Patho Final 14
A nurse educator is teaching a group of medical nurses about Kaposi's sarcoma. What would the educator identify as characteristics of endemic Kaposi's sarcoma
Affects people predominantly in the eastern half of Africa Affects men more than women Can progress to lymphadenopathic forms
A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time
After a rash appears
The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants
Air ducts and vents should be sealed.
A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make?
Alcohol and red meat can precipitate an acute exacerbation of gout.
Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines?
All foods must be cooked to avoid food-borne illness. The patient should avoid contact with individuals who have recently been ill or vaccinated.
A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?
Always carry a form of fast-acting sugar
A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding?
An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested.
Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what
An air-purified respirator
Nurses should assess the patient's ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching.
An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient?
50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
Assessment of a patient's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
An ulcer is skin loss extending past the epidermis with the involvement of necrotic tissue.
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Anaphylactic reaction after a bee sting Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen.
nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify?
Anaphylactic, Septic, Neurogenic The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock.
patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin is ordered. the nurse monitor for as a potential adverse effects
Anaphylaxis include hypotension, flank pain, chills, and tightness in chest, terminating with a slightly elevated body temperature and anaphylactic reaction.
A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?
Ans: The patient will remain in the clinic to be monitored for 30 minutes following the injection.
A cruise ship off the coast of Maryland has capsized, and the nurse is triaging victims who were submerged in cold water. Which supplies from the Push Packages would be of most use when caring for these victims? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Antibiotics would be used to help the victims of this emergency. Life support medications would be used to help the victims of this emergency. Intravenous administration equipment would be used to help the victims of this emergency. Airway maintenance supplies would be used to help the victims of this emergency.
A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
Anticipate the need for, and administer, appropriate analgesic medications.
A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication?
Apply a layer of ointment approximately 1/16 inch thick.
A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?
Apply cornstarch to the patient's skin after bathing to facilitate mobility.
The mother of a 4-year-old boy states, "I can't believe my son has type 1 diabetes. We eat well and I was so careful during the pregnancy. What could have caused this?" How should the nurse respond?
Are there others in your family that have type 1 diabetes?" We are not certain what causes type 1 diabetes." "It is thought to be a combination of factors."
A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis.
Arthrocentesis involves needle aspiration of synovial fluid.
A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention?
As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks.
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
Assess for a thrill or bruit over the vascular access site each shift.
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
Assess for signs and symptoms of anaphylaxis.
The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.
Assess for the presence of peripheral edema. Assess the patient's BP.
A nurse practitioner working in a dermatology clinic finds an open lesion on a patient who is being assessed. What should the nurse do next?
Assess the characteristics of the lesion.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
Assess the patient's peripheral pulses distal to the dressing.
A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
Assess the patient's psychosocial state.
The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on
Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments
Assessment of respiratory status
A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize
Assessment of the patient's joints for pain and decreased range of motion
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
Assessment of the quantity of the patient's urine output
An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse?
Assisting the patient and family to identify and mobilize community resources The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. The home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the patient and family, not just the family. The nurse performs continuous and ongoing assessment of the patient; he or she does not just reinforce the importance of that assessment.
A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug
Atropine
A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient?
Avoid hot-water bottles and heating pads.
older adult resident of a care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care?
Avoid using hot water during the patient's baths.
A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following?
Avoid using the same injection site more than once in 2 to 3 weeks.
A nurse is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications
Benzoyl peroxide and erythromycin Benzamycin Benzamycin gel is among the topical treatments available for acne.
A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged
Black The patient would be triaged as black due to the unlikelihood of survival.
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patient's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
Blood urea nitrogen level, Urine specific gravity, Creatinine level
The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock?
Bradycardia In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia,
nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus . What would the nurse expect to observe on inspection?
Butterfly rash An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE.
The nurse is performing a comprehensive assessment of a patient's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
By palpating the patient's skin
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
By protecting older adults against shearing injuries Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries
The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?
Cherry angiomas appear as bright red "moles,"
Which medication will the nurse prepare to administer as the primary antibiotic of choice for the treatment of anthrax?
Ciprofloxacin (Cipro) is the primary antibiotic used to treat anthrax, with a prophylaxis oral dose of 500 mg every 12 hours for 60 days.
A client is suspected of exposure to Clostridium botulinum because of respiratory distress experienced after eating food from a street vendor during a carnival. What care should the nurse provide for this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Clostridium botulinum paralyzes the muscles, and respiratory failure can occur. The nurse should prepare to assist with ventilatory support for this client. The antitoxin should be given as soon as possible and not delayed pending the microbiologic testing.
A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patient's care?
Communicate clearly and frequently with the patient's family.
A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Computed tomography with contrast solution
While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place
Conducting a critique and debriefing for all involved in the incident
A client is brought to the emergency department after being exposed to nitrogen mustard. Which symptoms is the nurse likely to assess?
Conjunctivitis is a symptom of nitrogen mustard exposure. Skin blisters are seen with nitrogen mustard exposure. Nasal irritation is a symptom of nitrogen mustard exposure. Rationale 4: Vomiting is not a symptom of nitrogen mustard exposure. Rationale 5: Excessive salivation is not a symptom of nitrogen mustard exposure.
A patient presents at the walk-in clinic complaining of diarrhea and vomiting. The patient has a documented history of adrenal insufficiency.
Considering the patient's history and current symptoms, the nurse should anticipate that the
nurse caring for a patient who has an immunosuppressive disorder knows that continual monitoring the primary rationale behind the need for continual monitoring?
Continual monitoring of the patient's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the patient's status.
The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
Cool, clammy skin In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
The nurse is attending a course to prepare for mass casualty incidents (MCIs). What technical skills will the nurse have to demonstrate to be a member of the response team?
Core competencies identified under technical skills include demonstrating the safe administration of medications. Core competencies identified under technical skills include demonstrating the safe administration of immunizations. Core competencies identified under technical skills include having knowledge of nursing interventions for adverse medication events.
A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following?
Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency.
Fasting plasma glucose greater than or equal to 126 mg/dL
Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.
nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment?
Current medication regimen Identification of patient's support system Immune system function History of sexual practices
30 year-old female patient has been diagnosed with Cushing syndrome. the psychosocial nursing diagnosis should nurse prioritize when planning the patient's care?
Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image.
A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation? Hirsutism
Cushing syndrome causes excessive hair growth, especially in women.
A patient is receiving a transfusion of packed RBCs. Shortly after initiation of the transfusion, patient begins to exhibit signs and symptoms of a transfusion reaction.
Cytotoxic type II A type II hypersensitivity reaction resulting in red blood cell destruction is associated with blood transfusions.
A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?
Dehydration
A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient?
Difficulty breathing, Cardiovascular overload, Pulmonary edema
A client is prescribed dimercaprol as treatment for acute poisoning. The nurse understands that this medication is used as an antidote for which agents? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Dimercaprol is a chelating agent that neutralizes the effects of various heavy metals such as arsenic. Dimercaprol is a chelating agent that neutralizes the effects of various heavy metals such as gold. Dimercaprol is a chelating agent that neutralizes the effects of various heavy metals such as mercury. Rationale 4: This medication is not used to remove lead. Rationale 5: This medication is not used to remove nickel.
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue?
Diminished protection of tissues and organs
nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease . medication should the nurse administer prior
Diphenhydramine and acetaminophen are administered 30 minutes prior to an IVIG infusion
A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following
Discuss own emotional responses to the disaster.
A patient's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?
Disturbed Body Image
A diabetes nurse educator is teaching a group of patients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic patient?
Do not eliminate insulin when nauseated and vomiting
patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. nurse should prioritize what question
Do you feel any muscle twitches or spasms?As the blood calcium level falls,hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching.
A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what
Doing the greatest good for the greatest number of people
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select
Drop in systolic blood pressure of 40 mm Hg from baselines, Serum lactate >4 mmol/L, Mean arterial pressure (MAP) of ˂65 mm Hg Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines or serum lactate >4 mmol/L.
Following an addisonian crisis, a patient's adrenal function has been gradually regained. nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances?
During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis.
A patient with a diagnosis of primary immunodeficiency informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the patient's vital signs are within reference ranges, what action should the nurse take? Teach the patient deep breathing and coughing exercises.
Dyspnea and cough are among the many signs and symptoms that may suggest infection in an immunocompromised patient.
The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patient's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess?
Dysrhythmias
critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock?
Early provision of nutritional support Nutritional support is necessary for all patients who are experiencing shock.
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock?
