediate action should the nurse take?

Stop Rationale Itching and hives indicate that the patient is experiencing a blood transfusion reaction. The transfusion should be discontinued immediately and disconnected. An infusion of normal saline may be started after the blood transfusion has been discontinued and disconnected. The patient should be further assessed, and the primary health care provider should then be notified. The blood transfusion rate should not be slowed or diluted with normal saline. An antihistamine may be prescribed by the primary health care provider after the blood is discontinued and disconnected. p. 650

The parents of a 4-year-old child call the health center and report that their child has a fever of 102.6° F (39.2° C), is complaining of a sore throat, and will not lie down, preferring to sit up and lean forward. The child is drooling and looks ill and agitated. In light of this information, what guidance should the nurse provide the family?

The child needs to be seen immediately by a healthcare provider Rationale This child is presenting with signs and symptoms of epiglottitis, which is a medical emergency. Cool mist is effective in reducing inflammation of croup, but usually it is not effective in epiglottitis; the child will not be able to drink any fluids because of the enlarged epiglottis. A nonsteroidal antiinflammatory drug such as ibuprofen will help reduce fever, but the child will have difficulty swallowing, which may cause the epiglottis to spasm and close off the airway. Waiting to call is unsafe.

Which type of delayed hypersensitivity reaction can be assessed in the client pictured in the image?

Type IV Rationale The client is having contact dermatitis[1][2] of the skin to rubber boots. This is a clinical example of a delayed hypersensitivity reaction, a type IV reaction. This is also called a cell-mediated immune response. Anaphylactic reactions are type I reactions that occur only in susceptible people who are highly sensitized to specific allergens. Hemolytic transfusion reactions are type II reactions that occur when a recipient receives ABO-incompatible blood from a donor. Tissue damage will occur in type III reactions, which are immune-complex reactions that usually occur secondary to antigen-antibody complexes.

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis?

redness of the eardrum Rationale Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.

The nurse provides education to a patient with infective endocarditis related to home care management. Which statement made by the patient indicates the need for further teaching?

"I should be aware that fever and fatigue are normal" Rationale: A patient with infective endocarditis should not consider fever and fatigue as normal and should notify the primary health care provider if these symptoms persist. The patient should cough every two hours and wear elastic compression stockings to prevent the complications of immobility. Patients with infective endocarditis should perform range-of-motion exercises to reduce problems related to reduced mobility.p. 784

The nurse provides discharge teaching to a patient who is newly diagnosed with coronary artery disease (CAD). Which statement made by the patient indicates understanding of the dietary modifications that need to be implemented after discharge home?

"I will not eat bacon or any pork products." Rationale Nutritional guidelines recommended for the patient with CAD include a low-cholesterol and low-fat diet; therefore the patient has to avoid bacon and any pork products. Egg yolk is high in cholesterol and the patient with CAD has to avoid fried food. French fries are high in fat because of their preparation process. Low-fat or nonfat milk is recommended for the patient with CAD. p. 709

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response?

"Your joints are still inflamed, and physical therapy can be harmful." Rationale Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

A patient's blood pressure is 180/100 mm Hg. To assess cardiovascular status, which question related to nutrition is appropriate for the nurse to ask?

"how much salt do you consume in an average day" Rationale A person's food habits impact the cardiovascular system greatly. A patient with hypertension needs to limit consumption of salt, because salt is known to increase blood pressure. Hence asking the patient about approximate consumption of salt in a day is important when assessing cardiovascular status. Consuming salads is good for overall health, but is not a definitive query for a patient with hypertension. Chili can cause gastrointestinal issues, but it is not an important factor in cardiovascular health. Meat is not an important factor for hypertension. p. 665

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?

Allergic contact dermatitis Rationale Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens. Utricaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A drug reaction may be caused by any drug such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How should the nurse best promote the health of the patient's integumentary system?

Alternate the patient's positioning between supine and side-lying. Rationale A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of two hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged. p. 1360

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?

