PNI Final

"A child with leukemia is complaining of nausea. A nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, most appropriately would offer which of the following during this episode of nausea? 1. Cool, clear liquids 2. Low protein foods 3. Low-calorie foods 4. The child's favorite food"

"Correct: 1. With nausea, cool and clear liquids are better tolerated. Do not offer foods when the child is nauseated so he doesn't associate if with being sick. Support nutrition with oral supplements and foods high in proteins and calories"

A 4 yo is admitted for abdominal pain. She has been pale and excessively tired and is bruising easily. On physical exam, lymphadenopathy and hepatosplenomaegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. Which diagnostic study would confirm this diagnosis "1. Platelet count 2. LUmbar puncture 3. bone marrow biopsy 4. wbc count"

"Correct: 3. 3 leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test is microscopic exam of bone marrow obtained by bone marrow aspirate and biopsy. a lumbar puncture may be done to look for blast cells in the scfluid that indicate CNS disease. The wbc count may be normal, high or low in leukemia an altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis"

"A client, diagnosed with chronic lymphocytic leukemia, is admitted to the hospital for treatment of hemolytic anemia. Which of the following measures, if incorporated into the nursing care plan, would best address the patient's needs? 1. Encourage activities with other patients in the day room. 2. Isolate him from visitors and patients to avoid infection. 3. Provide a diet high in Vitamin C 4. Provide a quiet environment to promote adequate rest.

"Correct: D. 1. does not meet need for rest 2. no info given about WBC or reverse isolation, on reverse isolation if neutrophil count is less than 500/mm3 3. needed for wound healing and resistance to infection, not best choice 4. primary problem activity intolerance due to fatigue. Correct"

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1. Administer oxygen to the client. 2.Continuedialysisataslowerrateaftercheck- ing the lines for air. 3. Notify the health care provider (HCP) and Rapid Response Team. 4. Stop dialysis, and turn the client on the left side with head lower than feet. 5. Bolus the client with 500 mL of normal saline to break up the air embolus.

1. Administer oxygen to the client. 3. Notify the health care provider (HCP) and Rapid Response Team. 4. Stop dialysis, and turn the client on the left side with head lower than feet.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? (Select all that apply). 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks.

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemo- dialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1. Palpation of a thrill over the fistula

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? (Select all that apply). 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if any contain or retain potassium. 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 4. Review the client's medications to determine if any contain or retain potassium.

440. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions? 1."A balance of rest and exercise is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.

2. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

2. These are psychosocial manifestations of PD. These should be discussed in the support meeting.

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1.Aortic stenosis 2.Atrial septal defect 3.Patent ductus arteriosus 4.Ventricular septal defect

3. A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles.

439. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1.Pallor 2.Hyperactivity 3.Exercise intolerance 4.Gastrointestinal disturbances

3. Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

434. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1.Pallor 2.Cough 3.Tachycardia 4.Slow and shallow breathing

3. Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign.

The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

3. Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease.

The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD.

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, painful scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3. Fever, nausea, vomiting, and painful scrotal edema

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

3. Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.

442. A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1.During sleep 2.When changing the infant's diapers 3.When the mother is holding the infant 4.When drawing blood for electrolyte level testing

4. Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

441. A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1."Has the child complained of back pain?" 2."Has the child complained of headaches?" 3."Has the child had any nausea or vomiting?" 4."Did the child have a sore throat or fever within the last 2 months?"

4. Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3.Restlessness,irritability,andgeneralizedweakness 4. Headache, deteriorating level of consciousness, and twitching

4. Headache, deteriorating level of consciousness, and twitching

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

4. Masklike facies and a shuffling gait are two clinical manifestations of PD.

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Swollen, and boggy prostate gland 3. Tender and edematous prostate gland 4. Tender, indurated prostate gland that is warm to the touch

4. Tender, indurated prostate gland that is warm to the touch

A patient is being educated on how to take their anti-thyroid medication. Which of the following statements are INCORRECT?* A. "I will continue taking aspirin daily." B. "I will take this medication at the same time every day." C. "It may take a while before I notice that the medication is helping my condition." D. "I will avoid foods containing high levels of iodine."

A

A patient is receiving radioactive iodine treatment for hyperthyroidism. What will you include in your patient education to this patient about this type of treatment?* A. Taste changes and swollen salivary glands B. Constipation C. Excessive thirst D. Sun protection

A

An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A) Between meals B) After meals C) After medication D) Around the child's play schedule

A

One of the most important pulmonary treatments in cystic fibrosis is: A) Chest physiotherapy. B) Inhaled beta agonists. C) Oral enzymes. D) Inhaled corticosteroids.

A

When administering pancrelipase to child with cystic fibrosis, nurse Faith knows they should be given: A) With meals and snacks B) After each bowel movement and after postural drainage C) On awakening, following meals, and at bedtime D) Every three hours while awake

A

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A. Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

The nurse is teaching coughing techniques to a client with chronic obstructive pulmonary disease. Which technique should the nurse​ include? A. Cough​ twice, the first time to loosen mucus and the second time to expel secretions. B. Limit fluid intake to decrease pulmonary secretions. C. Inhale deeply through the mouth prior to huff coughing. D. Utilize oxygen therapy as needed.

A. Cough​ twice, the first time to loosen mucus and the second time to expel secretions.

When the nurse applies a painful stimulus to the unconscious client, the client responds by stiffly extending and adducting the arms and hyperpronating the wrists. Which of the following does the nurse note in the client's record? A. Decerebrate posturing B. Decorticate posturing C. Purposeful movement D. Babinski response

A. Decerebrate posturing

The nurse is assessing a client who has chronic bronchitis. Which symptom should the nurse expect to​ find? (Select all that​ apply.) A. Distended neck veins B. Barrel chest C. Wheezing D. Diminished breath sounds E. Cough with sputum production

A. Distended neck veins B. Wheezing C. Cough with sputum production

The nurse is teaching a client with chronic obstructive pulmonary disease​ (COPD) about the benefits of an exercise regimen. Which information should the nurse​ include? (Select all that​ apply.) A. Dyspnea and fatigue may improve with exercise. B. An exercise regimen can improve the ability to perform activities of daily living​ (ADLs). C. Exercise can prevent the condition from worsening. D. Inhale and exhale rapidly to maintain oxygenation while exercising. E. Regular exercise improves exercise tolerance and muscle strength.

A. Dyspnea and fatigue may improve with exercise. B. An exercise regimen can improve the ability to perform activities of daily living​ (ADLs). C. Exercise can prevent the condition from worsening. E. Regular exercise improves exercise tolerance and muscle strength.

The GCS score for your client with a risk for increased intracranial pressure has been stable at 12 for the last 6 hours. This time you rate him at 9. Which of the following have you noted and what does it mean? A. He is less responsive, a sign that his intracranial pressure may be increasing B. He is more responsive, a sign that he may be improving C. His pupils are fixed and dilated, an ominous sign D. He does not move or make sounds, which may mean he got too much pain medication

A. He is less responsive, a sign that his intracranial pressure may be increasing

The nurse reviews the arterial blood gas​ (ABG) results of a client with​ end-stage chronic obstructive pulmonary disease​ (COPD). Which finding should the nurse​ expect? A. Hypercapnia with hypoxia B. Hypercapnia with normal oxygenation C. Low CO2 with hypoxia D. Normal CO2 with hypoxia

A. Hypercapnia with hypoxia

A 17 year-old man is admitted to the Trauma Intensive Care Unit after sustaining a closed head injury in a gang related fight. The nurse in the Emergency Department (ED) reported that his VS before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS: BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate response to this assessment data? A. Inform the attending physician of the change in assessment B. Give the client intravenous naloxone (Narcan) as ordered C. Call the laboratory and request a stat blood draw for drug screen D. Lower the head of the client's bed flat immediately

A. Inform the attending physician of the change in assessment

Saed, a registered nurse, is part of the emergency medical response team in the small community where he lives. He is first on the scene of an accident in which an unbelted driver hit a telephone pole at high speed. Which of the following assessments of the victim should he make first? A. Is the person breathing? B. Is the person aware of where he is? C. Is the person able to move his legs? D. Does the person have a pulse?

A. Is the person breathing?

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. His blood pressure is 190/100 mm Hg, and heart rate is 52 beats/min. What should the nurse do first? A. Place the patient in a sitting position. B. Page/notify the health care provider. C. Check the urinary catheter tubing for kinks or obstruction. D. Check the patient for fecal impaction.

A. Place the patient in a sitting position. Autonomic dysorflexia

The client is arousable only if his trapezius muscle is pinched. How will the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Drowsy

A. Stuporous

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

A. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

A. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

A. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

The nurse is discussing tests to evaluate the extent of chronic obstructive pulmonary disease​ (COPD). Which test should the nurse​ include? (Select all that​ apply.) ​A. Ventilation-perfusion testing B. Pulmonary function tests C. Lung biopsy D. Bronchoscopy E. Arterial blood gas analysis

A.Ventilation-perfusion testing B. Pulmonary function tests E. Arterial blood gas analysis

A patient with cystic fibrosis (CF) furiously refuses any more manual chest physiotherapeutic treatment. Which alternative is appropriate for the nurse to suggest? a. Flutter mucus device b. Increase ambulation to 1 to 2 hours a day c. Steam inhalator several times a day d. Drink 3 quarts of fluid per day

ANS: A A flutter mucus clearance device is a handheld vibrating tool that helps loosen and evacuate secretions in the lung.