Early removal of invasive devices can reduce the incidence of infections.
student is brought to the nurse after falling off a swing. nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
Ecchymoses are bruises
At a local health fair, the community nurse is educating the public on poison-control strategies. Which strategy should the nurse emphasize as the most important to follow?
Educating the community about accidental poisoning is an important part of community health nursing. Prevention is the first line of defense against accidental poisoning.
The nurse is facilitating a program on poison control and tells the group that if a known poison has been ingested, the first measure that must be taken is:
Education about accidental poisoning is an important part of nursing. Clients should keep the number of the local poison center close to the phone or call 1-800-222-1222.
nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. nurse should prioritize which of the following interventions?
Educational programs that focus on control and prevention
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
Elastic pressure garments are worn continuously (i.e., 23 hours a day).
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
Emergency equipment should be readily available.
The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk?
Encourage physical activity and range of motion exercises.
A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurse's most appropriate intervention
Encourage the patient to return to normal social roles when appropriate.
nurse is caring for a patient who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis?
Encouraging the patient and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis.
A nurse is providing care for a patient who has developed Kaposi's sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body
Endothelial cells lining small blood vessels Kaposi's sarcoma (KS) is a malignancy of endothelial cells that line the small blood vessels.
A nurse is caring for a patient who is suspected of having giant cell arteritis What laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply.
Erythrocyte sedimentation rate, C-reactive protein
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize?
Establishing a patent airway and beginning cardiopulmonary resuscitation If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. As well, a patent airway is an immediate priority.
A nurse works in a walk-in clinic. The nurse recognizes that certain patients are at higher risk for different disorders than other patients. What patient is at a greater risk for the development of hypothyroidism?
Even though osteoporosis is not a risk factor for hypothyroidism, the condition occurs most frequently in older women.
A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the patient?
Evidence shows minimal benefits from most CAM therapies.
A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?
Excess fluid volume
patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
Excess fluid volume related to generalized edema
Exercise
Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels.
A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action?
Facilitate referrals to occupational and physical therapy
patient diagnosed with systemic lupus erythematosus has been admitted . Which of the following nursing diagnoses is the most plausible inclusion in the plan of care?
Fatigue Related to Anemia
nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?
Fatigue Related to Pain.Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness.
Which sign or symptom is most typical of an untreated client with type 1 diabetes?
Fatigue is a typical sign/symptom of type 1 DM due to sustained hyperglycemia.
In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?
Fluid volume circulating in the blood vessels decreases. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patient's nutritional intake.
Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis.
A client is diagnosed with acute poisoning of acetylsalicylic acid (aspirin). The nurse knows that ion trapping will be the therapy of choice for this medication and prepares to:
Forced alkaline diuresis may be used to increase the excretion of acidic drugs like salicylates. A diuretic such as furosemide along with IV sodium bicarbonate makes the urine more alkaline.
The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications?
Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?
Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient.
A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply
Glycosuria Dehydration Hypernatremia Hyperglycemia
A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster?
Grouped vesicles in linear patches along a dermatome
A nurse is reviewing the blood work of a client who has recently begun treatment for type 2 diabetes. Which results would indicate that the client is on target with therapy?
HBA1C level is 6.3%. Fasting blood glucose is 100 g/dL.
Middle-aged or older people with either type 2 diabetes or no known history of diabetes
HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.
patient who has received a heart transplant is taking cyclosporine, animmunosuppressant. What should the nurse emphasize during health education about infection prevention?
Hand hygiene is imperative in infection control. A well-balanced diet is important, but for most patients this is secondary to hygiene as an infection-control measure.
nurse is planning the care of a patient who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. the most important component of infection control in the care of this patient?
Hand hygiene is usually considered the most important aspect of infection control.
A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions
Having an ethical framework in place prior to an emergency
Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring?
Heart and respiratory rates are elevated
Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it?
Heart failure
A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patient's subsequent care?
Helping the patient identify and avoid the offending agent
The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem?
Hematuria
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
Hemodynamic instability
While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique.
How should the nurse best interpret this patient's behavior?The patient may be experiencing anger about his circumstances that he is deflecting toward the nurse.
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours.
How should the nurse best respond to this finding? Recognize that the patient is experiencing an expected onset of diuresis.
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn."
How should the nurse cool the burn?Wrap cool towels around the affected extremity intermittently.
hospitalized patient is receiving spironolactone . A consulting physician sees the patient and orders lisinopril . What will be the primary assessment by the nurse?
Hyperkalemia
nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate Kayexalate?
Hyperkalemia a common complication of acute kidney injury, is life-threatening if immediate action is not taken to reverse it
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?
Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent
Hyperstimulation of the nerve endings
A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what?
I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."
A client is found at home unconscious with an empty bottle of diltiazem (Cardizem) near the couch. The emergency response team prepares to administer which antidote?
IV calcium is the antidote for Cardizem, a calcium channel blocker.
A patient with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
Identifying the offending agent, if possible
A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body
Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis?Teaching the patient how to use and care for the prosthesis
The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague? Immunodeficient patients will usually exhibit subtle and atypical signs of infection.
Immunodeficient patients often lack the typical objective and subjective signs and symptoms of infection.
A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?
Immunoglobulin E
A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi's sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposi's sarcoma?
Immunosuppression-associated Kaposi's sarcoma occurs in transplant recipients and people with AIDS.
A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
Impaired Skin Integrity Related to Kaposi's Sarcoma
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what
Impaired Skin Integrity Related to Scaly Lesions An appropriate diagnosis for a patient with psoriasis would include Impaired Skin Integrity as it relates to scaly lesions.
The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis
Impaired gas exchange
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
Importance of personal hygiene
What assessment finding is most consistent with the clinical presentation of RA? Joint stiffness, especially in the morning
In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied,
A patient with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the patient, the nurse should know that the patient's diminished thyroid function may have what effect?
In all patients with hypothyroidism, the effects of analgesic agents, sedatives, and anesthetic agents are prolonged.
To achieve consistency with the body's natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids?
In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM.
You are precepting a new nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. patient?
In light of this intervention, for what sign would you teach the new nurse to monitor the Hypothermia
patient's primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is the diagnosis?
In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome , white blood cells cannot initiate an inflammatory response to infectious organisms.
nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority.
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following?
Increased uric acid levels Gout is caused by hyperuricemia (increased serum uric acid).
nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia . Which nursing diagnosis has the highest priority
Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia . Airway and breathing take top priority
A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the parents do not understand why their baby did not develop an infection during the first months of life. The nurse should describe what phenomenon?
Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins (passive acquired immunity), which occurs at about 5 to 6 months of age.
patient has a diagnosis of rheumatoid arthritis and the provider has now prescribed cyclophosphamide (Cytoxan). nurse's assessments should address what potential adverse effect?
Infection.When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression and infection.
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action?
Inform the physician and assess the patient for signs of infection.
A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
Inform the primary care provider promptly because the graft may need to be removed.An infected graft may need to be removed,
A patient with SLE has come to the clinic for a routine check-up. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action?
Inform the primary care provider that a friction rub may be present.
Half of a cup of juice, followed by cheese and crackers
Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich.
after having a thyroidectomy for thyroid cancer. nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal?
Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels hypocalcemia
The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan?
Inspection and care of the incision
The client has type 1 diabetes and receives insulin. He asks the nurse why he can't just take pills instead. What is the best response by the nurse?
Insulin can't be in a pill because it is destroyed in stomach acid."
The client has type 1 diabetes mellitus and receives insulin. Which laboratory test will the nurse assess?
Insulin causes potassium to move into the cell and may cause hypokalemia.
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome . The nurse's plan of care should include which of the following
Interventions. Promoting communication with the patient and family along with addressing end-of-life issues
The client receives metformin Glucophage What will the best plan by the nurse include with regard to patient education with this drug?
It decreases sugar production in the liver. It reduces insulin resistance.
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient?
It dilates the blood vessels.
In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body's needs?
It promotes GI function through direct exposure to nutrients.
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do?
Keep her hands well-moisturized at all times.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
Keep the patient's bed linens free of wrinkles.
nurse is managing care for a group of patients on a renal failure unit. What does the nurse recognize as the most important patient safety precaution with regard to medication administration?
Know that patients will require less-than-average doses of medications.
The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock?
Lactated Ringer's a isotonic solution
The physician writes orders for the client with diabetes mellitus. Which order would the nurse validate with the physician?
Lantus insulin is usually prescribed in once-a-day dosing so an order for BID dosing should be validated with the physician.
