Adult Health 2B Final Practice Questions

ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

ANS: A, C, D, E The patient's age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy.

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk(select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications.

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C)

ANS: C Formation of diverticula is common when decreasedbulk of stool, combined with a more narrowed lumen in the sigmoid colon, causes high intraluminal pressures that result in saccular dilation or outpouching of the mucosa through the muscle of the intestinal wall. To prevent the high intraluminal pressure, fecal volume should be increased with use of high-fiber diets and bulk laxatives, such as psyllium (Metamucil). Anticholinergic drugs are used only during an acute episode of diverticulitis and the lesions are not premalignant.

What should the nurse teach the patient with diverticulosis to do? a. Use anticholinergic drugs routinely to prevent bowel spasm. b. Have an annual colonoscopy to detect malignant changes in the lesions. c. Maintain a high-fiber diet and use bulk laxatives to increase fecal volume. d. Exclude whole grain breads and cereals from the diet to prevent irritating the bowel.

Answer: B Rationale: A significant family history of breast cancer means that the patient has a first-degree relative who developed breast cancer, especially if the relative was premenopausal.

When assessing a patient for breast cancer risk, the nurse considers that the patient has a significant family history of breast cancer if she has a a. cousin who was diagnosed with breast cancer at age 38. b. mother who was diagnosed with breast cancer at age 42. c. sister who died from ovarian cancer at age 56. d. grandmother who died from breast cancer at age 72.

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenia patient.

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution.

Answer: A,B,C,D Rationale: Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which of the following vitamin supplements (select all that apply)? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K E. Vitamin B

B. "It's recommended that you get a mammogram each year after you turn 40." Annual mammograms are recommended after age 40. They are recommended for all women, not solely those with a family history of breast cancer. BSE is not a replacement for mammography, and clinical breast examinations are not necessary at each office visit, but recommended at least every 3 years for women in their 20s and 30s, and then every year beginning at age 40.

The nurse has been asked to participate in a healthy living workshop. While teaching about women's health, which guidelines should the nurse provide to the audience? A. "Mammograms are necessary if you have a family history of breast cancer." B. "It's recommended that you get a mammogram each year after you turn 40." C. "If you are not able to perform breast self-examination (BSE), you should go for regular mammograms." D. "You should ensure that your primary care provider performs a breast exam each time you visit."

ANS: C Antiperistalsis agents, such as loperamide (Imodium)and paregoric, should not be used in infectious diarrhea because of the potential of prolonging exposure to the infectious agent. Demulcent agents may be used to coat and protect mucous membranes in these cases. The other options are all appropriate measures to use in cases of infectious diarrhea.

The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea makes which statement? a. "I can use A&D ointment or Vaseline jelly around the anal area to protect my skin." b. "Gatorade is a good liquid to drink because it replaces the fluid and salts I have lost." c. "I may use over-the-counter Imodium or Parepectolin when I need to control the diarrhea." d. "I must wash my hands after every bowel movement to prevent spreading the diarrhea to my family."

B. A 48-year-old whose father died of metastatic prostate cancer The family history of prostate cancer and elevation of PSA indicate that further evaluation of the patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual.

The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is most important to report to the health care provider? a. A 38-year-old who is being treated for acute prostatitis b. A 48-year-old whose father died of metastatic prostate cancer c. A 52-year-old who goes on long bicycle rides every weekend d. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH)

Answer: A Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

C. Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.

The nurse teaches a 30-year-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? A. Grilled steak, French fries, and vanilla shake B. Hamburger with cheese, pudding, and coffee C. Baked chicken, peas, apple slices, and skim milk D. Grilled cheese sandwich, onion rings, and hot tea

Correct answers: a, b, c Rationale: The typical course of untreated HIV infection follows a predictable pattern. However, treatment can significantly alter this pattern, and disease progression is highly individualized. Late chronic infection is another term for acquired immunodeficiency syndrome (AIDS). The median interval between untreated HIV infection and a diagnosis of AIDS is about 11 years.

Which statements accurately describe HIV infection (select all that apply)? a. Untreated HIV infection has a predictable pattern of progression. b. Late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS). c. Untreated HIV infection can remain in the early chronic stage for a decade or more. d. Untreated HIV infection usually remains in the early chronic stage for 1 year or less. e. Opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low.

Correct answer: a Rationale: Access to sterile equipment is an important risk-elimination tactic. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment to users in exchange for used equipment. Cleaning equipment before use is a risk-reducing activity. It decreases the risk when equipment is shared, but it takes time, and a person in drug withdrawal may have difficulty cleaning equipment.

Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission? a. Using sterile equipment to inject drugs b. Cleaning equipment used to inject drugs c. Taking zidovudine (AZT, ZDV, Retrovir) during pregnancy d. Using latex or polyurethane barriers to cover genitalia during sexual contact

ANS: B The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis? a. Maintaining good nutrition b. Avoiding alcohol ingestion c. Taking lactulose (Cephulac) d. Using vitamin B supplements

ANS: A Doxorubicin hydrochloride is a chemotherapeutic vessicant that can cause severe tissue damage. The nurse should stop the administration of the drug immediately and then notify the patient's physician. Ice can be applied to the site once the drug therapy has stopped.

While a patient is receiving intravenous doxorubicin hydrochloride, the nurse observes that there is swelling and pain at the IV site. The nurse should A) stop the administration of the drug immediately. B) notify the patient's physician. C) continue to administer but decrease the rate of infusion. D) apply a warm compress to the site.

ANS: D Before engraphment, patients are at a high risk for infection, sepsis, and bleeding. Visitors should not visit if they've had a recent illness or vaccination. Plants should not be brought to the BMT patient. The patient cannot go to the cafeteria for meals. Disposable hospital gowns are worn when entering the patient's room.

You are a nurse working on a bone marrow transplant unit. Your patient is scheduled to receive a bone marrow transplant. What information will you provide to the patient's visitors? A) Bring plants to improve air quality. B) Take the patient to the cafeteria for meals. C) Wear hospital scrubs when entering the patient's room. D) Do not visit if you've had a recent infection.

ANS: A Alterations in oral mucosa, change and loss of taste, pain, and dysphasia often occur as a result of radiotherapy to the head and neck. The patient is at an increased risk of impaired nutritional status. Option B is incorrect; the oral mucosa is normally pink. Options C and D are incorrect; diarrhea and alopecia are not concerns for this patient.

You are caring for a patient who is to begin receiving external radiation for a malignant tumor of the head and neck. While doing patient education, what side effects should the nurse discuss with the patient that should be assessed because of the radiation treatment? A) Impaired nutritional status B) Pink oral mucosa C) Diarrhea D) Alopecia

ANS: C Patients with thrombocytopenia are at risk for bleeding due to decreased platelet counts. A priority goal for this patient is to prevent trauma related to decreased platelet count. A soft toothbrush or an electric razor can be used. No invasive procedures should be performed. Patients with thrombocytopenia do not exhibit interrupted sleep pattern, hot flashes, or increased weight.

Your patient is receiving carmustine, a chemotherapy agent. A significant side effect of this medication is thrombocytopenia. Which symptom would the nurse assess for in patients at risk for thrombocytopenia? A) Interrupted sleep pattern B) Hot flashes C) Nose bleed D) Increased weight

During care of the patient with SIADH, what should the nurse do? a. Monitor neurologic status at least every 2 hours. b. Teach the patient receiving treatment with diuretics to restrict sodium intake. c. Keep the head of the bed elevated to prevent antidiuretic hormone (ADH) release. d. Notify the health care provider if the patient's blood pressure decreases more than 20 mm Hg from baseline.

a. The patient with syndrome of inappropriate antidiuretic hormone (SIADH) has marked dilutional hyponatremia and should be monitored for decreased neurologic function and seizures every 2 hours. Sodium intake is supplemented because of the hyponatremia and sodium loss caused by diuretics. ADH release is reduced by keeping the head of the bed flat to increase left atrial filling pressure. A reduction in blood pressure (BP) indicates a reduction in total fluid volume and is an expected outcome of treatment.

What is an appropriate nursing intervention for the patient with hyperparathyroidism? a. Pad side rails as a seizure precaution. b. Increase fluid intake to 3000 to 4000 mL daily. c. Maintain bed rest to prevent pathologic fractures. d. Monitor the patient for Trousseau's and Chvostek's signs.

b. A high fluid intake is indicated in hyperparathyroidism to dilute the hypercalcemia and flush the kidneys so that calcium stone formation is reduced. Seizures are not associated with hyperparathyroidism. Impending tetany of hypoparathyroidism after parathyroidectomy can be noted with Trousseau's and Chvostek's signs. The patient with hyperparathyroidism is at risk for pathologic fractures resulting from decreased bone density but mobility is encouraged to promote bone calcification.