The parents of a child diagnosed with cystic fibrosis (CF) consult the nurse, stating they want to have more children but are worried about subsequent children also having the disease. Which information does the nurse provide the parents? A. "Each child has a 25% chance of inheriting the disease." B. "This disease is rare, so other children should not be affected." C. "Unfortunately, there is no way to predict if they will have it." D. "You should have genetic testing to see who the carrier is."

ANS: A Cystic fibrosis is an inherited autosomal recessive disorder. When both parents carry the defective gene, each child has a 25% chance of inheriting the defective gene from both parents and manifesting the disease. It is a common disorder, especially in Caucasians, affecting 1 in 3,000 live births.

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.

8. A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection

ANS: A Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support.

6. A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the clients formula. c. Dilute the clients formula. d. Slow the rate of infusion.

ANS: A Proteins and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses, or per protocol. The client may not be able to switch formulas. Diluting the formula is not appropriate. Slowing the rate of the infusion will not address the problem.

14. A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best? a. Assess the clients coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.

ANS: A The nurse should assess this clients coping styles and support systems in order to provide holistic care. The other options do not address the clients distress.

9. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the clients oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.

ANS: A This client has clinical indicators of dehydration, so the nurse calculates the clients 24-hour intake, output, and fluid balance. This information is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action.

1. A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

ANS: A This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

15. A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. Increase the fiber and water in your diet. b. Reduce fat to less than 30% each day. c. Report dry mouth and decreased sweating. d. Lorcaserin may cause loose stools for a few days.

ANS: A This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat.

5. When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.

ANS: A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty snacks are not recommended because all adults should limit sodium in their diets.

5.A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

ANS: A, B, D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

The pediatric nurse is providing care to a neonate diagnosed with cystic fibrosis. When discussing the clinical manifestations of this disease process, which topics will the nurse include in the teaching session? (Select all that apply.) A. Anemia B. Malnutrition C. Scant, hard stools D. Meconium ileus E. Rectal prolapse

ANS: A, B, D, E The initial presentation of cystic fibrosis in the neonate appears in the gastrointestinal system. The newborn may have a meconium ileus, with meconium so thick that it causes obstruction and requires surgical removal. The infant may initially have bulky stools that are frothy and foul-smelling. Prolapse of the rectum may also occur in infancy and childhood. Malnutrition, anemia, and growth failure persists despite normal caloric intake.

1. The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

ANS: A, C, D, E Many factors increase the hospitalized clients risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill clients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume the snacks are leading to malnutrition.

2.A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A-The patient was oriented and alert when admitted The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

23.A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond? a. Following the drug regimen more closely would have prevented this. b. One acute rejection episode does not mean that you will lose the new organs. c. Dialysis is a viable treatment option for you and may save your life. d. Since you are on the national registry, you can receive a second transplantation.

ANS: B An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.

A nurse is teaching the parents of a 10-year-old child diagnosed with cystic fibrosis. Which instruction by the nurse is most appropriate? A. "For Pseudomonas infections, we can use penicillin antibiotics." B. "Preventing respiratory infections is crucial for quality of life." C. "Unfortunately, your child is sterile and unable to have children." D. "With pancreatic enzymes, vitamin replacement is not needed."

ANS: B Cystic fibrosis (CF) is characterized by frequent, severe respiratory infections, often caused by Pseudomonas, which is treated with tobramycin (TOBI) or azithromycin (Zithromax). Preventing respiratory infections is a crucial part of caring for the child with CF. Reproduction is often affected in people with CF, but without testing, it is impossible to say that the child is sterile. Vitamin replacement is needed along with pancreatic enzyme replacement.

A nurse documents and reports the presence steatorrhea in a patient with cystic fibrosis (CF). What does this finding indicate about the patient? a. Is being adequately maintained on the present dose of pancreatic enzyme b. Is not adequately digesting food, leaving loose, fatty, sticky and foul smelling stool c. Has diarrhea related to excess mucus in the bowel d. Has inadequate hydration

ANS: B Foul, bulky stools are the result of inadequately digested food if oral pancreatic enzymes are inadequate.

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

ANS: B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? a. When ill, avoid eating or drinking to reduce vomiting and diarrhea. b. Monitor your blood glucose levels at least every 4 hours while sick. c. If vomiting, do not use insulin or take your oral antidiabetic agent. d. Try to continue your prescribed exercise regimen even if you are sick.

ANS: B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick

3. A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL

ANS: B A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

18. A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating quiet time so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

ANS: B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the clients tissues. The other options are appropriate for any client, and are not specific to obese clients.

16. Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State That is a violation of client confidentiality. c. Tell the nurse Dont look; Ill tell you her weight. d. Walk away and ignore the other nurses behavior.

ANS: B Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.

4. A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.

ANS: B For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met.

13. A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the clients readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

ANS: B Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the clients willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this clients situation, but safety takes priority.

19. A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

The pediatric nurse describes the effects of cystic fibrosis on the body systems to the parents of a child recently diagnosed with the disease. Which statements does the nurse include to the parents? (Select all that apply.) A. Altered protein and vitamin metabolism causes a type of dementia in older children. B. Increased mucus obstructs the airways, and stasis of fluid causes infections. C. Pancreatic ducts are often blocked by mucus, leading to poor nutrition. D. Reproduction is affected, as ovarian ducts and the vas deferens are occluded. E. Thick mucus affects several body systems, preventing some organs from working.

ANS: B, C, D, E Cystic fibrosis is an inherited autosomal recessive disorder that causes the production of thick mucus that blocks exocrine glands and affects several body systems, including the respiratory, gastrointestinal, and reproductive systems. It does not lead to a type of dementia.

4. A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

ANS: B, C, E If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

3. A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

ANS: B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%.

12. A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the clients pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

ANS: C All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management.

2. A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition

ANS: C Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.

17. A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

ANS: C The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again.

5. A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the clients gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.

ANS: C The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while he or she is vomiting.

7. A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L

ANS: C The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination.

10. A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

ANS: C While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the clients psychosocial status as the priority.

The nurse is assessing a patient diagnosed with cystic fibrosis. Which findings support the patient's diagnosis? (Select all that apply.) A. Concave chest B. Dry, scaly skin C. Protuberant abdomen D. Wasted buttocks E. Thick extremities

ANS: C, D Protuberant abdomen, barrel chest, wasted buttocks, and thin extremities are common features in children with cystic fibrosis.

2. A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesnt get spoiled. b. Assess the clients mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

ANS: C, D, E The UAP should make sure food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The UAP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

A father brings his 1-year-old son to the clinic and states that when he kisses the child's cheek, it tastes salty. Which diagnostic test does the nurse educate the father on based on the father's statement? A. Large bowel barium series B. Pancreatic enzyme analysis C. Pulmonary function studies D. Quantitative sweat chloride test

ANS: D Salty-tasting sweat and tears are a characteristic finding in cystic fibrosis. The diagnostic test for this disorder is the quantitative sweat chloride test. Pancreatic enzyme studies are invasive and not usually performed on children. Pulmonary function studies are done in older children who can cooperate. Large bowel barium studies are not needed.

Four children are in the pediatric clinic waiting to be seen. Which patient should the nurse see first? A. Afebrile, parent reports harsh barky cough B. Pulling on ear, temperature 103°F (39.5°C) C. Salty-tasting sweat, poor weight gain D. Wheezing, retracting, no wet diapers today

ANS: D This child not only has a respiratory problem, he or she is also dehydrated and is the sickest of the four. The nurse should see this patient first. The child with the barky cough is afebrile and has no signs of respiratory distress. Pulling on the ear indicates an ear infection, and these children often run high fevers. The child with salty-tasting sweat and poor weight gain is demonstrating a chronic condition, most likely cystic fibrosis.

11. A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. All weight-loss drugs can cause suicidal ideation. b. No drugs are currently available for weight loss. c. Only over-the-counter medications are available. d. There are three drugs currently approved for this.

ANS: D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation.

A client newly diagnosed with Parkinson disease asks the​ nurse, "What does dopamine do in the​ brain?" Which is the most appropriate​ response? A. "Dopamine enhances the action of​ acetylcholine." B. "Dopamine causes spinal cord neurons to transmit​ impulses." C. "Dopamine stimulates the neurons to transmit sensory and motor​ impulses." D. "Dopamine helps maintain coordinated motor​ movement."

Answer: ​Rationale: Dopamine is responsible for coordination. It balances the neurotransmitter​ acetylcholine, which stimulates the neurons. Dopamine prevents this stimulation from becoming excessive. Dopamine provides regulation rather than stimulation. Dopamine regulates motor neuron impulses and balances acetylcholine. Dopamine only works on certain brain neurons located in the basal​ ganglia, not the spinal cord. Dopamine minimizes and balances the effects of acetylcholine and does not enhance it.