A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what?
Laser treatment
A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered
Level B
The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patient's elevated energy requirements during prolonged rehabilitation?
Loss of skeletal muscle
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream.is the agent of choice when there is a need to penetrate thick eschar.
The nurse has identified the nursing diagnosis of "risk for infection" in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
Maintain aseptic technique when administering dialysate.
A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment?
Maintaining and monitoring the patient's fluid balance
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient's ear. The nurse knows that this lesion is consistent with what type of skin cancer?
Malignant melanoma presents itself as a superficial spreading melanoma which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white.
A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education?
Managing Raynaud's-type symptoms, Smoking cessation, The importance of vigilant skin care
A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient?
Managing postoperative pain
While assisting with the surgical removal of an adrenal tumor, the nurse is aware that the patient's vital signs may change upon manipulation of the tumor.
Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in BP and changes in heart rate.
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurse's choice of educational interventions?
Many older adults do not see themselves as being at risk for HIV infection.
The nurse understands that which of the following drugs falls under the classification of biguanides?
Metformin HCI is the only drug that falls within the classification of biguanides.
nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following?
Methotrexate Rheumatrex Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset.
The nurse is caring for a patient with hyperparathyroidism. What level of activity would the nurse expect to promote?
Mobility, with walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium.
A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern?
Modify the environment to reduce the severity of allergic symptoms.
A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthma exacerbations?
Montelukast Singulair
A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class?
Most calories should be derived from carbohydrates.
A client has taken 24 acetaminophen (Tylenol) tablets at once in a suicide attempt. Which medication would most likely be administered to reverse the effects of Tylenol?
Mucomyst is the antidote for acetaminophen (Tylenol) overdose.
The patient is receiving chlorothiazide (Diuril). The nurse assesses the patient for hypokalemia. What does the best assessment include?
Muscle weakness or cramps
The client has diabetes mellitus type 2. The nurse has taught the client about the illness and evaluates that learning has occurred when the client makes which statement?
My cells cannot use the insulin my pancreas makes."
The fact that patients with diabetes have an elevated risk of myocardial infarction
Myocardial infarction and stroke are considered macrovascular complications of diabetes,
patient's current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors . dietary counseling will the nurse provide based on the patient's medication regimen?
NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in
A client with spinal stenosis was found unconscious by family members. The client's opioid pain medication and tricyclic antidepressant medication containers were empty. What will the nurse prepare to administer to this client?
Naloxone (Narcan) is the antidote for opioid medication overdose. Sodium bicarbonate is the antidote for tricyclic antidepressant medication overdose.
A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patient's skin will eventually show what manifestation
Necrosis
A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent
Nerve agent
A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency
Nerve agents
The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. the nurse recognize that that patient is probably experiencing?
Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
Nits may have to be manually removed from the child's hair shafts.
A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patient's ability to prepare and self-administer insulin?
Observe the patient drawing up and administering the insulin.
patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
Obtain a stool culture to identify possible pathogens
Pharmacotherapy with diuretics can cause which of the following general adverse effects?
Orthostatic hypotension
A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR?
PMR has an association with the genetic marker HLA-DR4, Immunoglobulin deposits occur in PMR, PMR occurs predominately in Caucasians
A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves?
Palpation of a rash on the patient's trunk Palpation of a lesion on the patient's upper back
Participation in a support group for persons with diabetes
Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed.
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?
Patch testing is performed to identify substances to which the patient has developed an allergy.
The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem?
Patients with Addison's disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension.
A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the patient should prioritize which of the following? Protective isolation
Patients with Wiskott-Aldrich syndrome are at a grave risk for infection; infection prevention is a priority aspect of nursing care.
A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address?
Patients with aldosteronism exhibit a decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism.
A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?
Patients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005.
patient who has a diagnosis of paroxysmal nocturnal hemoglobinuria. When planning this patient's care, nurse should recognize patient's heightened risk of what complications.
Patients with paroxysmal nocturnal hemoglobinuriahave a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins.
A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders.
Patients with phagocytic cell disorders experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis.
A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
Perform hand hygiene.
A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do
Perform life-saving measures.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient's plan of care while the patient is ventilated?
Performing frequent oral care Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
Perianal region and oral mucosa
nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt nurse to consider that the patient is developing an infection?
Persistent diarrhea is among the varied signs and symptoms that may suggest infection in an immunocompromised patient.
The nurse explains to a group of concerned citizens that a biologic terrorism agent that is especially dangerous because of its high contagion and prolonged incubation period, which allow exposure to a large number of people during the early stages of the disease, is:
Personal contact is needed to spread smallpox, but only a few viral droplets spread through the air or on contaminated objects are needed to produce the disease. Humans are the only carriers.
A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following?
Physically repelling pathogens,Preventing fluid loss
A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurse's most appropriate action
Position the patient in the prone, left lateral position.
The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
Positive test results indicate that antibodies to the AIDS virus are present in the blood.
A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following
Practice outside of her normal area of clinical expertise.
A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders?
Preprocedure hydration and administration of acetylcysteine
A nurse's plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals?
Preserve and increase range of motion while limiting joint stress .
A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
Prevention of venous thromboembolism
nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency
Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system.
The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient
Primary phase
A client, newly diagnosed with type 1 diabetes, says, "I have heard this is a bad disease. What complications could I have?" How should the nurse respond?
Problems with arteries can occur that may cause such problems as heart disease, stroke, kidney disease, or blindness."
A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis?
Promote truthful communication. Teach the patient coping strategies. Provide positive reinforcement.
A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions?
Protect the graft from direct sunlight and temperature extremes.
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care?
Protect the patient's airway.
A patient's blistering disorder has resulted in the formation of multiple lesions in the patient's mouth. What intervention should be included in the patient's plan of care?
Provide chlorhexidine solution for rinsing the patient's mouth.
The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurse's role in caring for this patient? Select all that apply.
Providing emotional support for the family Monitoring for complications Participating in emergency treatment of fluid and electrolyte imbalances Providing nursing care for primary disorder (trauma)
A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal
Providing individuals with education about recognizing stress reactions
The ICU nurse is caring for a patient with multiple organ dysfunction syndrome due to shock. What nursing action should be prioritized at this point during care?
Providing information and support to family members
The nurse is assessing a patient prior to the administration of a diuretic. The nurse knows it is essential to assess which vital signs at this time?
Pulse Blood pressure
nurse has created a plan of care for an immunodeficient patient, specifying that care providers take the patient's pulse and respiratory rate for a full minute.
Pulse rate and respiratory rate should be counted for a full minute, because subtle changes can signal deterioration in the patient's clinical status.
The nurse is contacting the Centers for Disease Control and Prevention for supplies to be sent from the Strategic National Stockpile (SNS) to the site of a massive train derailment and chemical spill. What will the SNS provide?
Push Packages are preassembled caches of drugs, antidotes, and medical supplies that broadly cover a nonspecific emergency for use in early hours. Vendor-managed inventory (VMI) packages contain additional supplies that can be more event specific and ship within 24 to 36 hours.
The nurse is helping stock Push Packages. The purpose of these packages is to:
Push Packages include preassembled caches of drugs, antidotes, and medical supplies that broadly cover a nonspecific emergency for use in early hours. Stored strategically, deployment can be accomplished within 12 hours.
The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patient's output from surgical drains, the nurse should assess what parameters? Select all that apply.
Quantity of output Color of the output Visible characteristics of the output
decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. patient has been diagnosed with
RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane
A client who experienced whole-body radiation exposure 6 hours ago is brought to the emergency department with radiation sickness. On assessment, the nurse would expect the client to report:
Radiation sickness occurs after exposure to ionizing radiation and can last from hours to days. The initial symptoms include nausea and vomiting.
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy's mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock?
Rapid onset of respiratory distress Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided.
The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. the following is a component of CREST syndrome?
Raynaud's phenomenon The "R" in CREST stands for Raynaud's phenomenon.
A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor?
Recent administration of new medications
A nurse is teaching basic "survival skills" to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address?
Recognition of hypoglycemia and hyperglycemia
The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate
Regional efforts and aid from surrounding communities can manage the situation. Local efforts are likely to be overwhelmed, while state and federal assistance are not likely necessary.
The physician orders intravenous (IV) insulin for the client with a blood sugar of 563. The nurse administers insulin lispro Humalog intravenously (IV). What does the best evaluation by the nurse reveal?
Regular insulin is the only insulin that can be given intravenously
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active ROM exercises with the affected hand. How should the nurse best respond?