Bland foods Rationale: A bland, nonirritating diet is recommended during the acute symptomatic phase. Low carbohydrate foods do not decrease gastric acid secretion. Clients should be instructed to avoid substances that increase gastric acid secretion such as coffee, tea, and cola. Bed time snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten free foods do not decrease gastric acid secretion.

A woman with chlamydial infection complains of pelvic pain, nausea, vomiting, fever, and abnormal vaginal bleeding. What might be the possible cause of these symptoms?

Complications from chlamydial infections in women may result in pelvic inflammatory disease, which can lead to chronic pelvic pain. Pelvic inflammatory disease can also cause nausea, vomiting, fever, malaise, and abnormal vaginal bleeding. Ectopic pregnancy and infertility do not manifest with these symptoms. Reactive arthritis is a systemic condition accompanied by skin lesions and inflammation of the eye; it is usually a complication of epididymitis-related chlamydial infection.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client?

Control of pain Rationale After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

A patient receives a new prescription for a transfusion of two units of packed red blood cells (PRBCs). The nurse should take which action to ensure patient safety?

Have a second registered nurse check the identifying information on the unit of blood against the identification bracelet and blood-bank identification bracelet.The patient's identifying information (name, date of birth, medical record number) on the identification bracelet should match exactly the information on the blood-bank tag that has been placed on the unit of blood. If any information does not match, the transfusion should not be hung because of possible error and risk to the patient. Blood tubing, not primary tubing, is needed for blood transfusion and should not be administered as a secondary infusion. The nurse should remain with the patient for 15 minutes following initiation of transfusion.p. 649

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience the most pain and limited movement of the joints?

In the morning on awakening Rationale Inactivity over an extended time increases stiffness and pain in joints. The client typically has morning stiffness, or gel phenomenon. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The pain is not as severe in the evening as in the morning. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

A 6-year-old child who has colicky abdominal pain and guarding, as well as nausea, anorexia, and a low-grade fever, is admitted to the pediatric unit. During the admission assessment, a nurse palpates the abdomen and elicits pain in the right lower quadrant. Based on these findings, the child is at greatest risk for which pathophysiological condition?

Inflamed appendix Rationale The child has classic signs and symptoms of an inflamed appendix. The symptoms are caused by inflammation and altered gastrointestinal function. The general symptoms may be seen in children with viral infections, irritable bowel, and parasitic infestations. However, abdominal guarding and pain in right lower quadrant specifies a more specific condition, appendicitis.Test-Taking Tip: Make educated guesses when necessary.

A patient, admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find?

Kussmaul respirations Rationale In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and unlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis. pp. 1142-1144

A patient is admitted to the ICU. What care should a nurse take to ensure that the patient's sleep cycle is as normal as possible?

Limit noise in the ICU Schedule regular rest periods Dim the lights at night and open up the curtains during the day Rationale Sleep disturbance is associated with delirium and delayed recovery. The ambience in the ICU should be properly arranged in order to promote the patient's sleep-wake cycle. Reducing the noise may facilitate sound sleep. Scheduling rest periods between activities may also enhance the ability to sleep. Strategies like dimming lights during the night and opening curtains during the day may also regulate the sleep-wake cycle. Regular sponging keeps the patient hygienic but doesn't directly affect the sleep pattern. Having a caregiver present keeps the patient calm and oriented, but doesn't affect the patient's sleep. p. 1556

A client is diagnosed with a peptic ulcer. What should the nurse expect when assessing the client's pain?

Occurs one to three hours after meals Rationale Pain occurs after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain. Vomiting temporarily alleviates pain because acid secretions are removed. There is no intolerance of fats and eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever?

Positive antistreptolysin titer Rationale A positive antistreptolysin titer is present with rheumatic fever because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dyscrasias; it is unrelated to an infectious or inflammatory process. A positive, not a negative, C-reactive protein will be present; this is indicative of an inflammatory process. The erythrocyte sedimentation rate will be increased, not decreased, indicating the presence of an inflammatory process.