The healthcare provider of an older adult client with advancing Parkinson disease suggested that the client start an exercise regime. Which exercise should the nurse​ recommend? A. T'ai chi B. Running C. Weight lifting D. Football

Answer: ​Rationale: For a client with Parkinson​ disease, an exercise regime that promotes balance and walking is the best.​ So, the nurse may recommend​ t'ai chi. Considering the​ client's age,​ football, running, and weight lifting may be too strenuous.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A: Placing client on back with small pillow under the head B: Keeping portable suctioning equipment at the bedside C: Opening the client's mouth with a padded tongue blade D: Cleaning the clients mouth and teeth with toothbrush

Answer: A

Which client would the nurse identify as being MOST at risk for experiencing a CVA? A: 55yr. old African American Male B: 84yr. old Japanese female C: 67yr. old white male D: 39yr. old prego female

Answer: A

Which clinical manifestation would be required to confirm the diagnosis of Parkinson​ disease? A. Tremors at rest and bradykinesia B. Bradykinesia only C. Rigidity only D. Tremor at rest and flaccidity

Answer: A ​Rationale: A diagnosis of Parkinson disease requires the presence of two of the three cardinal​ manifestations: tremor,​ rigidity, and bradykinesia. Tremors at rest and bradykinesia are two of the cardinal signs. Bradykinesia alone would not be diagnostic. Tremors at rest are a cardinal​ sign, but flaccidity is not. Rigidity is a cardinal​ sign, but rigidity alone is not diagnostic.

Which recommendation should the nurse make to the client with Parkinson disease​ (PD) to improve gait and​ balance? (Select all that​ apply.) A. Looking ahead instead of down B. Not moving too quickly C. Not using an assistive device D. Standing straight E. Placing the heel on the ground before the toes

Answer: A, B, D, E Rationale: For improving gait and balance in the client with​ PD, the nurse may recommend walking technique that includes standing​ straight, not moving too​ quickly, looking ahead and not​ down, and placing the heel on the ground before the toes. The client may use assistive devices to improve balance and gait.

The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that​ apply.) A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. C. The​ client's blood pressure increases when the client stands up. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

Answer: A, B, D, E ​Rationale: PD causes slowed​ movements, including slurred speech. Tremors at rest are very common in PD and easy to identify. Tremors may occur in the​ hands, face,​ neck, lips,​ tongue, and jaw. PD causes a​ frozen, mask-like expression​ (lack of​ affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in Parkinson disease because of the loss of neurons and other changes in the brain. The client may develop dementia. Postural​ hypotension, not​ hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.

Which health promotion activity should be the focus of teaching for a client with Parkinson disease​ (PD)? (Select all that​ apply.) A. Participating in occupational therapy B. Improving balance C. Avoiding exercise D. Preventing injury from falls E. Promoting independence

Answer: A, B, D, E ​Rationale: The focus of teaching for the client with PD should be on improving​ balance, preventing​ falls, promoting​ independence, and participating in​ physical, occupational, and speech therapy. Clients should be taught to participate in exercise to optimize​ mobility, not avoid it.

The nurse is performing passive range of motion exercises for a client with Parkinson disease. Which nursing goal does this intervention​ address? (Select all that​ apply.) A. The client will remain free from injury. B. The client will participate in speech therapy for swallowing and verbal communication. C. The client will demonstrate normal bowel elimination patterns. D. The client will participate in occupational therapy to integrate assistive devices for​ self-care. E. The client will participate in physical therapy to improve walking and balance.

Answer: A, E ​Rationale: Physical​ therapy, including passive range of motion​ (ROM) exercises, will improve the​ client's walking and balance. This in turn helps prevent injury from falls. Assistive devices related to occupational therapy are different from those related to physical therapy. The occupational therapist would teach about devices that facilitate activities of daily​ living, such as button hooks and communication boards. Passive ROM exercises are not related to speech therapy or promoting normal bowel elimination patterns.

What is a priority nursing assessment in the first 24 hours after admission of client with a thrombotic stroke? A: Cholesterol level B: Pupil size and papillary response C: Vowel sounds D: Echo

Answer: B

An older adult client was diagnosed with Parkinson disease 3 months ago. Since the​ diagnosis, the client has not gone out of the house. Which statement by the nurse is most​ appropriate? A. "Tell your family to come and take you out of the​ house." B. "Can I ask why you​ aren't going out of the​ house?" C. "You need to start getting​ out." D. ​"Getting out of the house will help you to feel less​ depressed."

Answer: B ​Rationale: Asking an​ open-ended question and inquiring about the reason why the client is not going out of the house will encourage the client to discuss and share information. Advising the client about going​ out, telling the client that they will feel better by going​ out, or involving the family will not encourage the client to discuss the reason behind staying at home.

A client with Parkinson disease​ (PD) complains of increased tremor while eating. Which action should the nurse​ recommend? A. Having someone feed them B. Liquefying all meals and drinking them through a straw C. Holding a piece of bread in the other hand while eating D. Using their nondominant hand to eat

Answer: B ​Rationale: Holding a piece of bread in the opposite hand or purposeful movement will decrease tremors while eating. The client should be encouraged to eat independently for as long as possible. Using the nondominant hand may lack coordination. As the client with PD is prone to​ choking, liquefying all meals would not be recommended.

Which is the main pathology of Parkinson disease that causes changes in muscular and sensory​ function? A. Reduction of acetylcholine in the brain B. Reduction of dopamine in the brain C. Genetic predisposition D. Presence of Lewy bodies

Answer: B ​Rationale: The changes in muscular and sensory function in Parkinson disease​ (PD) are caused by a decreased amount of dopamine in the​ brain, which in turn​ increases, not​ reduces, the amount of acetylcholine. The presence of Lewy bodies​ (abnormal aggregates of​ proteins) in the neurons is a characteristic of​ PD, but it is unclear whether they are helpful or harmful. Although there is a genetic link in approximately 15dash​25% of​ cases, it is a risk factor rather than a cause of PD manifestations.

An older adult client with Parkinson disease uses a​ walker, speaks in a slurred manner with poor​ articulation, but tries to speak louder to accommodate for this impairment. The client​ states, "I catch my daughter looking at me angrily​ sometimes, but she​ doesn't say​ anything." Which nursing diagnosis is the priority​? A. Communication: Verbal, Impaired B. Caregiver Role Strain C. ​Falls, Risk for D. Nutrition, Imbalanced: Less than Body Requirements

Answer: B ​Rationale: The client is making accommodations for preventing falls by using a walker. Being the primary​ caregiver, the​ client's daughter assists the client in feeding so imbalanced nutrition is not a risk. The client is also practicing speech by speaking louder. It is the​ caregiver's role strain that is the major risk for this client.​

The nurse is assessing a client with Parkinson disease​ (PD). Which factor should the nurse include in the​ assessment? (Select all that​ apply.) A. Difficulty waking B. Response to medication C. Cognitive deficits D. Dizziness when sitting E. Bowel changes

Answer: B, C, E ​Rationale: While assessing the current​ condition, the nurse should ask about bowel​ changes, as clients with PD face problems with​ peristalsis, which contributes to constipation. The client may also have cognitive deficits such as memory​ loss, slowed​ thinking, and​ confusion, which eventually progress to dementia. Another aspect that needs to be assessed is responses to​ medication, especially for​ "on-off" or​ "wearing off" effects that indicate that medication is losing its effectiveness. Clients with PD have difficult falling and staying​ asleep, so difficulty in waking up is not related. Postural hypotension is common in Parkinson​ disease, resulting in blood pressure that drops when the client stands​ up, not while sitting.

A 78 year old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A: Prepare to administer recombinant tissue plasminogen activator (rt-PA) B: Discuss the precipitating factors that caused the symptoms C: Schedule a STAT CT scan of head D: Notify speech pathologist for emergency consult

Answer: C

A client arrives at the ED with ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is priority nursing assessment? A: Current medications B: Complete physical and history C: Time of onset of current stroke D: Upcoming surgical procedures

Answer: C

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the clients: A: Pulse B: Respiration C: BP D: Temperature

Answer: C

The Nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A: Place gait belt around client's waster prior to ambulating B: Places client on back with client's head to the side C: Places her hand under the client's right axilla to help them move up in bed D: Praises the client for attempting to perform ADL's independently

Answer: C

What is expected outcome of thrombolytic drug therapy? A: Increased vascular permeability B: Vasoconstriction C: Dissolved emboli D: Prevention of hemorrhage

Answer: C

Which assessment data would indicate to nurse that the client would be at risk for hemorrhagic stroke? A: Blood glucose level of 480mg/dL B: Right sided carotid bruit C: BP of 220/120 mm Hg D: Presence of bronchogenic carcinoma

Answer: C

Which type of therapy is used to manage problems with eating and​ swallowing? A. Physical B. Occupational C. Speech D. Nutritional

Answer: C ​Rationale: Speech therapy is used to manage problems with eating and swallowing. Occupational therapy is used to maintain​ self-care activities, not specifically eating and swallowing. Physical therapy is used to improve coordination of balance and gait. There is no nutritional therapy needed for a client with Parkinson disease.

The daughter of an older adult client with advancing Parkinson disease tells the nurse that they need to dress their mother each​ morning, because the mother is​ "not fast​ enough." Which is the most appropriate response from the​ nurse? A. "It is important for you to get to work on​ time." B. "Can you let her dress​ herself? C. "It is best for you to let your mother dress herself for as long as she​ can." D. "That is really quite​ normal."