Remind the patient of the need to immobilize the graft to facilitate healing.
The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures?
Removal of eschar until the point of pain and bleeding occurs
What is the nurse's most appropriate action?
Reposition the patient to facilitate drainage.
A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize?
Restrict consumption of foods high in purines. Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats.
Ask the patient to keep a food diary and review it with the nurse.
Reviewing the patient's actual food intake is the most accurate method of gauging the patient's diet
A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin Glucophage Following an ordered increase in the patient's daily dose of metformin, the nurse should prioritize which of the following assessments?
Reviewing the patient's creatinine and BUN levels
Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patient's clothing and then perform what action
Rinse the patient with water.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patient's care, what nursing diagnosis should be prioritized?
Risk for Impaired Gas Exchange Related to Airway Obstruction
A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included?
Risk for Infection Related to Lesions,Impaired Skin Integrity Related to Epidermal Blisters,Disturbed Body Image Related to Presence of Skin Lesions,Acute Pain Related to Disruption in Skin Integrity
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
Sclerae
woman was diagnosed with Raynaud's phenomenon because of a progressive worsening of her symptoms patient states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions."
Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands.the skin and the subcutaneous tissues become increasingly hard and rigid
What is the primary function of the islets of Langerhans in the pancreas?
Secretion of glucagon and insulin
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment?
Serum albumin level Weight history Body mass index Blood urea nitrogen (BUN) level
The patient is receiving chlorothiazide (Diuril). The nurse suspects the patient is exhibiting side effects to the medication. What will the best assessment of the nurse include?
Serum potassium level of 3.0 and low blood pressure
The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock?
Shallow, rapid respirations A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg.
A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? D
Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.
A client is believed to have been exposed to the variola virus while working in a laboratory. What should the nurse assess before administering the vaccination to this client?
Smallpox vaccinations are contraindicated for persons with an impaired immune system, which would be assessed by the client's current white blood cell count. Smallpox vaccinations are contraindicated for persons with impaired immune systems, such as those who are HIV positive. Smallpox vaccinations are contraindicated for persons with eczema.
The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants' risks of renal carcinoma?
Smoking cessation
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Sodium deficit potassium excess, base-bicarbonate deficit, and elevated hematocrit.
While assessing a 25-year-old female, nurse notes the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. nurse should suspect what type of health problem?
Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen.
An older adult patient is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse?
Spend time outdoors at least twice per week
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patient's chronic kidney disease is at what stage?
Stage 3
A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack
Stand up.
The difference between the standard emergency triage practice and the current emergency triage of mass casualties is that:
Standard emergency triage may be reversed, focusing on clients with the best chance to live.
A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient
Standard precautions The patient is not contagious, and anthrax cannot be spread from person to person, so standard precautions are initiated.
patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications?
Stomatitis is an adverse effect that is associated with gold therapy.
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?
Streptococcal infection
A patient with type 2 Dm achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on 2 occasions. nurse would identify what likely cause for this short-term change in treatment?
Stress has likely caused an increase in the patient's blood sugar levels
A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?
Subcutaneous tissue
A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
Surgical excision The primary goal of surgical management of squamous cell carcinoma is to remove the tumor entirely.
The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital
Survey the victims using a radiation survey meter.
The nurse's assessment reveals that the patient's submandibular lymph nodes are swollen, a finding that represents a change from the previous day.
Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment.
nurse is caring for a patient diagnosed with hypothyroidism secondary to Hashimoto's thyroiditis. When assessing this patient, what sign or symptom would the nurse expect?
Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, dry skin, voice huskiness or hoarseness, menstrual disturbance, and numbness and tingling of the fingers.
The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states?
Tachycardia Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states.
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a BP reading on the affected arm can damage the fistula.
The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse's most appropriate action?
Teach the patient about actions to slow the progression of nephropathy.
A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
Teach the patient about self-care after treatment.
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
Teach the patient guided imagery.
A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient?
Teaching about symptom management
A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?
Teaching about the importance of maintaining high standards of hygieneImpetigo is associated with unhygienic conditions disease is contagious because ,bacterial etiology, corticosteroids are ineffective.
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)?
Teaching participants to limit their sun exposure Sun exposure is the best known and most common cause of BCC. BCC
The nurse teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?
The 42-year-old client who is 50 pounds overweight Obesity increases the likelihood of developing diabetes mellitus due to overstimulation of the endocrine system.
The nurse needs to find out what antibiotics are being stored by the Strategic National Stockpile (SNS). What agency will the nurse contact for this information?
The Centers for Disease Control and Prevention manages the Strategic National Stockpile to ensure immediate availability and deployment of essentials to any state.
A group of concerned people ask the community nurse speaking at a local town hall meeting if there is a vaccine for anthrax and, if so, if they should get it. The nurse's best response would be:
The Centers for Disease Control and Prevention recommends vaccination only for select populations: laboratory personnel who work with anthrax, military personnel deployed to high-risk areas, and those who deal with animal products imported from areas with a high incidence of the disease.
A patient was tested for HIV using enzyme immunoassay results were positive. nurse should expect the primary care provider to order what test to confirm the EIA test results?
The Western blot test detects antibodies to HIV and is used to confirm the EIA test results.
The mechanism of action of regular insulin is to
The action of regular insulin is to promote entry of glucose into the cells, thereby lowering glucose.
The client has diabetes type 1 and receives insulin for glycemic control. The client tells the nurse that she likes to have a glass of wine with dinner. What will the best plan by the nurse for client education include?
The alcohol could predispose you to hypoglycemia.
The nurse contacts the pharmacy to have the antidote for nerve agent poisoning available when victims of a mass casualty event arrive in the emergency department. The agent that the nurse is requesting is:
The antidote for nerve gas is the anticholinergic drug atropine sulfate.
nurse is admitting a patient with an immunodeficiency to the medical unit. planning the care of this patient, nurse should assess for what common sign of immunodeficiency?
The cardinal symptoms of immunodeficiency include chronic or recurrent severe infections, infections caused by unusual organisms or organisms that are normal body flora,
An E D nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
The causative agent
A client is receiving edetate calcium disodium (Calcium EDTA) for lead poisoning. Which intervention should be part of this client's care?
The client should eat foods rich in zinc, calcium, magnesium, iron, and calcium to prevent storage of lead in the body.
A client is being treated for acute ethanol overdose. What interventions will the nurse perform when caring for this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
The client will need intravenous fluids. Dextrose 5% and water may be prescribed to treat hypoglycemia, which can occur as an effect of ethanol overdose. Electrolyte imbalances can occur because of acute ethanol overdose and should be reported to the health care provider to ensure appropriate treatment. Urine output should be monitored for all clients being treated for overdose.
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air.
A patient's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patient's drug regimen.
The drug should be used for as short a time as possible.
The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years."
The etiology of neuropathy may involve elevated blood glucose levels over a period of years
The nurse instructs a group of adults with young families that the five general principles for the treatment of acute poisoning are:
The five general principles are topical decontamination, prevention of absorption, neutralization, increase in the rate of excretion, and antidotes and symptomatic therapy.
Clients arrive in the emergency department complaining of difficulty breathing and eye tearing after a bomb explosion in a nearby store. The priority intervention of the health care team initially should be to:
The health care team should initially flush the skin and eyes with copious amounts of water to flush the offending agent.
A nurse at an allergy clinic is providing education for a patient starting immunotherapy for the treatment of allergies. What education should the nurse prioritize?
The importance of keeping appointments for desensitization procedures
The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body?
The major use of iodine in the body is by the thyroid. Iodized table salt is the best source of iodine.
A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man's current mental health problem
The man is experiencing a common response following a disaster.
A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?
The most comfortable position is the semi-Fowler's position, with the head elevated and supported by pillows.
The nurse is teaching a group of community members about common potentially toxic substances. Which vitamin or mineral supplement would be addressed in this instruction?
The most common dangerous substances can poison, such as medicines and iron pills.
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?
The need for the parents to carry an epinephrine pen
The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?
The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question
An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery.
The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? .Age-related physiologic changes Chronic systemic disease
When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue.
The nurse is aware that these findings are potential indicators of what? Epidermal necrosis,Increased metabolic needs,Possible gastrointestinal mucosal sloughing
Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates.
The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue?
Avoiding foot ulcers may mean the difference between institutionalization and continued independent living.
The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important
A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center.
The nurse should monitor the patient closely for what signs of the onset of burn shock? Decreased blood pressure
IVIG has been ordered for patient with an immunodeficiency. Which of the following actions should the nurse perform before administering this blood product?