A patient with SIADH is treated with water restriction. What does the patient experience when the nurse determines that treatment has been effective? a. Increased urine output, decreased serum sodium, and increased urine specific gravity b. Increased urine output, increased serum sodium, and decreased urine specific gravity c. Decreased urine output, increased serum sodium, and decreased urine specific gravity d. Decreased urine output, decreased serum sodium, and increased urine specific gravity

b. The patient with SIADH has water retention with hyponatremia, decreased urine output, and concentrated urine with high specific gravity. Improvement in the patient's condition is reflected by increased urine output, normalization of serum sodium, and more water in the urine, thus decreasing the specific gravity.

A patient with Addison's disease comes to the emergency department with complaints of nausea, vomiting, diarrhea, and fever. What collaborative care should the nurse expect? a. IV administration of vasopressors b. IV administration of hydrocortisone c. IV administration of D5W with 20 mEq KCl d. Parenteral injections of adrenocorticotropic hormone (ACTH)

b. Vomiting and diarrhea are early indicators of Addisonian crisis and fever indicates an infection, which is causing additional stress for the patient. Treatment of a crisis requires immediate glucocorticoid replacement and IV hydrocortisone, fluids, sodium, and glucose are necessary for 24 hours. Addison's disease is a primary insufficiency of the adrenal gland and adrenocorticotropic hormone (ACTH) is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's disease. Potassium levels are increased in Addison's disease and KCl would be contraindicated.

The patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find? a. Decreased body weight b. Decreased urinary output c. Increased plasma osmolality d. Increased serum sodium levels

b. With increased antidiuretic hormone (ADH), the permeability of the renal distal tubules is increased, so water is reabsorbed into circulation. Decreased output of concentrated urine with increased urine osmolality and specific gravity occur. In addition, fluid retention with weight gain, serum hypoosmolality, dilutional hyponatremia, and hypochloremia occur.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? 1.Facial drooping 2.Periorbital edema 3.Ptosis of the eyelid 4.Twitching on the affected side of the face

1. Facial drooping Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.

The nurse is preparing a client diagnosed with amyotrophic lateral sclerosis (ALS) for discharge. The nurse realizes that interventions for the following nursing diagnosis should be stressed for this client: 1. Ineffective Breathing Pattern related to neuromuscular dysfunction. 2. Impaired Urinary Elimination related to spastic or flaccid bladder. 3. Alteration in Vision acuity related to ocular muscle involvement. 4. Disturbed Thought Processes related to cognitive decline.

1. Ineffective Breathing Pattern related toneuromuscular dysfunction. Rationale: ALS affects the neuromuscular function; the client is at risk for respiratory dysfunction as a result of this disease process. Impaired urinary elimination is a result of a spastic or flaccid bladder resulting from MS. Visual acuity is impaired in clients diagnosed with MG. Disturbed thought processes is seen in AD clients.

The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.

1. Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1."I will perform facial exercises." 2."I will expose my face to cold to decrease the pain." 3."I will massage my face with a gentle upward motion." 4."I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

2 "I will expose my face to cold to decrease the pain." Exposure to cold or drafts is avoided in Bell's palsy because it can cause discomfort. Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical nerve stimulation. Local application of heat to the face may improve blood flow and provide comfort.

The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.

3. A potential suicide statement is priority for the nurse when caring for the client with MS.

The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis.

3. The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective. 1. The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state. 2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective. 4. Diaphoresis (sweating) occurs with hyper-thyroidism, not hypothyroidism

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4. Respiratory or gastrointestinal infection during the previous month Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.

4. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that hewill have room to move the extremities.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

8. A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "Symptoms of MS are likely to become worse during pregnancy." d. "MS is associated with a slightly increased risk for congenital defects."

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate several times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.

Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.

ANS: A The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

ANS: A The inflammation and infection of diverticula cause small perforations with spread of the inflammation to the surrounding area in the intestines. Abscesses may form or complete perforation with peritonitis may occur. Systemic antibiotic therapy is often used but medicated enemas would increase intestinal motility and increase the possibility of perforation, as would the application of heat. Surgery is only necessary to drain abscesses or to resect an obstructing inflammatory mass.

82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care? a. Monitor for signs of peritonitis. b. Treat with daily medicated enemas. c. Prepare for surgery to resect the involved colon. d. Provide a heating pad to apply to the left lower quadrant.

ANS: A, C, E, F Crohn's disease may have severe weight loss, segmented distribution through the entire wall of the bowel, and crampy abdominal pain. Rectal bleeding and toxic megacolon are more often seen with ulcerative colitis.

A 20-year old patient with a history of Crohn's disease comes to the clinic with persistent diarrhea. What are characteristics of Crohn's disease (select all that apply)? a. Weight loss b. Rectal bleeding c. Abdominal pain d. Toxic megacolon e. Has segmented distribution f. Involves the entire thickness of the bowel wall

ANS: D The patient is having symptoms of an acute abdomen and should be evaluated by a health care provider immediately. The patient's age, location of pain, and other symptoms are characteristic of appendicitis. Heat application and laxatives should not be used in patients with undiagnosed abdominal pain because they may cause perforation of the appendix or other inflammations. Fluids should not be taken until vomiting is controlled, nor should they be taken in the event that surgery may be performed.

A 22-year-old patient calls the outpatient clinic complaining of nausea and vomiting and right lower abdominal pain. What should the nurse advise the patient to do? a. Use a heating pad to relax the muscles at the site of the pain. b. Drink at least 2 quarts of juice to replace the fluid lost in vomiting. c. Take a laxative to empty the bowel before examination at the clinic. d. Have the symptoms evaluated by a health care provider right away.

C. 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.

A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? A. It is in situ. B. It has metastasized. C. It has spread locally. D. It has spread extensively.

ANS: C Because the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.

C. prostate specific antigen (PSA) testing. An annual digital rectal exam (DRE) and PSA are recommended starting at age 50 for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA are abnormal.

A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

Answer: D Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer).

A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? a. Cough, diarrhea, headaches, blurred vision, muscle fatigue d. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy c. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea

Answer: C Rationale: The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To which of the following diagnoses does the nurse attribute these findings? A. Malnutrition B. Osteomyelitis C. Alcohol abuse D. Diabetes mellitus

ANS: B The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

Answer: D Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

Correct answer: d Rationale: Progression is the final stage of cancer. This stage is characterized by increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site (i.e., metastasis). Progression occurs as a result of the following characteristics of cancer cells: rapid proliferation and decreased cell adhesion.

A characteristic of the stage of progression in the development of cancer is a. oncogenic viral transformation of target cells. b. a reversible steady growth facilitated by carcinogens. c. a period of latency before clinical detection of cancer. d. proliferation of cancer cells despite host control mechanisms.

ANS: A The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats.Limiting social contacts is not appropriate at a time when the patient is likely to need a goodsocial support system. The damage occurs at the hair follicles and will occur regardless ofgentle washing or use of a mild shampoo. The information that the hair will grow back is notimmediately helpful in maintaining the patient's self-esteem.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? a. Encourage the patient to purchase a wig or hat to wear when hair loss begins. b. Suggest that the patient limit social contacts until regrowth of the hair occurs. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete.

D Although all interventions might be appropriate, a client with late-stage cancer and bone metastases is at risk for severe pain. Giving the client pain medication around the clock is the best way to manage this type of pain.

A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing intervention does the nurse add to the care plan to address a priority problem? a. Provide six small meals and snacks daily. b. Offer the client prune juice twice a day. c. Ensure that the client gets adequate rest. d. Give the client pain medications around the clock.

B Oral candidiasis usually responds to topical treatments such as clotrimazole troches and nystatin suspension (nystatin "swish and swallow"). Systemic antifungal medication such as fluconazole or itraconazole may be necessary for oropharyngeal infections that do not respond to these treatments.

A client is diagnosed with oral candidiasis. Nurse Tina knows that this condition in AIDS is treated with: A. Trimethoprim + sulfamethoxazole B. Fluconazole C. Acyclovir D. Zidovudine

D The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client? a) consume foods and beverages that are high in glucose b) plan large menus and cook meals in advance c) eat low-calorie snacks between meals d) eat small, frequent meals throughout the day

A Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.