Answer: C ​Rationale: The nurse should tell the caregiver​ that, by allowing independence in​ dressing, the client will have an improved sense of​ well-being and lessened depression. Asking​ closed-ended questions or just remarking that it is normal will not support the​ client's needs.

The nurse is caring for a client with Parkinson disease​ (PD) who reports problems with stiffness and the ability to move. Which action by the nurse will address the​ client's mobility? A. Ask the client if they know about the medications to treat the stiffness B. Advise bedrest for muscle recovery C. Tell the client that this is part of the disease process that cannot be stopped D. Recommend a regular exercise routine and walking

Answer: D ​Rationale: The best way to promote mobility in the client with PD is to recommend the client ambulate daily and exercise on a regular basis. Bedrest would only make the stiffness worse. Although there are medications that can help with​ rigidity, it is outside of the​ nurse's scope of practice to recommend medication. Telling the client that this is just part of the disease process is not appropriate or therapeutic.

A nurse is preparing a presentation on Parkinson disease​ (PD) for a health fair at a local community center. Which information should the nurse include in the​ presentation? A. Parkinson disease affects both men and women at the same rate. B. Parkinson disease is the result of an infection. C. Parkinson disease is inherited in over​ 50% of those affected. D. Parkinson disease usually affects people older than the age of 60 years.

Answer: D ​Rationale: The cause of PD is not known. There is no evidence of an infection that causes Parkinson disease. It is inherited in only 15dash​25% of cases. Parkinson disease affects men more than it does women. Parkinson disease is more common in people over 60 years of age. It can also occur in younger​ people, but this is less common.

The nurse observed a client with Parkinson disease frequently wiping their mouth with a handkerchief. After the nurse requested a prescription for an anticholinergic medication from the healthcare​ provider, the client​ asked, "I feel​ better, why do I need another​ medication?" Which response by the nurse is​ correct? A. "It helps dopamine work​ better." B. ​"It will make you feel​ better." C. "The healthcare provider thinks it will help your​ symptoms." D. "It will help reduce tremors and uncontrolled​ drooling."

Answer: D ​Rationale: The client stated that they are feeling better. It is levodopa and not an anticholinergic that will make dopamine work better. Stating that the healthcare provider thinks it will help with the​ client's symptoms will be an incomplete answer. To give a complete​ response, the nurse would state that an anticholinergic reduces tremors and uncontrolled drooling.

Which recommendation should the nurse make to a client with Parkinson disease who reports​ constipation? (Select all that​ apply.) A. Decreasing fiber intake B. Limiting exercise C. Decreasing fluid intake D. Increasing fluid intake E. Increasing fiber intake

Answer: D, E ​Rationale: Increasing fluid and fiber intake is a known recommendation for the prevention of constipation. Decreasing the intake of fluids or fiber will not help to prevent constipation. Limiting exercise is not associated with constipation.

The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered? A To reduce psychotic symptoms B To reduce extrapyramidal symptoms C To control nausea and vomiting D To relieve anxiety

B

The recommended diet for someone with cystic fibrosis is: A) High fat diet B) High calorie and high protein diet C) Low fat diet D) High calorie diet

B

Which of the following clients is at high risk for developmental problem? A) A preschooler with tonsillitis B) A 2 1/2 -year old boy with cystic fibrosis C) A 5-year-old with asthma on cromolyn sodium D) A toddler with acute Glomerulonephritis on antihypertensive and antibiotics

B

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."

B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).

B The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

While the patient is monitored in the ED, which finding will you immediately report to the physician? A. Unresolved headache B. Blood pressure of 84/60 mm Hg C. Neck pain of "5" on a 0-to-10 scale D. Increase in the Glasgow Coma Scale score

B. Blood pressure of 84/60 mm Hg

The nurse administers intravenous mannitol for an unconscious client. A decrease in which of the following is expected as a therapeutic effect of this drug? A. Seizure activity B. Cerebral edema C. Cerebral metabolism D. Cerebral inflammation

B. Cerebral edema

The client with chronic obstructive pulmonary disease has severe​ hypercapnia, hypoxemia,​ lethargy, and cyanotic nail beds. Which treatment should the nurse expect to be​ ordered? A. Percussion and postural drainage B. Endotracheal intubation C. Respiratory treatment with bronchodilators D. High flow oxygen administration

B. Endotracheal intubation

In clients with closed head injury, a lumbar puncture is necessary to assess for presence of blood in the cerebral spinal fluid (CSF). A. True B. False

B. False

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

B. Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

A client has fluid leaking from the nose after a basilar skull fracture. Which of the following would indicate that the fluid is cerebrospinal fluid? A. It clumps together on the paper and has a pH of 7 B. It leaves a yellowish ring on the paper and tests positive for glucose. C. It is grossly bloody in appearance and has a pH of 6. D. It is clear in appearance and tests negative for glucose.

B. It leaves a yellowish ring on the paper and tests positive for glucose.

The client has had a traumatic brain injury and is comatose on a ventilator. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? A. Assessing for Turner's sign B. Maintaining CO2 levels at 35-38mmHg C. Placing the client in Trendelenberg position D. Suctioning the client frequently

B. Maintaining CO2 levels at 35-38mmHg

Nursing students have prepared a presentation on prevention of intracranial trauma. Where should they offer this in order to benefit the population with the highest risk? A. Education group for parents of teenagers B. Neighborhood center teen activity program C. Well-woman community health fair D. Federal office building for workers in tax office

B. Neighborhood center teen activity program

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

B. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

Ten days later the patient is to be discharged to a rehabilitation facility. What are priorities of care during rehabilitation? (Select all that apply.) A. Returning to pre-injury status B. Teaching self-care skills C. Working on mobility skills D. Bowel and bladder retraining E. Airway, breathing, and circulation

B. Teaching self-care skills C. Working on mobility skills D. Bowel and bladder retraining

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

C. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

On arrival to the ED, which nursing assessment has highest priority for the client with likely traumatic brain injury? A. Testing for alcohol or drugs B. Monitoring urine output C. Assessing level of consciousness D. Checking for pupil response to light

C. Assessing level of consciousness

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

C. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

Which of the following represents the best explanation of secondary brain injury? A. Trauma to the brain causes bleeding and swelling of the tissues increasing pressure within the brain B. Trauma to neurons from the impact of the injury impairs brain function C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling D. Swelling of the axon of the nerve causes it to disconnect from the cell body interrupting conduction of the impulse

C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

Your client is a morbidly obese 63 year-old female who sustained a closed head injury when she slipped on a wet floor in the supermarket. She is in the Intensive Care Unit, on a ventilator, and has intracranial pressure monitoring. Which of the following interventions is least likely to be a part of her plan of care? A. Nasogastric tube feeding around the clock B. Turning every 2 hours with skin care C. Suction every one hour and as needed D. Sterile dressing change to ICP monitoring catheter

C. Suction every one hour and as needed

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

C. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

C. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

C. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

A client is admitted to ICU from PACU after craniotomy to remove a clot in the frontal lobe. How will the nurse position the client? A. With flexed knees to decrease intra-abdominal pressure B. On the right side to prevent bleeding at incision site C. With head of bed elevated at least 30 degrees to promote venous drainage D. Log rolled to bed and head of bed no more than 15 degrees elevation

C. With head of bed elevated at least 30 degrees to promote venous drainage

A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient: A. To a private room so she will not infect other patients and healthcare workers B. To a private room so she will not be infected by other patients and healthcare workers C. To a semiprivate room so she will have stimulation during her hospitalization D. To a semiprivate room so she will have the opportunity to express her feelings about her illness"

Correct Answer: B A. To a private room so she will not infect other patients and health care workers — poses little or no threat B. To a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection C. To a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone D. To a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness"

A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.

Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment NCLEX: Physiological Integrity

Which of the following laboratory values could indicate that a child has leukemia? "1. WBCs 32,000/mm3 2. Platelets 300,000/mm3 3. Hemoglobin 15g/dL 4. Blood pH of 7.35"

Correct: 1. 1. YES! - A normal WBC count is approximately 4.5 mm3 - 11.0 mm3. In leukemia a high WBC count is diagnostic and is usually confirmed by a blood smear. 2-4. None of these indicate leukemia,"

"The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention? 1.T 99, P 102, R 22, and BP 132/68. 2.Hyperplasia of the gums. 3.Weakness and fatigue. 4.Pain in the left upper quadrant.

Correct: 4 1.These vital signs are not alarming. The vitalsigns are slightly elevated and indicate monitoring at intervals, but they do not indicate an immediate need. 2.Hyperplasia of the gums is a symptom of myeloid leukemia, but it is not an emergency. 3.Weakness and fatigue are symptoms of the disease and are expected. 4.Pain is expected, but it is a priority, and pain control measures should be implemented."

The nurse and the unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? A. Take the hourly vital signs on a client receiving blood transfusions. B. Monitor the infusion of antineoplastic medications. C. Transcribe the HCP's orders onto the Medication Administration Record. D. Determine the client's response to the therapy

Correct: A. Explanation: A. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. B. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. C. This is the responsibility of the word secretary or the nurse, not the unlicensed personnel. D. This represents the evaluation portion of the nursing process and cannot be delegated."

Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic 2. Morphine, a narcotic analgesic 3. Epogen, a biologic response modifier 4. Gleevec, a genetic blocking agent"

Correct: C 1. Because of the ineffective or nonexistent WBCs characteristic of leukemia, the body cannot fight infections, and antibiotics are given to treat infections. 2. Leukemic infiltrations into the organs or the CNS cause pain. Morphine is the drug of choice for most clients with cancer. 3. Epogen is a biologic response modifier that stimulates the bone marrow to produce RBCs. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth. 4. Gleevec is a drug that specifically works in leukemic cells to block the expression of the BCR-ABL protein, preventing the cells from growing and dividing."

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.

D. Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

Client sustained head injuries in an automobile accident. He was not wearing a seat belt and hit his head on the windshield. He has multiple bruises and facial lacerations but is alert and oriented. His VS on admit to ED were T 98.0, P 110, R 26, BP 140/80. Which of the following changes in assessment, 1 hour later, would not prompt the nurse to call the physician immediately? A. Confused and difficult to arouse B. Pupils sluggishly reactive C. Blood pressure 160/52 D. Mild headache and stiff neck

D. Mild headache and stiff neck

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

D. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

The nurse is caring for a client with chronic obstructive pulmonary disease​ (COPD) who has shortness of​ breath, a respiratory rate of 28​ breaths/min, and an O2 saturation of​ 92%. Which intervention is contraindicated in this​ client? A. Performing​ percussion, vibration, and postural drainage B. Applying oxygen C. Administering bronchodilators D. Putting the client in supine recumbent position

D. Putting the client in supine recumbent position

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?

Dialysis works by movement of wastes from lower to higher concentration.

A patient is scheduled to take Pancreatin. When will you administer this medication to the patient? A. Right before all meals and snacks B. Right before meals only C. Immediately after meals and snacks D. Immediately after meals only

The answer is A. Pancreatin is a pancreatic enzyme and the patient needs to take it right before ALL meals and snacks.

A patient completed a sweat test yesterday. The results are back and are 45 mmol/L. As the nurse you know this means: A. The patient tested positive for cystic fibrosis. B. The patient tested negative for cystic fibrosis. C. The patient needs further testing because results are not conclusive.

The answer is C. A sweat test is gold standard in testing for cystic fibrosis. The result interpretations are the following: 39 mmol/L or less in patients 6 months or older are NEGATIVE for cystic fibrosis 40 to 59 mmol/L needs further testing, not conclusive 60 or more mmol/L POSITIVE for cystic fibrosis

The physician orders chest physiotherapy on your patient with cystic fibrosis. This is best performed: A. immediately after a meal B. right before a meal C. 1-2 hours after a meal D. only at bedtime

The answer is C. It is best to perform CPT 1-2 hours after a meal (in between meals). You wouldn't want to do it immediately after a meal due to aspiration or vomiting risk OR right before because this can alter a patient's appetite due to the mucous that will be expelled (the mucous can have a foul taste or odor to it), and option D is wrong because CPT is done up to 2-4 times a day NOT only at bedtime.

A 2 year-old patient with cystic fibrosis is scheduled to take Pancrelipase. How will you administer this medication? A. orally with yogurt B. orally with pudding C. orally with applesauce D. orally with ice cream

The answer is C. Pancrelipase is a pancreatic enzyme and should be given in an acidic food like apple sauce. A two-year-old can NOT swallow pills, so the medication capsule must be opened and sprinkled in food. Never crush or chew the medication. Also, never mix it in an alkaline food or milk-based food like yogurt, pudding, or ice cream.....this will inactivate the enzymes.

You're assisting a patient with performing chest physiotherapy. It is very important you have the patient ___________ during the therapy sessions. A. bear down B. use the incentive spirometer C. huff cough D. use a peak flow meter

The answer is C. This is a special type of coughing that will help the patient cough up the mucous during the CPT. It is very important the patient performs this during their CPT sessions.

Cystic fibrosis is an autosomal recessive genetic disorder. Which option below best describes what most likely happens for a child to develop this condition? A. One parent, who is a carrier of the mutated gene, has to pass it to the child B. One of the parents has to have cystic fibrosis in order to pass it to their offspring C. Both of the parents must have cystic fibrosis in order for the child to develop it D. Both parents, who are carriers of the mutated gene, each pass one mutated gene to the child

The answer is D. CF is an autosomal recessive genetic disorder. This means that both of the parents are carriers of the disease (they won't have signs and symptoms of CF). They each have one healthy gene and one mutated gene. For CF to occur in their offspring, the parents will have to each pass ONE of the mutated genes to the child. In this case, it will be the CFTR gene....so the child receives one mutated gene from each parent and this leads to the child to develop CF.

The physician gives an order for a patient with cystic fibrosis to use a positive expiratory pressure (PEP) device to help with airway clearance. As the nurse you will order which device from supply: A. Incentive spirometer B. Bipap C. Peak flow meter D. Flutter valve

The answer is D. This device assists with moving mucous from the lungs to the airway so it can be expelled. Another device that does this is called an Acapella.

When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? a. Develop infections easily b. Maintain current status c. Require less supplemental oxygen d. Show permanent improvement.

a. Develop infections easily A client with COPD is at high risk for development of respiratory infections. COPD is a slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.)

a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis

A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. The nurse is assessing the child's respiratory status. Which of the following findings is consistent with cystic fibrosis? a. Production of thick, sticky mucous. b. Nonproductive, harsh cough. c. Stridor. d. Unilateral decrease in breath sounds.

a. Production of thick, sticky mucous Rationale: Cystic fibrosis is associated with the production of thick, sticky mucous. Children with cystic fibrosis often have repeated respiratory infections, including bronchitis and pneumonia. They may develop a chronic cough and wheezing because of obstruction of air passages, and sputum may be bloodstained at times. Other common symptoms include failure to thrive and loss of weight, abdominal discomfort and flatulence, clay-colored stools. Cystic fibrosis results in excessive loss of sodium in perspiration, so children may become easily dehydrated.

A school-age child with CF asks the nurse what sports she can be involved in as she becomes older. Which of the following activities would be most appropriate for the nurse to suggest? a. swimming b. track c. baseball d. javelin throwing

a. Swimming Rationale: Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an URTI and compromising her respiratory function.

The nurse is planning to teach a client with COPD how to cough effectively. Which of the following instructions should be included? a. Take three deep abdominal breath, bend forward, and cough while saying the word "who" on exhalation. b. Lie flat on back, splint the thorax, take two deep breaths and cough. c. Take several rapid, shallow breaths and then cough forcefully. d. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

a. Take three deep abdominal breaths, bend forward, and cough while saying the word "who" Rationale: The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process 3 or 4 times, the client should take a deep abdominal breath, bend forward and cough while saying the word "WHO" . This intervention is called "huff" cough. Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.)

a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.)

a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. d. You have flexible scheduling for the exchanges.

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which finding would the nurse expect to note on assessment of this client? Select all that apply: a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise d. A widened diaphragm noted on the chest x-ray e. Pulmonary function tests that demonstrate increased vital capacity

b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise Rationale: clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray reveal a hyper inflated chest and flattened diaphragm if the decease is advanced. Pulmonary function test will demonstrate decreased vital capacity.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)

b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)

b. My weight should be maintained at a body mass index of 30. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

An oxygen delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar

b. Venturi mask Rationale: The venturi mask delivers the most accurate O2 conc. It is the best O2 delivery system for the client with chronic airflow limitation because it delivers a precise o2 conc. the face tent, aerosol mask, and teach collar are also high flow o2 deliver systems but most often are used to admin at high humidity.

A client has been prescribed clozapine for treatment of schizophrenia. The patient must be taught to monitor which blood concentrations weekly while take this drug? a. Hematocrit b. WBC c. platelets d. hemoglobin

b. WBC Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Clients taking clozapine should have regular blood tests. White blood cell and granulocyte counts should be measure before treatment is initiated, and at least weekly or twice weekly after treatment begins.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a. Warm, dry skin b. Decreased wheezing c. Pulse rate of 90 beats/minute d. Respirations of 18 breaths/minute

b. decreased wheezing Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10 year old is 70-110 beats/min and normal respiratory rate is 16-20 breaths/minute.

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected? a. Normal breath sounds b. Prolonged inspiration c. Normal chest movement d. Coarse crackles and rhonchi

d. Coarse crackles and rhonchi Rationale: Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become over-distended.

Schizoaffective disorder has symptoms typical of both schizophrenia and which of the following type of disorder? a. Substance use disorders b. Anxiety disorders c. Eating disorders d. Mood disorders

d. Mood disorders Schizoaffective disorder has symptoms typical of both schizophrenia and mood disorders, but it is a separate disorder. Symptoms of anxiety, substance use, and eating disorders are not typically part of schizoaffective disorder

A nurse instructs a client to use the pursed lip method of breathing. The client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed lip breathing is: a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination

d. Promote carbon dioxide elimination Rationale: Pursed lip breathing facilitates maximum expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.