The nurse should obtain height and weight before treatment to verify accurate dosing. IVIG can be administered through a peripheral line.
A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem.
The nurse should recognize the need to interview the patient about what topic? Current medication use
A client was exposed to cyanogen chloride. What will the nurse do to help this client?
The nurse should remove all clothing contaminated with this chemical agent.
nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. the nurse best reduce this risk?
The nurse should take action to prevent the patient's risk for falls.
The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include
The nurse's typical work uniform
You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?
The nursing priority is to decrease the risk of injury by establishing a protective environment.
A client was exposed to iodine-131. Which medication would the nurse administer to counteract the effects of this exposure?
The only recognized treatment available to counter the thyroid uptake of radiation is ingestion of potassium iodine (KI) before or immediately after exposure.
The physician orders insulin lispro (Humalog), 10 units for the client. When will the nurse administer this medication? 5 minutes before a meal
The onset of action for insulin lispro Humalog is 10 to 15 minutes so it must be given when the client is eating
nurse has admitted a patient diagnosed with severe combined immunodeficiency disease to the unit. patient's orders include IVIG. How will the patient's dose of IVIG be determined?
The optimal dosage of IVIG is determined by the patient's response. In most instances, an IV dose of 200 to 800 mg/kg of body weight is administered
Fluid and electrolyte replacement
The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration
When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?
The palms of the hands and the soles of the feet.
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?
The patient is in the compensatory stage of shock.
A patient is in the primary infection stage of HIV. What is true of this patient's current health status?
The patient is infected with HIV but lacks HIV-specific antibodies.
nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching?
The patient must be made aware that all health-related instructions are lifelong. Immunizations may be contraindicated and infection usually requires inpatient treatment.
The patient has a routine urinalysis done, and the results show protein in the urine. What does the nurse correctly conclude about this result?
The patient probably has kidney damage; protein should not be present in the urine.
A patient presents at the free clinic with a black, wart-like lesion on his face, stating, "I've done some research, and I'm pretty sure I have malignant melanoma." Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?
The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable.Seborrheic keratoses are benign, wart like lesions of various sizes and colors, ranging from light tan to black.
A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patient's care, the nurse should implement what action
The patient should be carefully protected from infection.
The nurse is planning the care of a patient with hyperthyroidism. the nurse specify in the patient's meal plan?A patient with hyperthyroidism has an increased appetite.
The patient should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged.
nurse is preparing to discharge a patient with an immunodeficiency. preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?
The patient who is to receive IVIG at home will need information about adverse reactions and their management.
4 patients arrive at the emergency department. All attempted suicide by overdosing on medication. Which patient will nurse plan to transfer to the renal failure unit?
The patient who overdosed on ibuprofen (Advil)
A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include?
The patient will express satisfaction with her ability to perform ADLs.
patient will be instructed to do which of the following?
The patient will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis.
Several patients have been seen in the acute-care clinic. The nurse will plan to administer diuretic therapy to which patients?
The patient with a blood pressure of 200/98 The patient with generalized edema and decreased urine output
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
The patient's average urine output has been 10 mL/hr for several hours.
A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor?
The patient's body mass index is 34 obese.
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications?
The patient's diet should include which of the following modifications?
A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurse's care of this patient?
The patient's disease is incurable and the nurse's interventions will be supportive.
nurse is performing a visit to the home of a patient who has rheumatoid arthritis. On what aspect of the patient's health should the nurse focus most closely during the visit?
The patient's functional status
A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?
The patient's insulin levels are inadequate.
The nurse is performing a shift assessment of a patient with aldosteronism. What assessments should the nurse include?
The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and BP.
patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion is being cared for on the critical care unit. priority nursing diagnosis for patient with this condition is what?
The priority nursing diagnosis for a patient with SIADH is excess fluid volume, as the patient retains fluids and develops a sodium deficiency.
patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?
The safest way the test can be facilitated is to have a portable x-ray machine in the patient's room.
A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected?An area matching the color and texture of the skin at the surgical site is selected.
The site where the intact skin is harvested is called the donor site. Selection of the donor site is made to match the color and texture of skin at the surgical site and to leave as little scarring as possible.
A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated.
The supervisor will need to work with what organization responsible for coordinating interagency relief assistance Office of Emergency Management coordinates the disaster relief efforts at state and local levels
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
The total body surface area (TBSA) affected by the burn
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community.
These data are likely to support what health promotion effort? Education about home safety
Urinary anti-infectives are used only to treat urinary tract infections (UTIs). What causes urinary anti-infectives to be so effective in treating UTIs?
They act specifically within the urinary tract.
The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patient's siblings, parents, and grandparents.
This assessment addresses the patient's risk of what kidney disorder? Polycystic kidney disease (PKD)
After an explosion at a nearby restaurant, several individuals require treatment at the hospital. The clients arrive at the emergency department with complaints of visual disturbances, burning of the eyes and skin, and loss of hearing. The nurses prioritize care based on the nursing diagnosis of:
This diagnosis speaks directly to the assessment of the explosion incident, and care would be centered around the risk of poisoning.
A patient's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patient's immune response.
This physiologic state is known as which of the following? viral set point
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way?
Through a central venous line Whenever possible, vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately.
A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care?
Thyroid storm necessitates interventions to reduce heart rate and temperature.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?
To maintain adequate mean arterial pressure Feedback: Vasoactive medications can be administered in all forms of shock to improve the patient's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital.
To minimize the risks of contaminating the hospital, managers should perform what action Establish a triage outside the hospital.
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
To prevent contractures
A client is brought to the emergency department with acute poisoning from an unknown agent. Place in order the principles that will be followed to treat this client. Standard Text: Click and drag the options below to move them up or down.
Topical decontamination Prevention of absorption Neutralization Increase in the rate of excretion Antidotes and symptomatic therapy
Which of the five general principles for treating acute poisoning would the nurse use to treat a client who was exposed to an external chemical agent? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Topical decontamination includes the removal of contaminated clothing and flushing of the skin or eyes. This would be appropriate for exposure to an external chemical agent. Application of an agent to neutralize the poison would be appropriate for an exposure to an external chemical agent.
parents of a 1-month-old infant bring their child to the pediatrician with symptoms of congestive heart failure.infant is ultimately diagnosed with DiGeorge syndrome. What will prolong this infant's survival?
Transplantation of fetal thymus, postnatal thymus, or human leukocyte antigen matched bone marrow has been used for permanent reconstitution of T-cell immunity in infants with DiGeorge syndrome.
A diabetic patient calls the clinic complaining of having a "flu bug." The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient?
Try to eat small amounts of carbs, if possible."
The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury
Tympanic membrane rupture
"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."
Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia
A patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Type I Urticaria hives is a type I hypersensitive allergic reaction
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this
Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. .
A dermatologist has asked the nurse to assist with examination of a patient's skin using a Wood's light. This test will allow the physician to assess for which of the following?
Unusual patterns of pigmentation on the patient's skin
A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan
Use caution when taking nonprescription medications. The patient should be cautioned about taking nonprescription medications because some may aggravate mild psoriasis.
A nurse has had contact with a patient who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment
Vaccination
When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent
Vesicant
A group of students arrive at the emergency department with complaints of burning eyes, coughing, and skin burning with blisters. The nurse reviews these symptoms and suspects the students could have been exposed to:
Vesicants blister the skin, respiratory tract, or eyes on contact. An acid burns the eyes, skin, and lining of the respiratory tract on contact. Tear gas irritates the eyes and respiratory tract.
The nurse makes a home visit to a client with diabetes mellitus. During the visit, the nurse notes that the client's 3-month supply of insulin vials that were delivered a week ago are not refrigerated. What is the best action by the nurse at this time?
Vials can be stored at room temperature up to one month. For longer storage, they should be refrigerated.
A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury
Victims are thrown by the pressure wave.
While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis? Vitiligo
Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky white spots, often symmetric bilaterally.
The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?
Wash hands carefully and frequently.
5-year-old boy has been diagnosed with a severe food allergy. What is important parameter to address when educating the parents of this child about his allergy and care?
Wear a medical identification bracelet.
A client was exposed to radiation from a nuclear reactor explosion a month ago. What care will the nurse most likely provide to the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Weight loss and anorexia are long-term effects of radiation sickness. Fatigue is a long-term effect of radiation sickness. Radiation sickness causes suppression of the bone marrow, which increases the client's risk of developing or contracting infections.