A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living? a) provide supportive care with hygiene needs b) provide meals and snacks with high-protein, high calorie, and high-nutritional value c) provide small, frequent meals

Correct answer: a Rationale: AIDS is diagnosed when an individual with HIV infection meets one of several criteria; one criterion is a CD4+ T cell count below 200 cells/L.

A diagnosis of AIDS is made when an HIV-infected patient has a. a CD4+ T cell count below 200/µL. b. a high level of HIV in the blood and saliva. c. lipodystrophy with metabolic abnormalities. d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

Correct answer: 4 Although all of these are signs and symptoms that the patient may be experiencing a complication and should be reported, a new rash accompanied by a fever should be reported immediately by a patient with HIV infection. Headache, vomiting, and coughing are signs and symptoms that can be delayed up to 24 hours.

A human immunodeficiency virus (HIV) patient comes into the clinic for a follow-up appointment with a temperature of 102 degrees Fahrenheit. Which statement would the nurse report immediately? 1. "I woke up this morning with a mild headache." 2. "I vomited once this morning." 3. "I started coughing up some clear mucous when I woke up this morning." 4. "I have a rash that appeared on my stomach this morning."

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors.

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors.

Correct answer: 4, 5 Positive EIA and Western blot tests confirm the presence of HIV antibodies. A positive antibody test should be followed by a test to confirm (usually the Western blot). Engaging in high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. A positive tuberculin test does not confirm the presence of HIV infection; it just indicates that the person has been exposed to Mycobacterium tuberculosis. Extreme weight loss or high fever does not confirm the presence of HIV; these adaptations are related to many disorders, and not just HIV infection. The diagnosis of an opportunistic infection alone is not sufficient to confirm the diagnosis of HIV.

A medical team is conducting human immunodeficiency virus (HIV) screening in a community. Which finding would indicate a positive diagnosis for HIV infection? Select all that apply. 1. A history of fever, diarrhea, candidiasis, or weight loss 2. A history of intercourse with an HIV-positive woman or man 3. A positive tuberculin test 4. A positive Western blot test 5. A positive enzyme immunoassay (EIA) test

D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

A. The patient is diagnosed with acquired immunodeficiency syndrome (AIDS). Once CD4 count is below 200, patient is diagnosed with AIDS

A patient who has tested positive for the human immunodeficiency virus (HIV) arrives at the clinic with a report of fever, nonproductive cough, and fatigue. The patient's CD4 count is 184 cells/mcL. How should the healthcare provider interpret these findings? Please choose from one of the following options. A. The patient is diagnosed with acquired immunodeficiency syndrome (AIDS). B. The patient is now in the latent stages of HIV infection C. These findings provide evidence that the patient has seroconverted. D. This is an expected finding because the patient has tested positive for HIV.

ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or the use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain.

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse whatthe letters and numbers mean. Which response by the nurse is accurate? a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

B. All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction. All prostatectomies carry a risk of impotence because of potential damage to the pudendal nerves. If this damage occurs, the effects are permanent. Hormonal changes do not affect sexual functioning after prostatectomy.

A patient who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on his sexual function. What aspect of prostate surgery should inform the nurses response? A) Erectile dysfunction is common after prostatectomy as a result of hormonal changes. B) All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction. C) Erectile dysfunction after prostatectomy is expected, but normally resolves within several months. D) Modern surgical techniques have eliminated the risk of erectile dysfunction following prostatectomy.

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having ahospital bed does not necessarily address the fatigue. The better option is to stay as active aspossible while combating fatigue. Fatigue is expected during treatment and is not anindication of depression. Minimizing activity may lead to weakness and other complicationsof immobility.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: A It is likely that the patient could be developing a peritonitis, which could be life-threatening, and assessment of vital signs for hypovolemic shock should be done to report to the health care provider. If an IV line is not in place, it should be inserted and pain may be eased by flexing the knees.

A patient with a gunshot wound to the abdomen complains of increasing abdominal pain several hours after surgery to repair the bowel. What action should the nurse take first? a. Take the patient's vital signs. b. Notify the health care provider. c. Position the patient with the knees flexed. d. Determine the patient's IV intake since the end of surgery.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.

ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding protein powder does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem? a. Add protein powder to foods such as casseroles. b. Tell the patient to eat foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add spices to enhance the flavor of foods that are served.

Answer: C Rationale: An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

ANS: A The abdominal pain and distention that occur from the decreased motility of the bowel should be treated with increased ambulation and frequent position changes to increase peristalsis. If the pain is severe, cholinergic drugs, rectal tubes, or application of heat to the abdomen may be prescribed. Assessment of bowel sounds is not an intervention to relieve the pain and a high Fowler's position is not indicated. Opioids may still be necessary for pain control and motility can be increased by other means.

A postoperative patient has a nursing diagnosis of pain related to effects of medication and decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient? a. Ambulate the patient more frequently. b. Assess the abdomen for bowel sounds. c. Place the patient in high Fowler's position. d. Withhold opioids because they decrease bowel motility.

The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? a. Infuse normal saline at 250 mL/hr. b. Administer IV ondansetron (Zofran). c. Provide oral care with moistened swabs. d. Insert a 16-gauge nasogastric (NG) tube.

ANS: A Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

ANS: A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.

ANS: A Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain

ANS: A Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing action should be included in the postoperative plan of care? a. Elevate the head of the bed to at least 30 degrees. b. Reposition the nasogastric (NG) tube if drainage stops or decreases. c. Notify the doctor immediately about bloody NG drainage. d. Start oral fluids when the patient has active bowel sounds.

ANS: A Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the surgeon. b. irrigate the NG tube. c. administer the prescribed morphine. d. continue to monitor the NG drainage.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.

The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient makes which statement? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

ANS: A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? a. Dark red drainage b. Dark brown drainage c. Green-tinged drainage d. Light yellowish-brown drainage

ANS: A RFor the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds b. blood glucose c. blood urea nitrogen (BUN) d. level of consciousness (LOC)

ANS: A Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management.

Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease? a. "Avoid foods that cause pain after you eat them." b. "High-protein foods are least likely to cause pain." c. "You will need to remain on a bland diet indefinitely." d. "You should avoid eating many raw fruits and vegetables."

ANS: A The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

A 32-year-old pregnant patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patient's feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.

ANS: A The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. antacids 30 minutes before the sucralfate. b. sucralfate at bedtime and antacids before meals. c. antacids after eating and sucralfate 30 minutes before eating. d. sucralfate and antacids together 30 minutes before each meal.

ANS: C Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. lie down for about 30 minutes after eating. b. choose foods that are high in carbohydrates. c. increase the amount of fluid intake with meals. d. drink sugared fluids or eat candy after each meal.

ANS: A The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert an indwelling urinary catheter. b. Draw blood for a serum creatinine level. c. Schedule an intravenous pyelogram (IVP). d. Administer lorazepam (Ativan) 0.5 mg PO.

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve after the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP may be done as a diagnostic test but does not need to be done urgently.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.

ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)? a. Anaphylaxis b. Renal calculi c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output

ANS: C, E Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's triceps reflexes are absent. b. The patient is continuously drooling saliva. c. The patient complains of severe pain in the feet. d. The patient's blood pressure (BP) is 150/82 mm Hg.

ANS: B Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome

Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

ANS: B Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.

ANS: B The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data. c. check the vital signs for indications of hemorrhage. d. turn the patient to the left to relieve pressure on the right leg.

ANS: B The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.

Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has taken only sips of water. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has been vomiting several times a day for the last 4 days.

ANS: B A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.

A 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Apply absorbent incontinent pads liberally over the bed linens. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

ANS: D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

Which assessment data reported by a 28-year-old male patient is consistent with a lower urinary tract infection (UTI)? a. Poor urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, boardlike abdomen

ANS: D Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

ANS: B After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

ANS: B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

ANS: B Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders

A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? a. Irrigate the NG tube. b. Obtain the vital signs. c. Listen for bowel sounds. d. Give the ordered antacid.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be a. augmenting fluid volume. c. diluting nephrotoxic substances. b. maintaining cardiac output. d. preventing systemic hypertension.

