2016 - Fall - Medsurg exam 1 NCLEX questions
The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which statement, if made by the client, indicates an understanding of these measures? 1. "I need to avoid any exercise." 2. "I need to avoid increasing my fluid intake." 3. "I need to avoid going outdoors in warm weather." 4. "I need to avoid situations that may lead to an infection."
"I need to avoid situations that may lead to an infection."
Oncagenes
a gene that in certain circumstances can transform a cell into a tumor cell.
Dynamic Equilibrium
a state of balance between continuing processes.
The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement, if made by the client, indicates an understanding of this medication? "I need to increase my fluid intake." "I should eliminate fiber foods from my diet." "I need to take the medication with water before a meal." "I should be sure to chew the tablet thoroughly before swallowing it."
"I need to increase my fluid intake." Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? "I will need to isolate any tissues I use so as not to infect my family." "I will notify all of my sexual partners so they can get tested for HIV." "Unprotected sexual contact is the most common mode of transmission." "I do not need to worry about spreading this virus to others by sweating at the gym."
"I will need to isolate any tissues I use so as not to infect my family." HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."
"I'm going to take aspirin for my headache as soon as I get home." Rationale: During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.
The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record is associated with this diagnosis? Select all that apply. 1. Fever 2. Weight loss 3. Night sweats 4. Visual changes 5. Enlarged, painless lymph nodes
1. Fever 2. Weight loss 3. Night sweats 5. Enlarged, painless lymph nodes Rationale: Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.
The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. 1. Transfusions 2. Splenectomy 3. Radiation therapy 4. Corticosteroid medication 5. Immunosuppressive agents
1. Transfusions 3. Radiation therapy 4. Corticosteroid medication 5. Immunosuppressive agents Rationale: Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.
For the client with stomatitis resulting from chemotherapy for leukemia, the care plan should include which intervention? 1. Inspect the mouth every week for fungus. 2. Encourage foods with neutral or cool temperatures. 3. Give the client spicy foods to stimulate the sense of taste. 4. Perform frequent oral hygiene using a commercial alcohol-based mouthwash.
2. Encourage foods with neutral or cool temperatures. Rationale: Stomatitis is inflammation of the oral cavity, and using commercial mouthwashes containing alcohol or encouraging spicy foods will cause pain. Foods are better tolerated by the client with stomatitis when the food is cool or of neutral temperature. It is important to monitor for oral fungal infections, but this assessment should be completed at least daily
The nurse is teaching a group of adults about the warning signs of cancer. Which signs should the nurse provide to the group? Select all that apply. 1. Areas of alopecia 2. Sores that do not heal 3. Nagging cough or hoarseness 4. Indigestion or difficulty swallowing 5. Change in bowel or bladder habits 6. Absence or decreased frequency of menses
2. Sores that do not heal 3. Nagging cough or hoarseness 4. Indigestion or difficulty swallowing 5. Change in bowel or bladder habits
Which interventions are appropriate for a client with leukemia who is experiencing thrombocytopenia? Select all that apply 1. Use a straight-edge razor for shaving. 2. Obtain a rectal temperature every 8 hours. 3. Check secretions for frank or occult blood. 4. Give vitamin K by the intramuscular route. 5. Encourage fluid intake to avoid constipation. 6. Provide oral sponges or a soft toothbrush for oral care
3. Check secretions for frank or occult blood. 5. Encourage fluid intake to avoid constipation. 6. Provide oral sponges or a soft toothbrush for oral care Rationale: Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.
A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1. Heparin overdose 2. Vitamin K deficiency 3. Factor VIII deficiency 4. Disseminated intravascular coagulopathy (DIC)
4. Disseminated intravascular coagulopathy (DIC)
A client with chronic kidney disease is anemic. The nurse plans care, knowing that this problem is caused by the client's insufficient production of which substance? 1. Renin 2. Aldosterone 3. Angiotensin I 4. Erythropoietin
4. Erythropoietin
A client receiving chemotherapy is experiencing mucositis. The nurse should advise the client to use which item as the best substance to rinse the mouth? 1. Alcohol-based mouthwash 2. Hydrogen peroxide mixture 3. Lemon-flavored mouthwash 4. Weak salt and bicarbonate mouth rinse
4. Weak salt and bicarbonate mouth rinse
A client is seen by the nurse in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of her menstrual period. The client asks the nurse how much blood is lost during a menstrual period. What is the nurse's best response? 1. 40 mL 2. 50 mL 3. 60 mL 4. 70 mL
40 mL Rationale: During a menstrual period, a woman loses about 40 mL of blood. Because of the recurrent loss of blood, many women are mildly anemic during their reproductive years, especially if their diets are low in iron
According to the American Cancer Society, fecal occult blood testing should be done annually after which age? 30 40 50 60
60
Proto-oncogenes
A proto-oncogene is a normal gene that could become an oncogene due to mutations or increased expression
The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A new onset of polycythemia Presence of mononucleosis-like symptoms A sharp decrease in the patient's CD4+ count A sudden increase in the patient's WBC count
A sharp decrease in the patient's CD4+ count A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be most appropriate for the nurse to use to increase the patient's nutritional intake? Increase intake of liquids at mealtime to stimulate the appetite. Serve three large meals per day plus snacks between each meal. Avoid the use of liquid protein supplements to encourage eating at mealtime. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be helpful.