A nurse has provided education regarding type 2 diabetes to a newly diagnosed client. Which statements would the nurse interpret as indicating need for additional education?
Well, at least the medications I will be on will help me lose weight." "I can take an oral medication and will never have to inject myself."
A nurse is assessing a teenage patient with acne vulgaris. The patient's mother states, "I keep telling him that this is what happens when you eat as much chocolate as he does."
What aspect of the pathophysiology of acne should inform the nurse's response? Diet is thought to play a minimal role in the development of acne.
A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish.
What health problem should the nurse suspect?Classic Kaposi's sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age.
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient.
What is the nurse's best response? AIDS is commonly transmitted by contact with blood and body fluids.
A patient was prescribed an antibiotic for treatment of sinusitis. patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug.
What is the nurse's most appropriate response? Refer the woman to her primary care provider to have the medication changed.
A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurse's most recent assessments indicate that the patient is producing copious quantities of dilute urine.
What is the nurse's most appropriate response?Recognize this as an expected finding.
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation.
What nursing action should be prioritized during this phase of treatment? Providing education to the patient and family
A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia.
What nursing diagnosis is most likely to apply to this woman's care needs? Ineffective Role Performance Related to Pain
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms.
What risk nursing diagnosis should the nurse include in the patient's care plan? Risk for Disturbed Body Image Related to Skin Lesions
A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant.
What would be an appropriate response for the nurse to make? "Kidney transplants in patients your age are as successful as they are in younger patients."
patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it.
What would be the nurse's best response?"I can only imagine how you feel. Would you like to talk about it?"
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, "I can't wait to have surgery to reconstruct my face so I look normal again."
What would be the nurse's best response?"That's something that you and your doctor will likely talk about after your scars mature."
A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery.
What would be the nurse's most appropriate response to the family member?"His body has consumed his fat deposits for fuel because his calorie intake is lower than normal."
The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what?
Whatever fluid is most readily available in the clinic, due to the nature of the emergency
nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.
A client with diabetes mellitus type 1 is found unresponsive in the clinical setting. Which nursing action is a priority?Treat the client for hypoglycemia.
When a client with diabetes mellitus type 1 is found unresponsive, the nurse should focus on and treat for hypoglycemia, as this is more likely than hyperglycemia.
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs.
When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? Ischemia
Which health problem is a direct effect of exposure to ionizing radiation?
When exposed to large amounts of radiation, or to small amounts over many decades, people tend to develop certain malignancies such as leukemia or thyroid cancer.
physician has ordered hydrochlorothiazide for the patient in chronic renal failure. nurse suspects the patient is experiencing an ineffective response to the medication.
Which assessment is a priority for this patient? Auscultating breath sounds for wheezes
A patient is diagnosed with giant cell arteritis and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better.
Why must the nurse emphasize the need for continued adherence to the prescribed medication? To avoid complications such as blindness
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?Wide excision
Wide excision is the primary treatment for malignant melanoma, which removes the entire lesion and determines the level and staging. Chemotherapy may be used after the melanoma is excised.
The nurse is reviewing a list from the Centers for Disease Control and Prevention that identifies bioterrorism agents that can be spread by person-to-person contact. What agents would be on this list?
Within 1-6 days after exposure, a person with pneumonic plague would be infectious to everyone who has come in contact with the person during that time.
The client has been diagnosed with diabetes mellitus type 1. He asks the nurse what this means. What is the best response by the nurse?
Without insulin you will develop ketoacidosis (DKA)." "The endocrine function of your pancreas is to secrete insulin, but it isn't working.""It means your pancreas cannot secrete insulin."
A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following?
Wrinkles near the lips and eyes
He says he never knew what was wrong but his mother had him undergo "blood testing" as a child. Based on these statements, what health problem should the nurse suspect?
X-linked agammaglobulinemia
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper
airway edema may occur up to how long after the burn injury? 2 days Airway obstruction caused by upper airway edema can take as long as 48 hours to develop.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patient's discharge. In the event of an
anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site? Thigh
A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor
and identified the patient. What action should the nurse take next? Report to the emergency department or employee health department.
A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses anger
and irritation when her call bell isn't answered immediately. "You seem like you're feeling angry. Is that something that we could talk about?"
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed
calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time? With each meal
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are
common allergens? Eggs and wheat seafood lobster, legumes peanuts, peas, beans, licorice, seeds sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds),
The nurse in an allergy clinic is educating a new patient about the pathology of the patient's health problem. What response should the nurse describe as a possible
consequence of histamine release?Contraction of bronchial smooth muscle
An adolescent patient's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient
consequently faces an increased risk of what health problem? Asthma
The nurse is caring for a patient who is experiencing acute renal failure. The nurse knows that this patient may experience problems regulating
fluid balance. electrolyte composition. the pH of body fluids. blood pressure.
A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess
for evidence of what complication? Post-traumatic stress disorder
IV administration of 50% dextrose in water
for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia
immunodeficiency is admitted to the unit with an acute episode of upper airway edema. This is the fifth time in the past 3 months that the patient has had such as episode. nurse caring
for this patient, you know that the patient may have a deficiency of what?C1esterase inhibitor which opposes the release of inflammatory mediators.
A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to
function since her last office visit. Which of the following is the most appropriate action?Arrange for the patient to be assessed in her home environment.
The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this
health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? Decreased urinary output
A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patient's fingernail surfaces are pitted. The nurse should suspect the presence of what
health problem? Pitted surface of the nails is a definite indication of psoriasis.
A patient with chronic kidney failure is taking a loop diuretic. The nurse will advise the patient to take the drug
in the morning
The nurse is applying standard precautions in the care of a patient who has an immunodeficiency. What are key elements of standard precautions? Select all that apply.
include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.)
For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates
including foods usually avoided, such as juices, regular sodas, and gelatin. Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding
increased intestinal permeability and prevent early endotoxin translocation? Early enteral feeding
The nurse caring for a patient in shock is planning assessments and interventions related to the patient's nutritional needs. What physiologic process contributes to these
increased nutritional needs? The release of catecholamines that creates an increase in metabolic rate and caloric requirements
A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patient's health history, the nurse should identify what comorbidity as
increasing the patient's vulnerability to skin infections?Patients with diabetes are particularly susceptible to skin infections.
Loop diuretics
inhibit reabsorption of sodium and chloride in the loop of Henle.
A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papules, and severe itching. The nurse knows that this
is indicative of what strength reaction? Moderately positive
A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy
is needed to manage the patient's hypervolemia and hyperkalemia. Which of the following therapies will the patient's hemodynamic status best tolerate?Continuous venovenous hemodialysis (CVVHD)
nurse is caring for a patient with a phagocytic cell disorder. The patient states, "My specialist says that I will likely be cured after I get my treatment tomorrow." To what treatment
is patient most likely referring? Hematopoietic stem cell transplantation another form of cell therapy, has proven to be a successful curative modality.
nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, motor functions. nurse recognizes that these symptoms are most
likely related to the onset of what complication?HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, motor functions.
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most
likely to be the priority nursing diagnosis?Diarrhea is a problem in 50% to 60% of all AIDS patients.
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the
management of the patient's diarrhea? Sandostatin octreotide is a man made protein
home health nurse is assessing a patient who is immunosuppressed following a liver transplant. What is the most essential teaching for this patient and the family?
must be informed of the need for continuous monitoring for subtle changes in the patient's physical health status and of the importance of seeking immediate health care if changes are detected.
The primary functional unit of the kidney is the
nephron.
A client with DM is taking oral agents, and is scheduled for a diagnostic test that requires him to be NPO and to have contrast dye. What is the best plan by the nurse with regard to giving the client his oral medications?
notify the client's physician and request orders.
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the
nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? Administer IV fluids
A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patient's peritoneum. The
nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.
A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The
nurse knows that priority systems to be assessed include what?GI Assessment of systemic involvement with scleroderma attention to gastrointestinal, pulmonary, renal, and cardiac systems. Liver,
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the
office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1)
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?
patient is at increased risk of infection and masking of signs of infection. cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism.
home health nurse will soon begin administering IVIG to a new patient on a regular basis. What teaching should the nurse provide to the patient?
patient who is to receive IVIG at home will need information about the expected benefits and outcomes of the treatment as well as expected adverse reactions and their management.
A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the
patient's chest. The nurse should ask what priority question regarding the presence of a reddened rash? "Are you allergic to any foods or medication?"