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be a. augmenting fluid volume b. maintaining cardiac output c. diluting nephrotoxic substances d. preventing systemic hypertension

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid? (Select all that apply.) a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply): a. hypotension b. ECG changes c. hypernatremia d. pulmonary edema e. urine with high specific gravity

ANS: B, D The nurse monitors the patient in the oliguric phase of acute renal injury for the following:• Hypertension and pulmonary edema: When urinary output decreases, fluid retention occurs. The severity of the symptoms depends on the extent of the fluid overload. In the case of reduced urine output (i.e., anuria, oliguria), the neck veins may become distended with a bounding pulse. Edema and hypertension may develop. Fluid overload can eventually lead to heart failure (HF), pulmonary edema, and pericardial and pleural effusions.• Hyponatremia: Damaged tubules cannot conserve sodium. Consequently, the urinary excretion of sodium may increase, which results in normal or below-normal serum levels of sodium.• Electrocardiographic changes and hyperkalemia: Initially, clinical signs of hyperkalemia are apparent on electrocardiogram (ECG) demonstrating peaked T waves, widening of the QRS complex, and ST-segment depression.• Urinary specific gravity: Urinary specific gravity is fixed at about 1.010.

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth.

ANS: C Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing

A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm.

ANS: C The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment

The nurse should reposition the patient who has just had a laminectomy and discectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.

ANS: C The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? a. Weight loss b. Nausea and vomiting c. Pain relieved by food intake d. Pain radiating down the right arm

ANS: C A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI)caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Complaint of flank pain b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

ANS: B The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken. b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/minute.

ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.

A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence.

ANS: B The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence.

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital? a. Encouraging adequate oral fluid intake b. Testing urine with a dipstick daily for nitrites c. Avoiding unnecessary urinary catheterizations d. Providing frequent perineal hygiene to patients

ANS: C Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram(ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Review the chart for the patient's current creatinine level. d. Check the medical record for the most recent potassium level.

ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? a. Checking the level of consciousness b. Measuring the quantity of any emesis c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange.

A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. neutralizes stomach acid and provides relief of symptoms in a few minutes. b. reduces the reflux of gastric acid by increasing the rate of gastric emptying. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

ANS: D, E, F Intrarenal causes of acute kidney injury (AKI) include conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia. Anaphylaxis and other prerenal problems are frequently the initial cause of AKI. Renal stones and bladder cancer are among the postrenal causes of AKI.

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/μL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

A, B, C. Follow up is indicated for this client because his PSA is above 4.0 ng/mL and he reports a weak urine stream. An enlarged and nodular prostate is a possible indication of prostate cancer and requires further evaluation. Urinating once during the night is common in older adults due to redistribution of blood that may have been trapped in lower extremities during the day. Smegma is a normal secretion that can accumulate beneath the glans of the penis if not removed during hygiene.

An older adult client is having an annual physical exam at a provider's office. Which of the following client findings indicates additional follow up is needed in regard to the prostate gland? (Select all that apply.) A) PSA is 4.2 ng/mL. B) DRE reveals an enlarged and nodular prostate. C) The client reports a weak urine stream. D) The client reports urinating once during the night. E) Smegma is present below the glans of the penis.

ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient voids every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has crackles up to the midline posterior chest.

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

Ans: A Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

Ans: A During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

Ans: A Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally administered. Potassium chloride would exacerbate the patient's hyperkalemia.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patient's IV fluid infusion. B) Report the patient's early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

Ans: C As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

Ans: C As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to set the new dressing.

Ans: C Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be administered prior to the dressing change. ROM exercises do not normally follow a dressing change.

Correct answer: b Rationale: The goals of drug therapy in HIV infection are to (1) decrease the viral load, (2) maintain or raise CD4+ T cell counts, and (3) delay onset of HIV infection-related symptoms and opportunistic diseases.

Antiretroviral drugs are used to a. cure acute HIV infection. b. decrease viral RNA levels. c. treat opportunistic diseases. d. decrease pain and symptoms in terminal disease.

D Eradication of HIV infection cannot be achieved with available antiretroviral (ARV) regimens even when new, potent drugs are added to a regimen that is already suppressing plasma viral load below the limits of detection of commercially available assays.

As a knowledgeable nurse, you know that the primary goals of antiretroviral therapy (ART) include all, EXCEPT: A. Reduce HIV-associated morbidity and prolong the duration and quality of survival B. Restore and preserve immunologic function C. Maximally and durably suppress plasma HIV viral load D. Elimination of HIV entirely from the body

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

Ans: A Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

The nurse is educating the family of a patient in the late stages of amyotrophic lateral sclerosis (ALS). What teaching point is most important for the nurse to include? a. The patient's ability to move the upper limbs may be affected. b. The patient's cognitive and mental capacity will most likely remain intact throughout the disease progression. c. The patient's breathing should not be affected by the disease. d. The patient's ability to swallow will remain intact.

B Whereas the ability to move the upper limbs will likely be affected by the disease, it is important for families to remember that the patient's cognitive and mental capacity stays intact as the motor activity rapidly declines. Breathing and swallowing are often significantly affected by ALS.

Client is having tonic-clonic seizure. Nurse should take which of the following actions? SELECT ALL THAT APPLY A. Restrain client B. Maintain airway. C. Turn client to side. D. Place tongue blade in mouth E. Protect client from injury.

B, C, E

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following actions should the nurse take first? a. notify the provider b. sit the client upright in bed c.. check the client's urinary catheter for blockage d. administer antihypertensive medication

B. sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is a. you will have more normal function when spinal shock resolves and the reflex arc returns b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of unction, it will be years before we can tell when the complete effect will be

B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.

Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury

C. Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure....this is known as status epilepticus.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilator support as needed is the priority intervention.

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1."This is not a stroke, and many clients recover in 3 to 5 weeks." 2."This is caused by a small tumor, which can be removed easily." 3."This is similar to a stroke, but all symptoms will reverse without treatment." 4."This is a temporary problem, with treatment similar to that for migraine headaches."

1. "This is not a stroke, and many clients recover in 3 to 5 weeks." Clients with Bell's palsy should be reassured that they have not experienced stroke a (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

The nurse is discussing the future with a client recently diagnosed with amyotrophic lateral sclerosis (ALS). When the client asks about the possibility of continuing to work at his family's construction business, the nurse responses: 1. "Work as long at your job as you feel capable of keeping up with the demands it makes on you.". 2. "This is a progressively debilitating disease; you need to think of ways to conserve your energy, not expend it.". 3. "Can you do work that is less strenuous?" 4. "Is there a way that you can switch over to the office side of the business?"

1. "Work as long at your job as you feel capable of keeping up with the demands it makes on you.". Rationale: People with ALS do maintain careers and interests. They are encouraged to remain active for as long as possible. While it is important to minimize stress and conserve energy, it is not necessary to alter one's life dramatically until the symptoms of the disease demand it.

After the male client receives a diagnosis of amyotrophic lateral sclerosis (ALS), he expresses sadness and states he does not know what to do next. Which is the most effective response by the nurse to facilitate communication? 1. Ask the client what he finds comforting in his life. 2. Reassure the client his family will take care of him. 3. Refer the client to a church for spiritual counseling. 4. Tell the client hospice care is available immediately.

1. ALS is a progressive, degenerative neurological disease with no cure and, because of the grim diagnosis, the client expresses confusion and lacks a clear direction. To reduce anxiety enhance coping skills, and facilitate communication, the nurse provides a calm atmosphere by redirecting the client to identify comforting things. The nurse uses the comfort measures hoping they will reduce tension so the client can process information and make decisions.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the clients significant other? 1. wake the client every 3-4 hours. 2. monitor for increased intracranial pressure. 3. observe frequently for hypervigilance. 4. offer the client food every 3 to 4 hours.

1. Awakening the client every 3-4 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome, which would warrant a return to the emergency department.

Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.

2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism. 1. These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation. 3. Decreased blood pressure and slow heartrate are signs of myxedema coma. 4. These are signs/symptoms of myxedema coma.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1."Do your eyes feel dry?" 2."Do you have any spasms in your throat?" 3."Are you having any difficulty chewing food?" 4."Do you have any tingling sensations around your mouth?"

3. "Are you having any difficulty chewing food?" Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? 1."Do you have any visual problems?" 2."Are you having any problems hearing?" 3."Do you have any tingling in the face region?" 4."Is the pain experienced a stabbing type of pain?"

4. "Is the pain experienced a stabbing type of pain?" Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. The remaining options do not elicit data specifically related to this disorder.

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 1."It's a local reaction to nasal stuffiness." 2."It's due to a hypoglycemic effect on the cranial nerve." 3."Release of catecholamines with infection or stress leads to the pain." 4."Pain is due to stimulation of the affected nerve by pressure and temperature.