A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse monitors the client for which side effect of this medication? a. Constipation b. Diarrhea c. Bradycardia d. Tachycardia

d. Tachycardia Side effects that can occur from a beta 2 agonist include tremors, nausea, nervousness, palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or throat.

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? a. "The immunization schedule will need to be altered." b. "The child should not receive any hepatitis vaccines." c. "The child should receive all the immunizations except for the polio series." d. "The child should receive the recommended basic series of immunizations along with yearly influenza vaccination."

d. The child should receive the recommended basic series of immunizations along with yearly influenza vaccine. Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for a child with cystic fibrosis.

When teaching the parents of an older infant with CF (cystic fibrosis) about the type of diet the child should consume, which of the following would be most appropriate? a. low protein diet b. high fat diet c. low carbohydrate diet d. high calorie diet

d. high calorie diet Rationale: CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction, a moderate fat, high calorie diet is indicated.

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: a. Promises to do pursed lip breathing at home. b. States actions to reduce pain. c. States that he will use oxygen via a nasal cannula at 5 L/minute. d. Knows to call the physician if dyspnea on exertion increases.

d. knows to call the physician if dyspnea on exertion increases Rationale: Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)

low NA Low K+ high calories

The nurse is monitoring the client with ↑intracranial pressure (ICP). Which of the following does the nurse expect to be ordered to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) C. Mannitol (Osmitrol) D. Phenytoin (Dilantin)

C. Mannitol (Osmitrol)

The nurse is monitoring the client after supratentorial surgery. Which sign does the nurse report immediately to the provider? A. Periorbital edema B. Bilateral dark blue ecchymoses around eyes C. Moderate serosanguineous drainage on dressing D. Decorticate posturing when stimulated

D. Decorticate posturing when stimulated This increases ICP

The nurse is discussing dietary changes for a client with chronic obstructive pulmonary disease. Which advice should the nurse​ include? A. Follow a​ high-carbohydrate diet. B. Restrict fluids. C. Increase dairy products. D. Follow a​ low-salt diet.

D. Follow a​ low-salt diet.

"The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? "1. Administer an antidiarrheal medication prior to meals 2. Monitor the client's serum albumin levels 3. Assess for signs and symptoms of infection 4. Provide skin care to irradiated areas"

"Answer: 2 1. The nurse should administer an antiemetic prior to meals, not an antidiarrheal medication 2. Serum albumin is a measure of the protein content in the blood that is derived form food eaten; albumin monitors nutritional status 3. Assessment of the nutritional status is indicated for this problem, not assessment of the s/sx of infections. 4. This addresses an altered skin integrity problem"

"What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? A. potential for injury B. self-care deficit C. potential for self harm D. alteration in comfort"

"Answer: A potential for injury Low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. "

"In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous handwashing by all persons coming in contact with the client."

"Correct Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL."

A patient who is in her first trimester of pregnancy is diagnosed with hyperthyroidism. Which medication do you suspect the patient will be started on?* A. Propylthiouracil (PTU) B. Radioactive Iodine C. Tapazole D. Synthroid

A

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatin in e level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Increased number of white blood cells in the urine

1. Elevated creatinine level

The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

1. Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client.

Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

3. Memory deficits are cognitive impairments. The client may also develop a dementia.

Following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP before performing the catheterization. 2. Use a small-sized catheter and an anesthetic gel as a lubricant. 3. Administer parenteral pain medication before inserting the catheter. 4. Clean the meatus with soap and water before opening the catheterization kit.

1. Notify the HCP before performing the catheterization.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

1. The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgment that the UAP is not expected to possess.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP).

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5 °C (101.2 °F). Which nursing action is most appropriate? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

2. Notify the health care provider.

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4. Pallor, diminished pulse, and pain in the left hand

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3. Trauma to the bladder or abdomen

Amale client has a tentative diagnosis of urethritis. The nurse should assess the client for which man- ifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4. Dysuria and penile discharge

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.

4. The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.

4. The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks.

A client in the intensive care unit with acute kidney injury (AKI) must maintain a mean arterial pressure (MAP) of 65 mm Hg to promote kidney perfusion. What is the clients MAP if the blood pressure is 98/50 mm Hg? (Record your answer using a whole number.) _____ mm Hg

66

A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child: A) Pounding board and hammer B) Arranging stickers in the album C) Musical automobile D) Puzzle

A

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? A "That must be frightening to you. Can you tell me how you feel about it?" B "There are no people living on Mars." C "What do you mean when you say they're going to invade the earth?" D "I know you believe the earth is going to be invaded, but I don't believe that."

A

A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A benztropine (Cogentin) B dantrolene (Dantrium) C clonazepam (Klonopin) D diazepam (Valium)

A

You are performing discharge teaching with a patient who is going home on Synthroid. Which statement by the patient causes you to re-educate the patient about this medication?* A. "I will take this medication at bedtime with a snack." B. "I will never stop taking the medication abruptly." C. "If I have palpitations, chest pain, intolerance to heat, or feel restless, I will notify the doctor." D. "I will not take this medication at the same time I take my Carafate."

A

The client has a traumatic brain injury from a motor vehicle accident. Which sign does the nurse associate with increased intracranial pressure (ICP)? A. Changes in breathing pattern B. Dizziness when sitting up C. Increasing level of consciousness D. Equal and reactive pupils

A. Changes in breathing pattern

Which of the following are treatment options for hyperthyroidism? Please select all that apply:* A. Thyroidectomy B. Methimazole C. Liothyronine Sodium "Cytomel" D. Radioactive Iodine

A,B,D

A 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a "5" on a 0-to-10 scale. On arrival to ED, which assessment will you perform first? A. Airway B. Circulation C.Level of consciousness D. Sensory-motor

A. Airway

The nurse is assessing a client diagnosed with emphysema. Which clinical manifestation should the nurse expect to​ find? (Select all that​ apply.) A. Barrel chest B. Diminished breath sounds C. Cough with copious amounts of sputum D. Hypercapnia noted within laboratory results E. Use of accessory muscles when breathing

A. Barrel chest B. Diminished breath sounds E. Use of accessory muscles when breathing

A nurse is teaching a client about chronic obstructive pulmonary disease​ (COPD). Which information should the nurse​ include? (Select all that​ apply.) A. COPD exacerbations cause shortness of breath and increased sputum production. B. After a​ flare-up, the lung tissue returns to normal. C. COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. D. COPD is a curable disease. E. Intermittent​ flare-ups of the symptoms are expected.

A. COPD exacerbations cause shortness of breath and increased sputum production. C. COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. E. Intermittent​ flare-ups of the symptoms are expected.

21. A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.

ANS: D A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data.

20. A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene

ANS: D Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis

Administering intravenous fluids through the AV fistula

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?

Albumin level of 2.5 g/dL

The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following? A. Petechiae, fever, fatigue B. Headache, papilledema, irritability C. Muscle wasting, weight loss, fatigue D. Decreased intracranial pressure, psychosis, confusion"

Answer A is Correct. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia."

The client diagnosed with A-fib, has experienced a TIA. Which medication would the nurse anticipate being ordered for the client on discharge? A: PO anticoagulant medication B: Beta-blocker medication C: Anti-hyperuricemic medication D: Thrombolytic medication

Answer: A

When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: a.Discourage the use of stool softeners b.Assess temperature readings every six hours c.Avoid invasive procedures d.Encourage the use of a hard, brittle toothbrush

Answer: C Rationale: Thrombocytopenia is a deficiency of platelets, and leaves the patient more prone to hemmorrhage. For this reason, avoiding invasive procedures will limit the risk of hemorrhage. Stool softeners should be encouraged, while hard brittle toothbrushes should be avoided. Temperature is not the most important vital to track in this patient"

Which symptom for a client with Parkinson disease​ (PD) is due to the lack of automatic muscle​ movement? A. Diminished voice volume B. Reduced ability to swallow C. Alterations in sleep pattern D. Diminished physical mobility

Answer: C ​Rationale: Alterations in sleep pattern may occur due to lack of automatic muscle movement in a client with Parkinson disease. Reducing strenuous activities near​ bedtime, limiting intake of​ caffeine, and providing a glass of milk before bedtime are all examples of interventions that directly address issues with sleep pattern. Reduced ability to​ swallow, diminished voice​ volume, and diminished physical mobility are all related to dysfunction of voluntary muscle movement.

A 6-year-old with cystic fibrosis has an order for Creon. The nurse knows that the medication will be given: A) At bedtime B) With meals and snacks C) Twice daily D) Daily in the morning

B

A patient was recently discharged home for treatment of hypothyroidism and was ordered to take Synthroid for treatment. The patient is re-admitted with signs and symptoms of the following: heart rate 42, blood pressure 70/56, blood glucose 55, and body temperature of 96.8 'F. The patient is very fatigued and drowsy. The family reports the patient has not been taking Synthroid since being discharged home from the hospital. Which of the following conditions is this patient most likely experiencing?* A. Thryoid Storm B. Myxedema Coma C. Iodism D. Toxic Nodular Goiter

B

Cystic fibrosis is caused by: A) A defective gene that causes abnormalities in the brain B) A defective gene that leads to the making of an abnormal protein C) It is not known what the cause is D) Someone who eats too much salt

B

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: A delusions. B hallucinations. C loose associations. D neologisms.