The purpose of this exercise is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping.

Pursed-lip breathing (PLB) Rationale The purpose of PLB is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn, and it gives the patient more control over breathing, especially during exercise and periods of dyspnea. Another type of breathing retraining exercise is diaphragmatic breathing, which focuses on using the diaphragm to achieve maximum inhalation and slow respiratory rate, not prolong exhalation. Huff coughing is an effective forced expiratory technique, not a breathing exercise to prolong exhalation. Chest physiotherapy (CPT) consists of postural drainage, percussion, and vibration and is for patients who have difficulty clearing excessive bronchial secretions. p. 569

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?

Rebound tenderness Rationale Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve?

Reduce colonic irritation Rationale A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest?

Taking a hot tub bath or shower in the morning Rationale Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness. Although wearing loose but warm clothing is advisable for someone with arthritis, it does not relieve morning stiffness. Inactivity promotes stiffness. The practice of avoiding excessive physical stress and fatigue is related to muscle fatigue, not to stiffness of joints.

Based on adult learning principles, which situation indicates that the patient is ready to learn about taking enoxaparin injections at home?

The patient wanting to practice before injecting him- or herself is demonstrating the learner's orientation to learning by seeking out a resource for this stage of learning. The patient requesting pain medication and the tired patient demonstrate they do not have the readiness to learn. The nervous, unconfident patient demonstrates that the learner's self-concept is in need of encouragement and more teaching is needed. Other adult learning principles include the learner's need to know, prior experiences, and motivation to learn.TEST-TAKING TIP: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.Text Reference - p. 54

Prednisone is prescribed for a client with an exacerbation of colitis. What does the nurse teach the client before administering the first dose?

Although the medication decreases intestinal inflammation, it will not cure the colitis. Rationale Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The response usually is rapid. The drug suppresses the immune response and increases the potential for infection. Appetite is increased; weight gain may result from this or from fluid retention.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

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?

Analgesic Rationale 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.Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply.

Asthma Hay fever Rationale Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis result from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.

To determine how well a patient's diabetes mellitus has been controlled over the past two to three months, what assessment parameter should the nurse review?

Glycosylated hemoglobin Rationale When the glucose level is increased, glucose molecules attach to hemoglobin in the red blood cells (RBCs). This attachment lasts for the life of the RBC, two to three months. Monitoring the numbers of these attachments makes it possible to assess the average blood glucose for the previous two to three months. Fasting blood glucose, oral glucose tolerance, and random fingerstick blood glucose tests are used to measure the current blood glucose level, which is different from the glycosylated hemoglobin level. p. 1123

The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care?

Instructing the client to drink at least 3L of fluid daily Rationale Increasing fluid intake[1][2] dilutes the urine, and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate basis. Producing only 2000 mL of urine per 24 hours is inadequate.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client identifies which action as the primary purpose of the medication?

Reduce inflammation at the surgical site Rationale Steroids are used for their antiinflammatory, vasoconstrictive, and antipruritic effects. Steroids increase the incidence of infections because they are antiinflammatory agents and mask symptoms of infection. Steroids increase fluid retention because they promote the reabsorption of sodium from the tubular fluid into the plasma. Although steroid ointments have an antipruritic effect, their major purpose after surgery is their systemic antiinflammatory effect.

Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?

Moisture-retentive dressing Rationale A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis. Rationale The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion do not address the underlying problem and may further irritate the vein and precipitate a thrombophlebitis. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which diagnostic study is used to investigate the cause of an inflamed joint and determines a client's response to antiinflammatory drug therapy?

Thermography Rationale Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy. Plethysmography is used to record variations in volume and pressure of blood passing through tissues. Duplex venous Doppler records blood flow abnormalities to the lower extremities, which helps to detect deep vein thrombosis. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neuron and primary muscle disease.