4. "Pain is due to stimulation of the affected nerve by pressure and temperature." The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air. The remaining options are incorrect.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1.Prevent stressful situations. 2.Avoid activities that may cause fatigue. 3.Avoid contact with people with an infection. 4.Avoid activities that may cause pressure near the face.

4. Avoid activities that may cause pressure near the face. The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air. The remaining options are not associated with triggering episodes of pain.

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.

4. Dysphagia is a common problem of clients diagnosed with multiple sclerosis, and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray

4. Electrocardiographic monitoring electrodes and intubation tray The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.

A nurse cares for a client who has a family history of colon cancer. The client states, "My father & brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. If you eat a low-fat and low-fiber diet, your chances decrease significantly. b. You are safe. This is an autosomal dominant disorder that skips generations. c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. d. You should have a colonoscopy more frequently to identify abnormal polyps early.

ANS: 1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and significant abdominal distention.

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. 1. Projectile vomiting. 2. Significant abdominal distention. 3. Copious diarrhea. 4. Rapid onset of dehydration. 5. Increased bowel sounds.

3. Persistent cough Persistent cough and hoarseness are two of the earliest signs of lung cancer. Chest pain, diaphoresis, and fever may develop along with later symptoms of lung cancer.

A nurse is assessing a patient in whom lung cancer is suspected. Which symptom is the patient most likely to report first? 1. Chest pain 2. Diaphoresis 3. Persistent cough 4. Low-grade fever

Correct answer: 4 AIDS can be transmitted from one individual to another by unprotected anal or vaginal sexual intercourse. Any sexual activity that involves contact with body fluids, such as semen, vaginal secretions, or blood, can spread the infection. Shaking hands, using common toilet seats, and sharing utensils do not involve contact with body fluids. Therefore, the HIV infection cannot be transmitted through these modes.

A nurse is caring for a patient who is diagnosed with AIDS. The nurse should inform the patient that the virus can be spread through which method? 1. Shaking hands 2. Sharing a toilet seat 3. Eating from the same utensils 4. Having unprotected sex

Answer: D Rationale: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder

Answer: B Rationale: Shoulder pain occurs due to free air that is introduced into the abdomen during laparoscopic surgery.

A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."

Answer: D Rationale: The greatest risk to the client is hypocalcemia due to the risk of cardiac dysrhythmia. Hand spasms when taking a blood pressure is an indication of hypocalcemia and is the priority finding to report to the provider

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. History of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked

a. red meat and fat Some studies have shown an increase of prostate cancer in societies with diets high in red meats and fats. The other options have not been shown to impact the incidence of prostate cancer.

A nurse is providing a program for older men in a senior community about measures that can be taken to reduce the risk for prostate cancer. Which of the following would the nurse include in the program? a. Decrease red meat and fat intake. b. Decrease lycopene intake. c. Increase fiber intake. d. Avoid foods high in sodium.

Answer: C Rationale: Cullen's sign is indicated by a bluish-grey discoloration in the periumbilical area.

A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.

Correct answer: 1, 3, 5 Patients with a poor immune status are more susceptible to any kind of infection, including HIV. The concentration of the virus is an important variable. Other variables that influence the transmission are the volume of blood, virulence of the virus, and concentration of the organism in the blood. Large amounts of HIV can be found in the blood, and to a lesser extent in the semen, during the first 6 months of infection and again during the late stages. HIV positive patients can transmit the infection at any age to a person of any age when the route of transmission is established. Therefore, the age of the patient or nurse does not affect the transmission of HIV infection to the nurse.

A nurse is taking a blood sample with a syringe and large bore needle from a patient with chronic human immunodeficiency virus (HIV) who has a CD4+ T-cell count of 123/μL. If the nurse gets a needle injury, what factors may affect the transmission of HIV infection? Select all that apply. 1. Viral load 2. Age of the nurse 3. Volume of blood exposed to 4. Age of the patient 5. Immune status of nurse

A) Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and the PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound and CBC with BUN and creatinine assessment are usually done after diagnosis to identify the extent of disease and potential metastases.

A nurse is teaching a 53-year old man about prostate cancer. What information should the nurse provide to best facilitate the early identification of prostate cancer? A) Have a digital rectal examination and prostate specific antigen (PSA) test done yearly. B) Have a transrectal ultrasound done every 5 years. C) Perform monthly testicular self-examinations, especially after age 60. D) Have a complete blood count (CBC), blood urea nitrogen (BUN) and creatinine assessment performed annually.

C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

3. Cigarette smoking As many as 90% of patients with lung cancer have a history of cigarette smoking. Cigarette smoke contains several organ-specific carcinogens. Genetics and occupational exposure are risks but not as high as cigarette smoking. Chewing tobacco is not associated with lung cancer; it is related to oral cancer.

A nurse preparing educational information about lung cancer notes that the primary risk factor related to the development of lung cancer is: 1. Genetics 2. Chewing tobacco 3. Cigarette smoking 4. Occupational exposure

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work.

ANS: D Because the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply prescribed anesthetic gel to oral lesions before meals.

ANS: C

A patient has been receiving chemotherapy and radiation for a diagnosis of non-Hodgkin's lymphoma. In your morning assessment you notice the patient has new onset facial edema, distention of head and neck veins, and dyspnea. Which oncologic emergency would be suspected? a. Hypercalcemia b. Spinal Cord Compression c. Superior Vena Cava Syndrome (SVCS) d. Tumor Lysis Syndrome (TLS)

D. late chronic infection or AIDS Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.

A patient is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV testing is positive. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having a. acute infection. b. early chronic infection. c. intermediate chronic infection. d. late chronic infection or AIDS.

ANS: B Nausea and vomiting are the most common side effects of chemotherapy and may persist for as long as 24 to 48 hours after its administration. Antiemetic drugs are frequently prescribed for these patients. Other side effects include bone marrow suppression, anorexia, vaginal dryness, and hair loss. Less common effects include altered glucose metabolism and jaundice.

A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment. The patient asks the nurse what the most common side effect of chemotherapy is. What would be the best answer the nurse could give? A) Alopecia B) Nausea and vomiting C) Altered glucose metabolism D) Increased appetite

ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk.

A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? a. Providing IV fluids and inserting a nasogastric (NG) tube b. Administering oral bicarbonate and testing the patient's gastric pH level c. Performing a fecal occult blood test and administering IV calcium gluconate d. Starting parenteral nutrition and placing the patient in a high-Fowler's position

ANS: A A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? a. Administer prescribed analgesics. b. Monitor temperature every 4 hours. c. Encourage increased oral fluid intake. d. Give antiemetics as needed for nausea.

ANS: A Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take? a. Remind the patient about the need to drink 1000 mL of fluids daily. b. Obtain a midstream urine specimen for culture and sensitivity testing. c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms. d. Tell the patient to take the trimethoprim and sulfamethoxazole for 3 more days.

ANS: B Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole, the patient is likely to need a different antibiotic.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line.

ANS: B Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.

A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A dish of lemon gelatin c. A cup of coffee with cream d. A bowl of hot chicken broth

ANS: B Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with human immunodeficiency virus.

ANS: B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. prevent aspiration of gastric contents. b. inhibit the development of stress ulcers. c. lower the chance for H. pylori infection. d. decrease the risk for nausea and vomiting.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating a. milk and cheese. b. sardines and liver. c. legumes and dried fruit. d. spinach, chocolate, and tea.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Pyridium may cause photosensitivity b. Pyridium may change the urine color. c. Take the Pyridium for at least 7 days. d. Take Pyridium before sexual intercourse.

ANS: B Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI.

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

ANS: B This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, "insert a short, small, 'mini' catheter attached to a collecting container" describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary, and might result in suppressing the growth of some bacteria. The technique described in the answer beginning "have the patient empty the bladder completely" would not result in a sterile specimen.

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

ANS: B When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for a. sodium restriction to prevent fluid retention. b. insulin to maintain normal blood glucose levels. c. oral corticosteroids to replace endogenous cortisol. d. chemotherapy to prevent malignant tumor recurrence.

ANS: C Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema

ANS: C Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

A patient with deep partial-thickness burns experiences severe pain associated with nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. The patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

ANS: C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer.

ANS: C Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? a. Ambulate following a meal. b. Eat high-carbohydrate foods. c. Limit the fluids taken with meals. d. Sit in a high Fowler's position during meals.

ANS: C Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know about CKD that could cause this patient's Kussmaul respirations? a. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.

ANS: C Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.

ANS: C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should a. check for unilateral eyelid droop. b. shine a light into the patient's pupil. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book.