The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply)? Assessment of lung sounds Assessment of sexual behavior Assessment of living conditions Assessment of drug and syringe use Assessment of exposure to an ill person
Assessment of sexual behavior Assessment of drug and syringe use With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for the HIV virus should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).
The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? Presence of HIV antibodies CD4+ T cell count below 200/µL Presence of oral hairy leukoplakia White blood cell count below 5000/µL
CD4+ T cell count below 200/µL Diagnostic criteria for AIDS include a CD4+ T cell count below 200/µL and/or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease but do not define the advancement of HIV infection to AIDS.
Which clinical manifestation is consistent with the medical diagnosis of chronic lymphocytic leukemia (CLL)? 1. Anemia 2. Bleeding 3. Pancytopenia 4. Lymphadenopathy
Lymphadenopathy Rationale: CLL causes a slow increase in immature B cells. These cells infiltrate the bone marrow, lymph nodes, spleen, and liver. CLL eventually causes bone marrow failure; therefore the client will have enlarged and swollen lymph nodes. Options 1 and 2 are clinical manifestations of acute leukemias. Option 3 is a clinical manifestation of hairy cell leukemia.
A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells genetic structure is mutated. Exposure to what may have functioned as a carcinogen for this patient? Bacteria Sun exposure Most chemicals Epstein-Barr virus
Epstein-Barr virus Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.
When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? 1. Folic acid intake 2. Dietary intake of iron 3. A history of gastric surgery 4. A history of sickle cell anemia
Dietary intake of iron Rationale: Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.
Which cellular dysfunction in the process of cancer development allows defective cell proliferation? Proto-oncogenes Cell differentiation Dynamic equilibrium Activation of oncogenes
Dynamic equilibrium Dynamic equilibrium - is the regulation of proliferation that usually only occurs to equal cell degeneration or death or when the body has a physiologic need for more cells. Cell differentiation is the orderly process that progresses a cell from a state of immaturity to a state of differentiated maturity. Mutations that alter the expression of proto-oncogenes can activate them to function as oncogenes, which are tumor-inducing genes and alter their differentiation
The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which abnormality associated with this oncologic emergency? Hypokalemia Hypouricemia Hypocalcemia Hypophosphatemia
Hypocalcemia TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.
The nurse is providing instructions to the client receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? 1. "I will dry affected areas with patting motions." 2. "I will wear soft clothing over the affected site." 3. "I will use a washcloth to wash the affected area." 4. "I need to make sure I carry my purse on the unaffected side."
I will use a washcloth to wash the affected area." Rationale: External radiation therapy requires markings to be placed on the skin so that therapy can be aimed at the affected areas. The hand rather than a washcloth should be used to wash the area to avoid irritation. The nurse should instruct the client undergoing external radiation therapy to dry affected areas with a patting (rather than rubbing) motion so as not to disrupt the markings on the skin. Soft clothing should be worn so that the affected area is not irritated. The client should be sure to carry her purse on the unaffected side.
When caring for the patient with cancer, what does the nurse understand as the response of the immune system to antigens of the malignant cells? Metastasis Tumor angiogenesis Immunologic escape Immunologic surveillance
Immunologic surveillance Immunologic surveillance is the process where lymphocytes check cell surface antigens and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells' evasion of immunologic surveillance that allows the cancer cells to reproduce.
The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? 1. Initiate an intravenous (IV) line for the administration of fluids. 2. Consult with the psychiatric department regarding genetic counseling. 3. Call the blood bank and request preparation of a unit of packed red blood cells. 4. Call the respiratory department to prepare for intubation and mechanical ventilation.
Initiate an intravenous (IV) line for the administration of fluids. Rationale: The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the client is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Opioid analgesics may be given to relieve the pain that accompanies the crisis. Genetic counseling is recommended but not during the acute phase of illness. Red blood cell transfusion may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Oxygen would be administered according to individual need, but the client would not require intubation and mechanical ventilation.
Nutrients essential for red blood cell production include:
Iron, B12 and Folic Acid
A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? It is in situ. It has metastasized. It has spread locally. It has spread extensively.