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the
patient's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Foods, Medications, Insect stings,latex
nurse is working with the team to care for a patient who has recently been diagnosed with severe combined immunodeficiency disease . What treatment is likely of most benefit to this
patient?Treatment options for SCID include stem cell and bone marrow transplantation, but HSCT is the definitive therapy for the disease and
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize?
patients develop oral manifestations and need education about promoting good dental hygiene to diminish the oral discomfort and complications that frequently result in inadequate nutritional intake.
A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care
planning during the administration of a vasoactive drug? The drug dose should be tapered down once vital signs improve.
patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, nurse should anticipate
preoperative administration of which of the following? IV administration of corticosteroids may begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency.
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will
present with what alteration in laboratory values? Increased eosinophils
The presence of a tingling sensation Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias
prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication
A patient diagnosed with common variable immune deficiency has been admitted to the acute medicine unit. When reviewing this patient's laboratory findings, the nurse should
prioritize what values? patient diagnosed with CVID often develops pernicious anemia; the patient's hemoglobin and vitamin B12 levels would be used to assess for complications
A nurse is providing an educational presentation addressing the topic of "Protecting Your Skin." When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for
producing the pigmentation of the skin? Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin.
Family members of an immunocompromised patient have asked the nurse why antibiotics are not being given to the patient in order to prevent infection.the nurse best respond
prophylactic drug treatment effectively prevents some bacterial and fungal infections, it must be used with caution because it has been implicated in the emergence of resistant organisms.
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always
put me to sleep." How should the nurse best respond "The newer antihistamines are different than in years past, and cause less sedation."
child has been transported to the ED after a severe allergic reaction. The ED nurse is evaluating the patient's respiratory status. How should the nurse evaluate the patient's
respiratory status?Assess breath sounds, Measure the child's oxygen saturation by oximeter, Monitor the child's respiratory pattern, Assess the child's respiratory rate
The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic
shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? Level of consciousness
A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic
status. What is this patient's most likely diagnosis? Systemic lupus erythematosus (SLE)
The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?An insect bite
stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma
The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient?
symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness.
A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate
the administration of what fluid? Lactated Ringer's
The client injects his insulin as prescribed, but then gets busy and forgets to eat. What is the nurse's most likely assessment finding?
the client will have moist skin
nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, nurse should address
the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises,
patient diagnosed with rheumatoid arthritis patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids.
the nurse best facilitate the patient's adherence to her medication regimen?Encourage her to have pharmacy replace the tops with alternatives that are easier to open.
A patient who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should
the nurse implement? The patient's test should be cancelled until he is off his corticosteroids.
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would
the nurse in the ED receiving the call instruct the father to do? Immerse the child in a cool bath.
After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy,
the nurse should promote what action?Removing the cat from the family's home
A patient's decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies
the patient's health problem? The patient's body has mistakenly identified a normal constituent of the body as foreign. Type II reactions, or cytotoxic hypersensitivity,
The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on
these care priorities, the patient is in what phase of burn care? Acute
nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. nursing intervention best addresses this risk?
thorough mouth care has the potential to prevent or limit the severity of this infection.
A patient with diagnosis of common variable immunodeficiency begins to develop thick, sticky, tenacious sputum. The patient has a history of episodes of pneumonia at least one
time per year for the last 10 years. What does the nurse suspect the patient is developing? bronchiectasis and pulmonary failure.
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question
to ask this patient at this time?"Do you take any over-the-counter drugs or herbal preparations?"
A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patient's susceptibility
to heat loss is related to atrophy of what skin component?The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation.
A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for
treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? Visual changes
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having
trouble breathing. What should the nurse suspect? Anaphylaxis due to a latex allergy
nurse is instructing a patient with congestive heart failure on daily self-monitoring between home care visits. The nurse should instruct the patient to monitor and record
weight. pulse. blood pressure.
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern
when planning this patient's care? Fluid status
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient
who has been burned and suffered smoke inhalation? Airway management
A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate adverse effects of this drug?
"I have this ringing in my ears that just won't go away."
The nurse has finished teaching a client with diabetes mellitus how to administer insulin. The nurse evaluates that learning has occurred when the client makes which statement?
"I should only use a calibrated insulin syringe for the injections." To ensure the correct insulin dose, a calibrated insulin syringe must be used.
The elderly patient is receiving ethacrynic acid (Edecrin) and tells the nurse he doesn't hear as well as he used to. What is the best response by the nurse?
"I will let your doctor know about this; it could be a side effect of your medication."
A patient with systemic lupus erythematosus is preparing for discharge. nurse knows that the patient has understood health education when the patient makes what statement?
"I'll make sure to monitor my body temperature on a regular basis."
A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer?
"If you are going to use up the vial within 1 month it can be kept at room temperature."
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurse's best response?
"It's possible that your baby could contract HIV, either before, during, or after delivery."
patient has been diagnosed with chronic renal failure and is receiving hydrochlorothiazide . nurse has taught the patient about importance of kidney function, and evaluates that learning has occurred when the patient makes which statements?
"Kidneys help my heart by balancing potassium.""Kidneys balance the fluid and electrolytes in my body.""Kidneys keep blood pressure from getting too low."
An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes?
"Lately, I drink and drink and can't seem to quench my thirst."
nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. nurse teach this family about the child's health problem?
"Many children outgrow their food allergies in a few years if they avoid the offending foods."
The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse?
"OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The teen asks the nurse what she can do keep from getting HIV. What would be the nurse's best response?
"Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."
The patient is receiving hydrochlorothiazide (HCTZ). The patient asks the nurse what the best fluid to drink to avoid dehydration is. What is the best response by the nurse?
"Plain water is really the best."
The elderly patient is receiving chlorothiazide (Diuril). What does the best teaching by the nurse include with this medication?
"Take the medication early in the morning."
A patient with SLE asks the nurse why she has to come to the office so often for "check-ups." What would be the nurse's best response?
"Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working."
patient is receiving spironolactone . nurse has completed dietary education and evaluates that the patient needs additional education when the patient makes which statement?
"Thank goodness I can still have my orange juice and bananas for breakfast."
A nurse has asked the nurse educator if there is any way to predict the severity of a patient's anaphylactic reaction. What would be the nurse's best response?
"The faster the onset of symptoms, the more severe the reaction."
The patient is receiving bumetanide (Bumex) and asks the nurse, "What is all this about 'loops' in my medicine?" What is the best response by the nurse?
"This is a loop diuretic, which refers to where it acts in your kidney. Not all diuretics work the same way."
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
"Wash your face with water and gentle soap each morning and evening."
The patient is receiving chlorothiazide (Diuril). What is the best medication education by the nurse?
"Weigh yourself, and report a gain of more than 2 pounds in 24 hours."
A client has been prescribed exenatide Byetta. What medication education should the nurse provide?
"You should take this medication twice each day." You may develop diarrhea while taking this drug." "This drug will help you secrete more insulin."
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently
"coughed up some blood." What is the nurse's most appropriate action? Place the patient on respiratory isolation and inform the physician.
The danger from radiation exposure arises primarily from: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
1. The amount of exposure. 2. The long-lasting effects. 3. The amount of cellular death. 4. The distance from the initial incident.
A medical nurse is caring for a patient with type 1 diabetes. The patient's medication administration record includes the administration of regular insulin three times daily. Knowing that the patient's lunch tray will arrive at 11:45, when should the nurse administer the patient's insulin?
11:15
Lose weight, if obese. Obesity is a major modifiable risk factor for diabetes.
A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the child's pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes?
A patient who adheres closely to a meal plan and meal schedule
A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?
A 4-year-old scald victim burned over 24% of the body
Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia
A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what?
"I will make sure to follow the weight loss plan designed by the dietitian."the primary treatment of type 2 diabetes is weight loss.
A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA's recommendations include?
High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.
A diabetes nurse is assessing a patient's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient's knowledge of nutritional therapy in diabetes?
After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patient's initial symptoms, the care team should anticipate what event
A latent phase
While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what? Macules
A macule is a flat, nonpalpable skin color change
The effects of hormonal changes during pregnancy
A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur?
Type 1 diabetes Beta cell destruction is the hallmark of type 1 diabetes
A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe?
Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted
A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy?
recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body's need for insulin?
Infection Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections
A patient has been brought to the emergency department by paramedics after being found unconscious. The patient's Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.
A patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following?
Regular insulin is usually administered 20-30 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.
A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient?
If a vial of insulin will be used up within 1 month, it may be kept at room temperature
A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurse's priority action?
Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating
A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?
Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient's renal function
A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?