ANS: C The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to: a. cough and deep breathe every 2 hours postoperatively. b. remain on bed rest for the first 48 hours after the surgery. c. avoid brushing teeth for at least 10 days after the surgery. d. be positioned flat with sandbags at the head postoperatively.

ANS: C To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

All of the following orders are received for a patient who has vomited 1500 mL of bright red blood. Which order will the nurse implement first? a. Insert a nasogastric (NG) tube and connect to suction. b. Administer intravenous (IV) famotidine (Pepcid) 40 mg. c. Draw blood for typing and crossmatching. d. Infuse 1000 mL of lactated Ringer's solution.

ANS: D Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."

ANS: D Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

ANS: D An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? a. Blood in urine b. Left flank bruising c. Left flank discomfort d. Decreased urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of fat in the diet. b. history of recent weight gain or loss. c. any family history of gastric problems. d. use of nonsteroidal anti-inflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement.

ANS: D In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.

What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels

ANS: D The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

Ans: C The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dÈbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

Ans: C To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

Ans: D Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the patient's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances. B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patient's psychosocial state.

Ans: D Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

A client who is recently diagnosed with amyotrophic lateral sclerosis (ALS) is to be discharged home. The nurse should teach the family to: 1. monitor the client's urine output at home. 2. check the client's level of consciousness frequently. 3. check bony prominences and reposition the client every 2 hours. 4. serve the client a high red meat diet.

Answer: 3 1. It is not necessary to monitor the client's urine output, but the family is encouraged to provide good hydration.2. Clients with ALS maintain their mental acuity.3. The client is usually bedridden, and should be turned every 2 hours and monitored for breakdown on bony prominences.4. Clients with ALS lose their ability to swallow, and could aspirate on pieces of meat.

A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"

B. Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

C. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable.

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

Correct Answer: C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

Correct Answer: 2 Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

Correct Answer: 3 Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

The nurse is caring for a patient with increased intracranial pressure (ICP). The nurse realizes that some nursing actions are contraindicated with increased ICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) increased ICP. Keeping the patient properly oxygenated may also help to control ICP.

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours

D. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

Correct answer: c Rationale: Immune dysfunction in HIV disease is caused predominantly by damage to and destruction of CD4+ T cells (i.e., T helper cells or CD4+ T lymphocytes).

During HIV infection a. the virus replicates mainly in B-cells before spreading to CD4+ T cells. b. infection of monocytes may occur, but antibodies quickly destroy these cells. c. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells. d. a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication.

ANS: A The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Obtain more information about the family history. b. Schedule a sigmoidoscopy to provide baseline data. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood.

ANS: C Early menarche and late menopause are risk factors for breast cancer because of the prolongedexposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk

During a well-woman physical examination, a 43-yr-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask? a. "Do you currently smoke tobacco?" b. "Have you ever had a breast injury?" c. "At what age did you start having menstrual periods?" d. "Is there a family history of fibrocystic breast changes?"

ANS: D The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment d. Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

ANS: A, B, E, F With an acute exacerbation of inflammatory bowel disease (IBD), to rest the bowel the patient will be NPO, receive IV fluids and parenteral nutrition, and have nasogastric suction. Sedatives would be used to alleviate stress. Enteral nutrition will be used as soon as possible

For the patient hospitalized with inflammatory bowel disease (IBD), which treatments would be used to rest the bowel (select all that apply)? a. NPO b. IV fluids c. Bed rest d. Sedatives e. Nasogastric suction f. Parenteral nutrition

Answer: B Prostate cancer growth largely depends on androgens, and androgen deprivation is a primary therapeutic approach for some men with prostatic cancer. Hormone therapy, also known as androgen-deprivation therapy (ADT), focuses on reducing the levels of circulating androgens to diminish tumor growth.

For the patient with inoperable prostate cancer, you expect the physician to order which type of hormone? A. Gonadotropin-releasing hormone B. Androgen deprivation C. Luteinizing hormone D. Estrogen

ANS: A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.

Interleukin-2 (biotherapy) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the body's immunologic response to tumor cells. b. IL-2 prevents bone marrow depression caused by chemotherapy. c. IL-2 protects normal cells from harmful effects of chemotherapy. d. IL-2 stimulates malignant cells in the resting phase to enter mitosis.

ANS: B A normal new colostomy stoma should appear bright red, have mild to moderate edema, and have a small amount of bleeding or oozing of blood when touched. A purplish stoma indicates inadequate blood supply and should be reported. The colostomy will not have any fecal drainage for 2 to 4 days but there may be some earlier mucus or serosanguineous drainage. Bowel sounds after extensive bowel surgery will be diminished or absent

On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find? a. Hyperactive, high-pitched bowel sounds b. A brick-red, puffy stoma that oozes blood c. A purplish stoma, shiny and moist with mucus d. A small amount of liquid fecal drainage from the stoma

Correct answer: c Rationale: Management of HIV infection is complicated by the many opportunistic diseases that can develop as the immune system deteriorates.

Opportunistic diseases in HIV infection a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions.

Correct answer: c Rationale: The most useful screening tests for HIV detect HIV-specific antibodies.

Screening for HIV infection generally involves a. laboratory analysis of blood to detect HIV antigen. b. electrophoretic analysis for HIV antigen in plasma. c. laboratory analysis of blood to detect HIV antibodies. d. analysis of lymph tissues for the presence of HIV RNA.

ANS: 4 Ammonia is a by product of protein metabolism and contributes to hepatic encephalopathy. reducing protein intake should decrease ammonia levels.

The client diagnosed with end stage liver failure is admitted with hepatic encephalopathy. which dietary restriction should be implemented by the nurse to address this complication? 1. restrict sodium intake to 2g a day 2. limit oral fluids to 1500ml a day 3. decrease the daily fat intake 4. reduce protein intake to 60 to 80g a day

ANS: 1 Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

The client has end stage liver failure secondary to alcoholic cirrhosis. which complication indicates the client is at risk for developing hepatic encephalopathy? 1. gastrointestinal bleeding 2. hypoalbuminemia 3. splenomegaly 4. hyperaldosteronism

ANS: 3 Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

The client has had a liver biopsy. which post procedure intervention should the nurse implement? 1. instruct the client to void immediately 2. keep the client NPO for 8 hours 3. place the client on the right side 4. monitor BUN and creatinine level

D A person's CD4 count is an important factor in the decision to start ART. A low or falling CD4 count indicates that HIV is advancing and damaging the immune system. A rapidly decreasing CD4 count increases the urgency to start ART. Regardless of CD4 count, there is greater urgency to start ART when a person has a high viral load or any of the following conditions: pregnancy, AIDS, and certain HIV-related illnesses and co infections.

The decision to begin antiretroviral therapy is based on: A. The CD4 cell count B. The plasma viral load C. The intensity of the patient's clinical symptoms D. All of the above

ANS: D Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels

Answer: C Rationale: Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? A) Gastric pH B) Blood glucose C) Serum amylase D) Serum potassium

A. Cells are abnormal and moderately differentiated. Grade II cells are more abnormal than Grade I and moderately differentiated. Grade I cells differ slightly from normal cells and are well-differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine.

The laboratory reports that the cells from the patient's tumor biopsy are Grade II. What should the nurse know about this histologic grading? A. Cells are abnormal and moderately differentiated. B. Cells are very abnormal and poorly differentiated. C. Cells are immature, primitive, and undifferentiated. D. Cells differ slightly from normal cells and are well-differentiated.

ANS: C Cobalamin and iron injections will help to correct malnutrition. Correcting malnutrition will also indirectly help to improve quality of life and fight infections.

The medications prescribed for the patient with inflammatory bowel disease include cobalamin and iron injections. What is the rationale for using these drugs? a. Alleviate stress b. Combat infection c. Correct malnutrition d. Improve quality of life

ANS: D Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

The nurse is admitting a 68-year-old man with severe dehydration and frequent watery diarrhea. He just completed a 10-day outpatient course of antibiotic therapy for bacterial pneumonia. It is most important for the nurse to take which action? A. Wear a mask to prevent transmission of infection. B. Wipe equipment with ammonia-based disinfectant. C. Instruct visitors to use the alcohol-based hand sanitizer. D Don gloves and gown before entering the patient's room.

Answer: B Rationale: Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102o F (38.9o C)

ANS: B Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has multiple spider-shaped blood vessels on the abdomen.

C. Assess blood pressure only on unaffected arm. Blood pressure readings, venipunctures, and injections should not be done on the affected arm. Elastic bandages should not be used in the early postoperative period because they inhibit collateral lymph drainage. The affected arm should be elevated above the heart, and isometric exercises are recommended and gradually increased starting in the recovery room to reduce fluid volume in the arm.