It has spread locally. Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes metastasis.
Organs of the Hematologic system that have filtering functions include the
Lymph nodes, spleen and Liver
The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. 1. Pallor 2. Fever 3. Joint swelling 4. Blurred vision 5. Abdominal pain
Pallor, Fever, Joint swelling and abdominal pain Rationale: Sickle cell crises are acute exacerbations of the disease. Vaso-occlusive crisis is caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction. Manifestations include fever; pallor, painful swelling of hands, feet, and joints; and abdominal pain. Blurred vision is not a manifestation of crisis.
The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 cells/mm3, the platelet count is 150,000 cells/mm3, the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL. Which nursing action would be appropriate? 1. Place the client on bleeding precautions. 2. Place the client on neutropenic precautions. 3. Remove the rectal thermometer from the client's room. 4. Instruct the dietary department to eliminate all proteins from the diet.
Place the client on neutropenic precautions. Rationale: The normal white blood cell count is 4500 to 11,000 cells/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. This includes protective isolation techniques to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops below 90,000 to 100,000 cells/mm3. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes, and the normal ammonia level is 10 to 80 mcg/dL. Removing the rectal thermometer from the client's room would be done if bleeding precautions were initiated. There is no useful reason to eliminate all protein from the diet.
The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? 1. Dyspnea 2. Dusky mucous membranes 3. Shortness of breath on exertion 4. Red tongue that is smooth and sore
Red tongue that is smooth and sore Classic signs of pernicious anemia include weakness, mild diarrhea, and smooth, sore, red tongue. The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion. The client does not exhibit dyspnea, the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.
The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 cells/mm3. The nurse should prepare to implement which specific action based on this finding?
Remove the rectal thermometer from the client's room. Rationale: When the client's platelet count is low, he or she is at risk for bleeding. Options 1, 3, and 4 relate to the risk for infection. Rectal temperatures should not be taken on the client who is at risk for bleeding because the thermometer could cause an alteration in the delicate rectal membranes and lead to bleeding.
The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are a component of these types of precautions? Select all that apply. 1. Allowing only fresh fruits in the client's room 2. Removing fresh-cut flowers from the client's room 3. Encouraging the client to eat any type of fresh vegetables 4. Instructing family members on the proper technique for hand washing 5. Instructing family members to wear a mask when entering the client's room
Removing fresh-cut flowers from the client's room Instructing family members on the proper technique for hand washing Instructing family members to wear a mask when entering the client's room Rationale: In the immunocompromised client a low-bacteria diet is necessary. This includes avoiding the intake of fresh fruits and vegetables. Thorough cooking of all food also is required. Cut flowers or any standing water is removed from the room because either tends to harbor bacteria. Anyone who enters the client's room should perform strict and thorough hand washing and wear a mask.
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? Acute pain Hypothermia Powerlessness Risk for infection
Risk for infection myel - bone marrow Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.
The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to note which sign or symptom in the client as a result of the anemia? Bradycardia Muscle cramps Increased respiratory rate Shortness of breath with activity
Shortness of breath with activity The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.
The oncology nurse specialist provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease? 1. Reed-Sternberg cells are present. 2. The lymph nodes, spleen, and liver are involved. 3. The prognosis depends on the stage of the disease. 4. The disease occurs most often in those older than 75 years of age.
The disease occurs most often in those older than 75 years of age. Rationale: Hodgkin's lymphoma is a cancer that can occur at any age but appears to peak in two different age groups: in teens and young adults and in adults in their 50s and 60s. The remaining options are characteristics of this disease.
What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development? Teach the patient to exercise daily. Teach the patient promoting factors to avoid. Tell the patient to have the cancer surgically removed now. Teach the patient which vitamins will improve the immune system.
The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of cancer development. Daily exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible without a critical mass of cells, and this advice would not be the nurse's role.
The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis (select all that apply)? Take fluconazole (Diflucan). Take amphotericin B (Fungizone). Use condoms for risk-reducing sexual relations. Take emtricitabine and tenofovir (Truvada) regularly. Have regular HIV testing for herself and her husband.
Use condoms for risk-reducing sexual relations. Take emtricitabine and tenofovir (Truvada) regularly. Have regular HIV testing for herself and her husband. Using male or female condoms, having monthly HIV testing for the patient and her husband, and the woman taking emtricitabine and tenofovir regularly has shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcosus neoformans, which are all opportunistic diseases associate with HIV infection.
A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? Together they will cure HIV. Viral replication will be inhibited. They will decrease CD4+ T cell counts. It will prevent interaction with other drugs.
Viral replication will be inhibited. The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.