B

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level

B. The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

B. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

A patient is admitted with complaints of palpations, excessive sweating, and unable to tolerate heat. In addition, the patient voices concern about how her appearance has changed over the past year. The patient presents with protruding eyeballs and pretibial myxedema on the legs and feet. Which of the following is the likely cause of the patient's signs and symptoms?* A. Thyroiditis B. Deficiency of iodine consumption C. Grave's Disease D. Hypothyroidism

C

At what age is this disease diagnosed? A) Childhood years [5-12] B) Teenage years [12-17] C) Early years [0-5] D) Adult years [18-50]

C

The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A. Amnesia for events of accident B. Bleeding head laceration C. Pupil changes in one eye D. Restlessness and confusion

C. Pupil changes in one eye

Which of the following nursing diagnoses are most appropriate for the client who has an intraventricular catheter for intracranial pressure monitoring? A. Risk for fluid volume excess related to infusion into ventricle B. Risk for altered skin integrity related to need to remain in supine position C. Risk for infection related to catheter inserted into ventricle D. Pain related to wound in scalp for insertion of monitoring device

C. Risk for infection related to catheter inserted into ventricle

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

Check the clients digoxin (Lanoxin) level.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will the nurse document in the plan of care? 1 Monitor closely for signs of infection 2. Monitor the temperature every 4 hours 3. Initiate protective isolation precautions 4. Use a soft small toothbrush for mouth care

Correct Ans 4 If a child is severely thrombocytopenic and has a platelet count less than 20,000/ul, bleeding precautions need to be initated because of increased risk of bleeding or hemorrhage. Options 1,2,3 are related to the prevention of infection rather than bleeding

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Bulky greasy stools B) Meconium ileus C) Positive sweat test D) Moist, productive cough

D

A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A) Hair loss B) Brittle nails C) Weight gain D) Sore throat

D

A patient has an extremely high T3 and T4 level. Which of the following signs and symptoms DO NOT present with this condition? A. Weight loss B. Intolerance to heat C. Smooth skin D. Hair loss

D

A patient is 6 hours post-opt from a thyroidectomy. The surgical site is clean, dry and intact with no excessive swelling noted. What position is best for this patient to be in?* A. Fowler's B. Prone C. Trendelenburg D. Semi-Fowler's

D

Cystic fibrosis is diagnosed by: A) Echocardiogram B) Chest X-ray C) Complete blood panel D) Sweat test

D

How is CF diagnosed? A. Sweat test B. Blood test C. Lung volume test D. A and B

D

The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have: A) Enlarged adenoids B) Choanal atresia C) Septal deviations D) Nasal polyps

D

The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to: A) Use the heel of her hand during percussion B) Change the child's position every 20 minutes C) Do percussion after the child eats and at bedtime D) Use cupped hands during percussion

D

The next morning, the patient's heart rate is 48/min and blood pressure is 78/66. His skin is warm and dry. What is the nurse's best first action? A.Increase the IV rate from 50 to 75 mL/hr. B. Raise the head of bed to 45 degrees. C. Apply oxygen at 2 L per nasal cannula. D. Notify the provider immediately.

D. Notify the provider immediately.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D. The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

The nurse gave discharge instructions to a client who has chronic obstructive pulmonary disease​ (COPD). Which action by the client indicates that the teaching was​ effective? A. Maintains adequate fluid intake by taking at least 5 quarts of fluid daily B. Eats a least two large meals per day C. Maintains oxygen saturation of at least​ 95% D. Wears an identification band and carries a list of medications

D. Wears an identification band and carries a list of medications

True or False: Clients with traumatic brain injuries are given barbiturates to prevent injuries due to grand mal seizures.

False

True or False: With good rehabilitation care, the client who survives traumatic brain injury should return to his/her baseline within 3-6 months.

False

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed?

I am thrilled that I can continue to eat fast food.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate?

Increase the dose of immunosuppression. bc high BUN and creatinine

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time?

No adventitious sounds in the lungs

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority?

Prepare protamine sulfate

A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)

a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. d. Administer a 250-mL bolus of normal saline.

The nurse who is explaining the pathophysiology of COPD to a client includes the fact that alveolar destruction results in which manifestations? Select all that apply. a. Decrease surface area for gas exchange b. Increased dead space air c. Development of pulmonary emboli d. Chronic dilation of bronchioles e. Airway collapse related to loss of elasticity

a. decrease surface area for gas exchange e. Airway collapse related to loss of elasticity Rationale: The loss of elasticity in the airway of a client with COPD can be airway attributed to repeated infections and inflammation, which leads to airway collapse. Airway collapse can cause alveolar destruction because of either over or under inflation of alveolar sacs. The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area available for gas exchange. Destruction of alveoli is not related to increased dead space air, pulmonary emboli, or chronic dilation of bronchioles.

Which of the following is a priority goal for the client with COPD? a. Maintaining functional ability b. Minimizing chest pain c. Increasing carbon dioxide levels in the blood d. Treating infectious agents

a. maintaining functional ability

What should the nurse include when teaching health maintenance strategies to the client with COPD? Select all that apply. a. Yearly influenza immunizations b. Immunization against pneumonia c. Limitation of physical activity d. Oral fluid restrictions e. Adequate caloric intake

a. yearly influenza immunizations b. immunization against pneumonia e. Adequate caloric intake Rationale: Clients with COPD are highly susceptible to respiratory infections such as influenza, so they should be immunized yearly. Clients with COPD use a large amount of calories because of labored respiratory function; increased caloric intake is necessary to maintain a healthy weight. Clients with COPD should undergo a progressive rehabilitation program to increase their activity tolerance. Fluid restriction is not needed with COPD unless there is a fluid retention from another etiology.

When taking the nursing history of a child with cystic fibrosis, what piece of information about the child's newborn period would the nurse expect the mother to report? a. That the child required resuscitation in the delivery room b. That labor was longer than 24 hours c. That the child had a meconium ileus d. That labor was less than 4 hours

c. That the child had a meconium ileus Rationale: Meconium ileus in the newborn period is often the first indication of CF. - fatty stinky poop due to clogged panc duct.

The nurse teaches a client with COPD to assess for s/sx of right-sided heart failure. Which of the following s/sx would be included in the teaching plan? a. Clubbing of nail beds b. Hypertension c. Peripheral edema d. Increased appetite

c. peripheral edema Rationale: Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse?

check BP to make sure kidney working

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?

collect sample and send to lab

A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client? a. Initiate oxygen therapy and reassess the client in 10 minutes. b. Draw blood for an ABG analysis and send the client for a chest x-ray. c. Encourage the client to relax and breathe slowly through the mouth d. Administer ordered bronchodilators

d. Administer ordered bronchodilators Rationale: In an acute asthma attack, diminished or absent breath sounds can be an ominous sign of indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing an ABG and obtaining a chest x-ray. It would be futile to encourage the client to relax and breathe slowly without providing necessary pharmacologic intervention.

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best?

hold med will be dialyzed

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse?

monitor temp

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching?

stool softener for constipation

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement?

tell me more about your feelings

A client with Parkinson disease​ (PD) is prescribed an anticholinergic agent to treat tremors and rigidity. The nurse should teach the client about which adverse effect they may experience from this​ medication? (Select all that​ apply.) A. Drooling B. Dry mouth C. Rigidity D. Loss of perspiration E.Tremors

​Answer: B, D Rationale: Anticholinergic medications can cause a decrease in​ salivation, causing dry mouth. This medication decreases tremors and reduces rigidity by blocking acetylcholine. The client taking this medication will have problems with temperature control because the client will not be able to perspire to cool off.

A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? A "Your behavior won't be tolerated. Go to your room immediately." B "You're just doing this to get back at me for making you come to therapy." C "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." D "I'm disappointed in you. You can't control yourself even for a few minutes."

A

The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable? A The client spends more time by himself. B The client doesn't engage in delusional thinking. C The client doesn't harm himself or others. D The client demonstrates the ability to meet his own self-care needs.

A

A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. "The EIA test will need to be repeated to verify the results." b. "A viral culture will be done to determine the progression of the disease." c. "It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS)." d. "The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed."

A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

A Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

A The current Center for Disease Control (CDC) policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

26.A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the clients chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.

24.After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? a. If I develop an infection, I should stop taking my corticosteroid. b. If I have pain over the transplant site, I will call the surgeon immediately. c. I should avoid people who are ill or who have an infection. d.

ANS: A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

42.A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.

15.A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

18.An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102 F (38.9 C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

ANS: A The clients blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the clients blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the clients blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

4.A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

ANS: A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

3.A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Do not walk around barefoot. b. Soak your feet in a tub each evening. c. Trim toenails straight across with a nail clipper. d. Treat any blisters or sores with Epsom salts. e. Wash your feet every other day.

ANS: A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

1.A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I need to have an annual appointment even if my glucose levels are in good control. b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. c. I can still develop complications even though I do not have to take insulin at this time. d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? a. Many people with long-term diabetes become depressed after a while. b. Its for peripheral neuropathy. Do you have burning pain in your feet or hands? c. This antidepressant also has anti-inflammatory properties for diabetic pain. d. No. Many medications can be used for several different disorders.