The nurse is caring for a patient diagnosed with breast cancer who just underwent an axillary lymph node dissection. What intervention should the nurse use to decrease the lymphedema? A. Keep affected arm flat at the patient's side. B. Apply an elastic bandage on the affected arm. C. Assess blood pressure only on unaffected arm. D. Restrict exercise of the affected arm for 1 week.

ANS: C 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 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? A. Hypokalemia B. Hypouricemia C. Hypocalcemia D. Hypophosphatemia

ANS: C The adverse effects of intravesical chemotherapy are confined to the bladder. The otheradverse effects are associated with systemic chemotherapy.

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia

ANS: D Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk.

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening. d. Discuss risks associated with cigarette smoking during each patient encounter.

1. Notify the health care provider (HCP). Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?1. Notify the health care provider (HCP). 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform the surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

Answer: D ​Rationale: Genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. Female​ sex, being over the age of​ 40, American​ Indians, and Mexican Americans are most at risk for gallstones. Family history is also associated with increased risk.

The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing​ gallstones? A. Young adult Asian American women B. Middle-aged Caucasian American men C. African American clients D. Women over the age of 40

4. Monitor the characteristics of the stool and compare them with the patient's baseline normal. Warming the castor oil is incorrect; it should be chilled to make it more palatable. Cascara does not make the urine look green; it makes the urine look pink or brownish in color. Decreasing fluid intake with watery stools is incorrect; intake should be increased with watery stools. It is correct to monitor the characteristics of the stool and compare them to the baseline normal.

The nurse is providing care for a patient who has been receiving laxative agents and stimulants to treat chronic constipation. Which nursing intervention is appropriate in caring for this patient? 1. Warm the castor oil to make it easier to swallow. 2. Tell the patient that cascara can make the urine look green. 3. Have the patient monitor fluid intake and decrease the amount if stools become watery. 4. Monitor the characteristics of the stool and compare them with the patient's baseline normal.

B. A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years Cancer prevention and early detection are associated with the following behaviors: limited alcohol use; regular physical activity; maintaining a normal body weight; obtaining regular cancer screenings; avoiding cigarette smoking and other tobacco use; using sunscreen with SPF 15 or higher; and practicing healthy dietary habits (e.g., reduced fat and increased fruits and vegetables).

The nurse is teaching a wellness class to a group of women at their workplace. The nurse knows that which woman is at highest risk for developing cancer? A. A woman who obtains regular cancer screenings and consumes a high-fiber diet B. A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years C. A woman who exercises five times every week and does not consume alcoholic beverages D. A woman who limits fat consumption and has regular mammography and Pap screenings

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. An elevated WBC may indicate infection but does not reflect the effectiveness of the colorectal cancer therapy.

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a. Frequent loose stools b. Nausea and vomiting c. Elevated white blood count (WBC) d. Increased carcinoembryonic antigen (CEA)

ANS: C A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation

Answer: B Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/μL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/μL

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

D. "Self-breast examination is a reliable way to detect breast cancer early." Screening for the early detection of breast cancer includes yearly mammograms starting at age 40 and clinical breast examination every year at age 40. An alternative suggestion is to begin screening mammograms at age 50. Breast self-examination has benefits and limitations and may not be a reliable method for early detection of breast cancer. BSE is optional but should be done in premenopausal women right after the menstrual period when the breasts are less lumpy and tender.

The nurse teaches a 53-year-old patient about screening for early detection of breast cancer. Which statement by the patient requires an intervention by the nurse? A. "I should plan to have a mammogram every year." B. "I will see a health care provider every year for a breast examination." C. "A breast examination should be done right after my menstrual period." D. "Self-breast examination is a reliable way to detect breast cancer early."

Correct answer: 2 Immune problems start to occur when the count drops below 500 CD4 T cells. When it drops below 200 CD4 T cells, severe immune problems will develop and the patient is diagnosed with acquired immunodeficiency syndrome (AIDS). The immune system generally remains healthy if there are more than 500 CD4 T cells. A count between 800 to 1200 CD4 T cells is normal for adults that do not have any immune dysfunction.

The nurse understands that a patient with human immunodeficiency virus (HIV) starts to develop immune problems when their CD4 count: 1. Drops below 200 2. Drops below 500 3. Is greater than 500 4. Falls between 800 to 1200

Answer: C Rationale: Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.

ANS: D Care to the affected area must focus on preventing further skin irritation, drying, and damage. Soaps, petroleum ointment, and shaving the area could worsen the erythema. Ice is also contraindicated.

The nursing instructor is discussing the care of oncology patients with her junior nursing students. The instructor presents this scenario: An oncology patient develops erythema following radiation therapy. What should the nurse instruct the patient to do? A) Apply ice to the area. B) Keep the area cleanly shaven. C) Apply petroleum ointment to the affected area. D) Avoid using soap on the area of treatment.

Answer: d Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

C. Serum PSA level 10 ng/mL E. Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth.

The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations now indicate that the prostate cancer may be growing and he needs a change in his care (select all that apply)? A. Casts in his urine B. Presence of α-fetoprotein C. Serum PSA level 10 ng/mL D. Onset of erectile dysfunction E. Nodularity of the prostate gland

ANS: C IV fluid replacement along with antibiotics, NG suction, analgesics, and surgery would be expected. Peritoneal lavage may be used to determine abdominal trauma. Peritoneal dialysis would not be performed. Oral fluids would be avoided with peritonitis.

The patient has peritonitis, which is a major complication of appendicitis. What treatment will the nurse plan to include? a. Peritoneal lavage b. Peritoneal dialysis c. IV fluid replacement d. Increased oral fluid intake

ANS: B The patient's manifestations are characteristic of appendicitis. After laboratory test and CT scan confirmation, the patient will have surgery. Laxatives are not used. The 6 hours of fluids and antibiotics preoperatively would be used only if the appendix was ruptured. The NG tube is more likely to be used with abdominal trauma.

The patient has persistent and continuous pain at McBurney's point. The nursing assessment reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the right leg flexed. What should the nursing interventions for this patient include? a. Laxatives to move the constipated bowel b. NPO status in preparation for possible appendectomy c. Parenteral fluids and antibiotic therapy for 6 hours before surgery d. NG tube inserted to decompress the stomach and prevent aspiration

ANS: D The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.

The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? A. The medications the patient is taking B. The nutritional supplements that will help the patient C. How much time is needed to provide the patient's care D. The time the nurse spends at what distance from the patient

ANS: B Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

ANS: C Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, nonmedicated lotions may be used to prevent skin damage. The patient will want to avoid wearing tight-fitting clothing such as a bra over the treatment field and will want to expose the area to air as often as possible.

The patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin? A. Use Dial soap to feel clean and fresh. B. Scented lotion can be used on the area. C. Avoid heat and cold to the treatment area. D. Wear the new bra to comfort and support the area.

Answer: B ​Rationale: Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A) Immediately start enteral feeding to prevent malnutrition. B) Insert an NG and maintain NPO status to allow pancreas to rest. C) Initiate early prophylactic antibiotic therapy to prevent infection. D) Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Correct answer: a Rationale: Cancer cells may display altered cell surface antigens as a result of malignant transformation. These antigens are called tumor-associated antigens (TAAs). One of the functions of the immune system is to respond to TAAs.

The primary protective role of the immune system related to malignant cells is a. surveillance for cells with tumor-associated antigens. b. binding with free antigen released by malignant cells. c. production of blocking factors that immobilize cancer cells. d. reacting to a new set of antigenic determinants on cancer cells.

ANS: B The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

Correct answer: a Rationale: Unprotected sexual contact (semen, vaginal secretions, or blood) with a partner infected with human immunodeficiency virus (HIV) is the most common mode of HIV transmission.

Transmission of HIV from an infected individual to another most commonly occurs as a result of a. unprotected anal or vaginal sexual intercourse. b. low levels of virus in the blood and high levels of CD4+ T cells. c. transmission from mother to infant during labor and delivery and breastfeeding. d. sharing of drug-using equipment, including needles, syringes, pipes, and straws.

ANS: D A high fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? A. White bread, cheese, and green beans B. Fresh tomatoes, pears, and corn flakes C. Oranges, baked potatoes, and raw carrots D. Dried beans, All Bran (100%) cereal, and raspberries

B. Teach the patient promoting factors to avoid. 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.

What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development? A. Teach the patient to exercise daily. B. Teach the patient promoting factors to avoid. C. Tell the patient to have the cancer surgically removed now. D. Teach the patient which vitamins will improve the immune system.