The cuffs are made of Dacron polyester. The cuffs stabilize the catheter. The cuffs prevent the dialysate from leaking. The cuffs provide a barrier against microorganisms.
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patient's abdomen is increasing in girth.
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
A patient with diabetes mellitus and poorly controlled hypertension
Which of the following individuals would be the most appropriate candidate for immunotherapy?
A patient with severe allergies to grass and tree pollen
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs?
A patient-controlled analgesia (PCA) system
During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones epinephrine, norepinephrine, glucagon, cortisol, and growth hormone
A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse's best response?
A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient?
A pregnant woman at 30 weeks' gestation
A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?
A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin.
A patient with human immunodeficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what?
A reduction in the patient's CD4 count
while the effects on vision and renal function are considered to be microvascular.
A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual's risk for developing diabetes?
A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?
A skin biopsy is done to rule out malignancies of skin lesions.
Assess the patient's readiness to learn. Before initiating diabetes education, the nurse assesses the patient's and family's readiness to learn
A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
A vein and an artery in your arm will be attached surgically.
A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
A wheal is a primary skin lesion that is elevated and has fluid contained in the dermis. An example of a wheal would be an insect bite or hives.
The critical care nurse is monitoring the patient's urine output and drains following renal surgery. What should the nurse promptly report to the physician?
Absence of drain output
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
Acute pain Pain is inevitable during recovery from any burn injury.
A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster
Acyclovir (Zovirax) Acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease.
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Addressing possible barriers to adherence
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis,
A patient has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention
Administration of penicillin
nurse is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is
Advances in medical treatment have meant that patients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer.
A biguanide
Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective
The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient?
Abdominal compartment syndrome
An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many "spots" on her skin. What would be an appropriate response by the nurse?
"As people age, they normally develop uneven pigmentation in their skin."
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
"Does anyone in your family have eczema or psoriasis?"
A nurse in ED is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?
"Has she eaten any new foods today?"
A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. "What should the nurse teach the patient about hemodialysis?
"Hemodialysis is a treatment option that is usually required three times a week."
Which substances enter the filtrate by active secretion? Select all that apply.
. Hydrogen. Potassium. Phosphate
In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes.
. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space
. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia.
. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose
"I don't run the risk of blindness and kidney disease like type 1 diabetics."
/
You could have nerve problems that lead to numbness or tingling in your feet or hands." "One of the most serious complications is diabetic ketoacidosis."
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The nurse is reviewing the components of the Strategic National Stockpile (SNS), which include: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
1. Intravenous administration equipment. 2. Antibiotics. 3. Life-support medications. 4. Chemical antidotes.
A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have?
18%
assessment of an HIV-positive patient whose CD4+ count has fallen, nurse carefully assesses for signs and symptoms related to opportunistic infections. most common life-threatening infection?
AIDS is Pneumocystis pneumonia , caused by P. jiroveci (formerly carinii). Other infections may involve Salmonella, Mycobacterium tuberculosis, and Clostridium difficile.
A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in
AIDS patients by increasing body fat stores? Megestrol
The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' disease would the nurse expect to find?
Clinical manifestations of the endocrine disorder Graves' disease include exophthalmos (bulging eyes) and fine tremor in the hands.
The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?
BP and heart rate monitoring are priorities
patient who has been placed on a loop diuretic for the treatment of congestive heart failure. the nurse encourage the patient to
Bananas Oranges Dried dates to prevent serious adverse effects associated with the medication?
patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. important for the nurse to monitor
Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out.
The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as
Demobilization response
A client recovering from plutonium poisoning from a nuclear reactor explosion is receiving edetate calcium disodium (Calcium EDTA). What will the nurse do to support this client?
Calcium EDTA may produce renal damage such as proteinuria and microscopic hematuria. Treatment-induced nephrotoxicity is dose dependent and may be reduced by ensuring adequate diuresis before therapy begins. Clients should be monitored for cardiac rhythm irregularities and other electrocardiogram changes during IV therapy. This medication can cause hypotension.
An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is a cherry-red color. What should the nurse suspect?
Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa.
A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis What aspect of physical assessment should the nurse prioritize?
Careful attention should be directed toward assessing the head for changes in vision, headaches, and jaw claudication.
A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions?
Cataract development is possible.
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?
Cells lack an adequate blood supply and are deprived of oxygen and nutrients
Which agent would the nurse administer to prevent the absorption of a poison that the client ingested?
Charcoal is used to prevent absorption of the poison.
Which interventions will the nurse include when planning care to enhance the removal of poison from a client who has overdosed on drugs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
Charcoal works by binding with the poison agent. The client's urine output should be monitored, noting the characteristics of urine for early identification of rhabdomyolysis. The client might need dialysis for rapid removal of lethal toxins. A nasogastric tube might be needed for lavage of stomach contents.
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown.
There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patient's likelihood of survival be characterized
Improbable
nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. the nurse explain that this test will involve?
Dexamethasone (1 mg) is administered orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning.
A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient?
Decreased BP
nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
Decreased coordination is likely to constitute a risk for falls.
Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings?
Decreased platelets
The patient's diet should include which of the following modifications?
Decreased protein intake Decreased sodium intake Fluid restriction
When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect?
Decreased venous return Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
A 3-year-old child ingested approximately 20 tablets of iron that were prescribed to the child's mother. The medication that the nurse will prepare to reverse iron is:
Deferoxamine (Desferal) is the antidote for iron overdose.
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
Deficient Knowledge about Early Signs of Melanoma
A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient? Ecchymosis
Ecchymosis refers to a round or irregular macular lesion, which is larger than petechiae. This occurs secondary to blood extravasation.
nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
Educating participants about the early signs and symptoms of skin cancer
Which of the following is a common adverse effect of furosemide (Lasix)?
Hypotension
The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify?
Improved coping with lifestyle modifications
An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment?
Increased time required for wound healing
A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks' duration can suppress the adrenal cortex for how long?
Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks' duration.
A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?
The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus.
The nurse is instructing a patient on the importance of eating foods rich in potassium while taking a diuretic that causes hypokalemia.
Which diuretics do not require potassium supplements? Amiloride (Midamor) Spironolactone (Aldactone)
The nurse must explanation the "sick day rules" again to the patient who plans to stop taking insulin when sick
Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control?
The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The nurse's assessment should reflect the patient's increased risk for what complication?
cancer Frequent causes of death in patients with ataxia-telangiectasiaare chronic pulmonary disease and malignancy.
A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patient's CD4+ T-cell membranes. This process characterizes what phase in the HIV
cleavage
nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply?The nurse should administer pretreatment
acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. patient should be weighed prior and IV infusion rate should not exceed 200 ml/Hr
nurse's assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. nurse should prepare to
administer what intervention? When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate.
nurse is providing care for an older adult whose current medication regimen includes levothyroxine . nurse should be aware of the heightened risk of adverse effects when
administering an IV dose of what medication? thyroid hormones interact with many other medications. small IV doses, hypnotic and sedative agents may induce profound somnolence,
A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of
adrenocortical insufficiency. Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency. The other options also cause adrenocortical insufficiency, but they are not the most common causes.
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin
appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well.
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurse's most recent hourly assessment reveals a significant drop in level of consciousness and BP
as well as scant urine output over the past hour. What is the nurse's best response? Assess the patient for signs of bleeding and inform the physician.
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for Mycobacterium
avium complex (MAC disease). The nurse should anticipate the administration of what drug? Azithromycin
The most appropriate food for the patient taking loop diuretics is
bananas.
Insulin is released when
blood glucose increases.
She states that she is frustrated by her chronic nasal congestion, anosmia inability to smell inability to concentrate. nurse should identify which of the following nursing
diagnoses? Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this
diagnosis? Spina bifida Patients with spina bifida are at a particularly high risk for developing a latex allergy.
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed
diagnostic workup that reveals a phagocytic disorder.This patient faces an increased risk of what complication? Patients with phagocytic cell disorders develop severe neutropenia.
A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse
effect. What should the nurse recommend? Muscle wasting can be partly addressed through increased protein intake.
The diuretic drug that will most likely be used to reduce mortality in heart failure is
spironolactone (Aldactone).
A 30-year-old male patient has just returned from the operating room after having a "flap" done following a motorcycle accident. The patient's wife asks the nurse about the major complications following this type of
surgery. What would be the nurse's best response? "The major complication is when the blood supply fails and the tissue in the flap dies."
football player is thought to have sustained an injury to his kidneys from being tackled from behind. nurse caring for the patient reviews the initial orders written by physician and notes that an order to collect all voided
urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.