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti-inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.

A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? a. You need to start with multiple injections until you become more proficient at self-injection. b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns. c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the clients risk of insulin shock.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? a. Change positions slowly when you get out of bed. b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). c. If you miss a dose of this drug, you can double the next dose. d. Discontinue the medication if you develop a urinary infection

ANS: B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

ANS: B Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

ANS: B Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories.

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.

44.A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Serum potassium: 2.6 mEq/L Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

41.A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

ANS: B The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

19.A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B-Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B-Schedule the patient for more frequent appointments

34.A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the clients state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the clients chart. b. Assess tactile sensation in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the clients chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

40.After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I should increase my intake of vegetables with higher amounts of dietary fiber. b. My intake of saturated fats should be no more than 10% of my total calorie intake. c. I should decrease my intake of protein and eliminate carbohydrates from my diet. d. My intake of water is not restricted by my treatment plan or medication regimen.

ANS: C The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

45.At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) Dietary Intake At 0630: 95 At 1130: 70 At 1630: 47 Breakfast: 10% eaten client states she is not hungry Lunch: 5% eaten client is nauseous; vomits once After reviewing the clients assessment data, which action is appropriate at this time? a. Assess the clients oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the clients forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

ANS: C The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The clients oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

25.A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem.

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C-choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? a. Examine your feet using a mirror every day. b. Rotate your insulin injection sites every week. c. Check your blood glucose level before each meal. d. Use a bath thermometer to test the water temperature.

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

37.When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you dont know another way to manage the disease is dismissive of the clients concerns.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian

ANS: D Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.

17.After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I have so many complications; exercising is not recommended. b. I will exercise more frequently because I have so many complications. c. I used to run for exercise; I will start training for a marathon. d. I should look into swimming or water aerobics to get my exercise.

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

39.A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.

16.A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? a. Test your urine daily for ketones. b. Use only buffered insulin in your pump. c. Store the insulin in the freezer until you need it. d. Change the needle every 3 days.

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

22.A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? a. Limit your fluid intake to 2 liters a day. b. Animal organ meat is high in insulin. c. Limit your carbohydrate intake to 80 grams a day. d. Walk at a moderate pace for 1 mile daily.

ANS: D Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. Ill take this medicine during each of my meals. b. I must take this medicine in the morning when I wake. c. I will take this medicine before I go to bed. d. I will take this medicine immediately before I eat.

ANS: D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the clients blood glucose levels. The medication should be taken before meals instead of during meals.

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

ANS: D-"What did you eat for breakfast?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia

38.A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

ANS: D The clients tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

20.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

21.A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? a. Drinking any wine or alcohol will increase your insulin requirements. b. Because of poor kidney function, people with diabetes should avoid alcohol. c. You should not drink alcohol because it will make you hungry and overeat. d. One glass of wine is okay with a meal and is counted as two fat exchanges.

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

ANS: D-assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate? A Helping the client to participate in social interactions B Establishing a one-on-one relationship with the client C Establishing alternative forms of communication D Allowing the client to decide when he wants to participate in verbal communication with the nurse

B

The nurse is aware that antipsychotic medications may cause which of the following adverse effects? A Increased production of insulin B Lower seizure threshold C Increased coagulation time D Increased risk of heart failure

B

Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? A Monthly blood tests will be necessary. B Report a sore throat or fever to the physician immediately. C Blood pressure must be monitored for hypertension. D Stop the medication when symptoms subside.

B

Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)? A The absence of anticholinergic effects B A lower incidence of extrapyramidal effects C Photosensitivity and sedation D No incidence of neuroleptic malignant syndrome

B

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

The thyroid hormones, T3 and T4, play many roles in the human body. Which of the following functions are performed by T3 and T4? Note: Select all that apply* A. Storing calories B. Increasing the Heart Rate C. Stimulating the Sympathetic Nervous System D. Decreasing the body's temperature E. Regulating TSH produced by the anterior pituitary gland

B,C,E

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? A Take the medication 1 hour before a meal. B Decrease the dosage if signs of illness decrease. C Apply a sunscreen before being exposed to the sun. D Increase the dosage up to 50 mg twice per day if signs of illness don't decrease.

C

Which non-antipsychotic medication is used to treat some clients with schizoaffective disorder? A phenelzine (Nardil) B chlordiazepoxide (Librium) C lithium carbonate (Lithane) D imipramine (Tofranil)

C

A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.

C Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu.

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.

Correct Answer: C Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.

Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read. Cognitive Level: Application Text Reference: p. 1571 Nursing Process: Planning NCLEX: Physiological Integrity

Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.

Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors. Cognitive Level: Application Text Reference: p. 1568 Nursing Process: Evaluation NCLEX: Physiological Integrity

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown

Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity

A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.

Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Implementation NCLEX: Physiological Integrity

To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.

Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation. Cognitive Level: Application Text Reference: p. 1577 Nursing Process: Implementation NCLEX: Physiological Integrity

A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house

Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications. Cognitive Level: Application Text Reference: pp. 1563, 1567 Nursing Process: Implementation NCLEX: Physiological Integrity

Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.

Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity

When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.

Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering. Cognitive Level: Application Text Reference: p. 1573 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.

Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation. Cognitive Level: Application Text Reference: pp. 1574-1575 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.

Correct Answer: D Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. Cognitive Level: Application Text Reference: p. 1562 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?"

D More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.

D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

A client diagnosed with delusional disorder is telling everyone that he is the president of the United States. This client is exhibiting which type of delusion? a. Grandiose b. Jealous c. Nihilistic d. Somatic

a. Grandiose Clients presenting with grandiose delusions are convinced they have a great, unrecognized talent or have made an important discovery. A less common presentation is the delusion of a special relationship with a prominent person, or actually being a prominent person. Nihilistic delusions focus on impending death or disaster. Persons who have somatic delusions believe they have a physical ailment. The central theme of the jealous subtype is the unfaithfulness or infidelity of a spouse or lover.

A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of which of the following? a. Infection b. Nausea c. Weight loss d. Hypotension

a. Infection Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Therefore the nurse needs to be alert for signs of infection, particularly bacterial infection. Hypotension may occur with any antipsychotic drug. Nausea is a common side effect of many drugs. Weight gain, not loss, can occur with olanzapine and clozapine

Which of the following is an anticholinergic side effect associated with some antipsychotic medications? a. Photophobia b. Salivation c. Diarrhea d. Increased tearing

a. Photophobia Photophobia, dry mouth, decreased lacrimation, and constipation are anticholinergic side effects associated with some antipsychotic mediations

A client with schizophrenia is prescribed a second-generation antipsychotic. The client's mother asks, "About how long will it take until we see any changes in his symptoms?" Which response by the nurse would be most appropriate? a. "You should see improvement in about 36 to 48 hours." b. "Generally, it takes about 1 to 2 weeks to be effective in changing symptoms." c. "It will take about 6 to 12 weeks until the drug is effective" d. "His symptoms should subside almost immediately"

b. "Generally, it takes about 1 to 2 weeks to be effective in changing symptoms" Generally, it take about 1 to 2 weeks for antipsychotic drugs to effect a change in symptoms. During the stabilization period, the selected drug should be given an adequate trial, generally 6 to 12 weeks, before considering a change in the drug prescription. If treatment effects are not seen, another antipsychotic agent may be tried.

Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter? a. Epinephrine b. Dopamine c. Acetylcholine d. Norepinephrine

b. Dopamine Positive symptoms of schizophrenia, such as delusions and hallucinations, are thought to be caused by dopamine hyperactivity in the mesolimbic tract at the D2 receptor site in the striatal area, where memory and emotion are regulated. Hyperactivity of acetylcholine, norepinephrine, and epinephrine are not associated with schizophrenia

A client diagnosed with schiophreniform disorder must have symptoms present for at least 1 month but with a duration of less than how long? a. 2 weeks b. 4 weeks c. 6 months d. 12 months

c. 6 months The essential features of schizophreniform disorder are identical to those of criteria A for schizophrenia, with the exception of the duration of the illness, which can be less than 6 months. Symptoms must be present for at least 1 month to be classified as a schizophreniform disorder.

A client diagnosed with schizophrenia is having delusions that he is being plotted against by the government. This would be documented as which of the following type of delusion? a. Somatic b. Grandiose c. Persecutory d. Nihilistic

c. Persecutory A persecutory delusion is a belief that one is being watched, ridiculed, harmed or plotted against. The belief that one has exceptional powers, wealth, skill, influence, or destiny is a grandiose delusion. A nihilistic delusion is the belief that one is dead or a calamity is impending. A somatic delusion is a belief about abnormalities in bodily functions or structures

Which of the following extrapyramidal side effects is noted by a client who has bradykinesia and a shuffling gait? a. Tardive dyskinesia b. Acute dystonia c. Pseudoparkinsonism d. Akathisia

c. Pseudoparkinsonism Pseudoparkinsonism is noted by a resting tremor, rigidity, a masklike face, and shuffling gait. Akathisia occurs when the client has motor restlessness evidenced by pacing, rocking, or shifting from foot to foot. Symptoms of acute dystonia are intermittent or fixed abnormal postures of the eyes, face, tongue, neck, trunk, and extremities