Correct answers: a, c Rationale: Two major dysfunctions in the process of cancer are defective cell proliferation (i.e., growth) and defective cell differentiation. Cancer cells lack contact inhibition and are poorly differentiated. Cancer cell growth is infiltrative and expansive, and cancer cells are abnormal and become more unlike parent cells.

What features of cancer cells distinguish them from normal cells (select all that apply)? a. Cells lack contact inhibition. b. Oncogenes maintain normal cell expression. c. Cells return to a previous undifferentiated state. d. Proliferation occurs when there is a need for more cells.

Correct answer: d Rationale: The best approach to improve adherence to a treatment regimen is to learn about the patient's life and assist with problem solving within the confines of that life.

What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? a. "Set up" a drug pillbox for the patient every week. b. Give the patient a video and a brochure to view and read at home. c. Tell the patient that the side effects of the drugs are bad but that they go away after a while. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

ANS: C Wearing gloves will avoid hand contamination and washing hands with soap and water will remove more Clostridium difficile spores than alcohol-based hand cleaners and ammonia-based disinfectants. The entire room will need to be disinfected with a 10% solution of household bleach. Probiotics may help to prevent diarrhea in the patient on antibiotics by replacing normal intestinal bacteria.

What is the most important thing the nurse should do when caring for a patient who has contracted Clostridium difficile? a. Clean the entire room with ammonia. b. Feed the patient yogurt with probiotics. c. Wear gloves and wash hands with soap and water. d. Teach the family to use alcohol-based hand cleaners.

ANS: B Because there is no definitive treatment for irritable bowel syndrome (IBS) and patients become frustrated and discouraged with uncontrolled symptoms, it is important to develop a trusting relationship that will support the patient as different treatments are implemented and evaluated. Diagnosis of IBS can be established by Rome criteria and by elimination of other problems. Although IBS can be precipitated and aggravated by stress and emotions, it is not a psychogenic illness. High-fiber diets may help but they might also increase the bloating and gas pains of IBS. Medications are available but usually used as a last resort because of side effects.

When caring for a patient with irritable bowel syndrome (IBS), what is most important for the nurse to do? a. Recognize that IBS is a psychogenic illness that cannot be definitively diagnosed. b. Develop a trusting relationship with the patient to provide support and symptomatic care. c. Teach the patient that a diet high in fiber will relieve the symptoms of both diarrhea and constipation. d. Inform the patient that new medications for IBS are available and effective for treatment of IBS manifested by either diarrhea or constipation.

ANS: A, B, C, E Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

D. 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.

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? A. Metastasis B. Tumor angiogenesis C. Immunologic escape D. Immunologic surveillance

ANS: D Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

Answer: A Rationale: Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.

Answer: C Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

A. "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.

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? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."

1. Smoking cessation Lung cancer and the risks associated with it can be reduced by smoking cessation, and the patient should be counseled to discontinue use of tobacco and avoid secondhand smoke as much as possible. Drinking more fluids, eating more grains, and using steam inhalation are general measures to promote health and do not have much impact on reducing risks of lung cancer.

When teaching the patient about reducing the risks of lung cancer, what is the most important topic for the nurse to address? 1. Smoking cessation 2. Drinking more fluids 3. Eating more grains 4. Using steam inhalation

ANS: D The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adofevir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be checked for chronic HCV and other liver problems."

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

Answer: D Rationale: Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

Answer: B The PSA value is used to detect prostate cancer and to monitor the success of treatment. When treatment has been successful in removing prostate cancer, PSA levels should decrease and reach normal levels (less than 4 ng/mL). The regular measurement of PSA levels after treatment is important to evaluate the effectiveness of treatment and possible recurrence of prostate cancer.

Which best indicates that treatment for cancer of the prostate is effective? A. Increase in urinary stream B. Decrease of PSA to 2 ng/mL C. Decreased blood in the urine D. White blood cell (WBC) count of 10,000/μL

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters should also be monitored, but they are not directly associated with the patient's current symptoms.

Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

ANS: A The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

ANS: B The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify sources of hepatitis exposure.

ANS: D A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash are not used because they would damage the oral tissue.

Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? A. Firm-bristle toothbrush B. Hydrogen peroxide rinse C. Alcohol-based mouthwash D. 1 tsp salt in 1 L water mouth rinse

ANS: D 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.

Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? A. Acute pain B. Hypothermia C. Powerlessness D. Risk for infection

A patient with acromegaly is treated with a transsphenoidal hypophysectomy. What should the nurse do postoperatively? a. Ensure that any clear nasal drainage is tested for glucose. b. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leakage. c. Assist the patient with toothbrushing every 4 hours to keep the surgical area clean. d. Encourage deep breathing, coughing, and turning to prevent respiratory complications.

a. A transsphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip and gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates cerebrospinal fluid (CSF) leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica. Coughing and straining are avoided to prevent increased intracranial pressure and CSF leakage. Although mouth care is required every 4 hours, toothbrushing should not be performed because injury to the suture line may occur.

Which statement accurately describes Graves' disease? a. Exophthalmos occurs in Graves' disease. b. It is an uncommon form of hyperthyroidism. c. Manifestations of hyperthyroidism occur from tissue desensitization to the sympathetic nervous system. d. Diagnostic testing in the patient with Graves' disease will reveal an increased thyroid-stimulating hormone(TSH) level.

a. Exophthalmos or protrusion of the eyeballs may occur in Graves' disease from increased fat deposits and fluid in the orbital tissues and ocular muscles, forcing the eyeballs outward. Graves' disease is the most common form of hyperthyroidism. Increased metabolic rate and sensitivity of the sympathetic nervous system lead to the clinical manifestations. Thyroid-stimulating hormone (TSH) level is decreased in Graves' disease.

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function

a. maintaining a patent airway Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patients neuro status.

During discharge teaching for the patient with Addison's disease, which statement by the patient indicates that the nurse needs to do additional teaching? a. "I should always call the doctor if I develop vomiting or diarrhea." b. "If my weight goes down, my dosage of steroid is probably too high." c. "I should double or triple my steroid dose if I undergo rigorous physical exercise." d. "I need to carry an emergency kit with injectable hydrocortisone in case I can't take my medication by mouth."

b. A weight reduction in the patient with Addison's disease may indicate a fluid loss and a dose of replacement therapy that is too low rather than too high. Because vomiting and diarrhea are early signs of crisis and because fluid and electrolytes must be replaced, patients should notify their health care provider if these symptoms occur. Patients with Addison's disease are taught to take two to three times their usual dose of steroids if they become ill, have teeth extracted, or engage in rigorous physical activity and should always have injectablehydrocortisone available if oral doses cannot be taken.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to a. call the physician b. check the patient's temperature c. take the patient's BP d. elevate the HOB to 90 degrees

c. Take the patient's BP

A patient with mild iatrogenic Cushing syndrome is on an alternate-day regimen of corticosteroid therapy. What does the nurse explain to the patient about this regimen? a. It maintains normal adrenal hormone balance. b. It prevents ACTH release from the pituitary gland. c. It minimizes hypothalamic-pituitary-adrenal suppression. d. It provides a more effective therapeutic effect of the drug.

c. Taking corticosteroids on an alternate-day schedule for pharmacologic purposes is less likely to suppress ACTH production from the pituitary and prevent adrenal atrophy. Normal adrenal hormone balance is not maintained during glucocorticoid therapy because excessive exogenous hormone is used.

During assessment of the patient with acromegaly, what should the nurse expect the patient to report? a. Infertility b. Dry, irritated skin c. Undesirable changes in appearance d. An increase in height of 2 to 3 inches a year

c. The increased production of GH in acromegaly causes an increase in thickness and width of bones and enlargement of soft tissues, resulting in marked changes in facial features, oily and coarse skin, and speech difficulties. Infertility is not a common finding because GH is usually the only pituitary hormone involved in acromegaly. Height is not increased in adults with GH excess because the epiphyses of the bones are closed.

A patient who recently had a calcium oxalate renal stone had a bone density study, which showed a decrease in her bone density. What endocrine problem could this patient have? a. SIADH b. Hypothyroidism c. Cushing syndrome d. Hyperparathyroidism

d. The patient with hyperparathyroidism may have calcium nephrolithiasis, skeletal pain, decreased bone density, psychomotor retardation, or cardiac dysrhythmias. The other endocrine problems would not be related to calcium kidney stones or decreased bone density.