Chronic Medsurg Exam 3

Which of the following medications prescribed for a patient with acute gout requires an intervention by the nurse? 1. Allopurinol 2. Colchicine 3. Cortisone 4. Indocin

ANS: 1 1 Acute gout is never treated with uric acid-lowering agents such as allopurinol. For unknown reasons, a rapid change in serum uric acid levels may provoke or worsen a gout attack. 2 Acute gout management is focused on pain relief and reduction of inflammation. Common medications used include NSAIDs such as indomethacin (Indocin) and colchicine (Colcrys), which decrease the buildup of uric acid crystals in the joint. 3 Acute gout management is focused on pain relief and reduction of inflammation. Glucocorticoids, such as cortisone, are used to reduce inflammation and provide pain relief. 4 Acute gout management is focused on pain relief and reduction of inflammation. Common medications used include NSAIDs such as indomethacin (Indocin) and colchicine (Colcrys), which decrease the buildup of uric acid crystals in the joint.

A patient being evaluated for Guillain-Barré syndrome (GBS) presents with bilateral symmetrical muscle weakness and sensory changes of both feet and legs. The nurse correlates which key finding to this disease process? 1. Areflexia 2. Hyperreflexia 3. Hypothermia 4. Hyperanalgesia

ANS: 1 1 After the first few days of weakness, neurological assessment demonstrates diminished or absent deep tendon reflexes (areflexia). Areflexia is recognized as a key finding in GBS. 2 After the first few days of weakness, neurological assessment demonstrates diminished or absent deep tendon reflexes (areflexia). Areflexia is recognized as a key finding in GBS. 3 There is no evidence that the patient with GBS will develop hypothermia. 4 There is no evidence to suggest that the patient with GBS will have a heightened pain response.

A patient is recovering from a thyroidectomy. Which observation needs to be reported immediately to the healthcare provider? 1. Changes in voice tone 2. Hypoactive bowel sounds 3. Blood pressure 138/70 mm Hg 4. Incisional pain

ANS: 1 1 Assessing for damage to the laryngeal nerve is also a priority in the postoperative period after thyroidectomy. Changes in voice quality, particularly hoarseness or a husky tone, may be indicative of laryngeal nerve damage. 2 Hypoactive bowel sounds could be caused by general anesthesia. 3 Blood pressure of 138/70 mm Hg could be within normal limits for this patient. 4 Postoperative pain would be expected in the perioperative period.

A patient spontaneously develops manifestations of hypoparathyroidism. The nurse correlates which data from the patient's history as the cause for this health problem? 1. Diabetes mellitus 2. Thyroid hypertrophy 3. Low intake of calcium-rich foods 4. Congenital absence of parathyroid glands

ANS: 1 1 Autoimmune disease is suspected in patients with spontaneous presentation of hypoparathyroidism with no identifiable cause. In these cases, antiparathyroid antibodies have been detected in patients with other autoimmune disorders such as diabetes mellitus. 2 Thyroid hypertrophy would cause hyperthyroidism. 3 A low intake of calcium-rich foods does not cause hypoparathyroidism. 4 The patient would have experienced symptoms at birth if the parathyroid glands were congenitally absent.

The nurse suspects that a patient with type 2 diabetes mellitus is experiencing autonomic neuropathy. What did the nurse assess to make this clinical determination? 1. Bloating 2. Foot pain 3. Tingling of the fingers 4. Numbness of the lower legs

ANS: 1 1 Autonomic neuropathy results when there is damage to the nerves of the autonomic nervous system. Common manifestations include diabetic gastroparesis, which results when the nerves that enervate the stomach are damaged, leading to delayed or erratic emptying of stomach contents into the intestine. Clinical manifestations include symptoms such as bloating. 2 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include pain. 3 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include tingling. 4 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include numbness.

The nurse is caring for a patient with myasthenia gravis. Which assessment data provide the nurse with the earliest indication of the patient's potential respiratory deterioration? 1. Vital capacity 2. Pulse oximetry 3. Breath sounds 4. Arterial blood gas analysis

ANS: 1 1 Because of the potential for respiratory weakness, a bedside vital capacity testing is performed. Vital capacity is defined as the maximum amount of air exhaled after maximal inhalation. 2 Pulse oximetry data would be a later sign of deteriorating respiratory status because of impaired breathing secondary to muscle weakness. It is not helpful in determining respiratory deterioration in a patient with myasthenia gravis because failure is due to weakness of the diaphragm and intercostal muscles. Changes in oxygenation and ventilation is a later sign secondary to decreased vital capacity. 3 Breath sounds do not provide information about respiratory functioning based on muscle strength. 4 An arterial blood gas may be ordered if the patient's respiratory status deteriorates, but changes in oxygenation/ventilation would be a later sign compared with decreased vital capacity in the patient with myasthenia gravis.

A patient with hypothyroidism is prescribed levothyroxine (Synthroid). At which time should the nurse schedule this medication to be administered? 1. 0800 hours 2. 1200 hours 3. 1700 hours 4. 2300 hours

ANS: 1 1 Because thyroid hormone affects metabolism, the medication is to be taken in the morning. 2 This medication should be taken in the morning. 3 This medication should be taken in the morning. 4 This medication should be taken in the morning.

A patient is newly diagnosed with type 2 diabetes mellitus. The nurse correlates which medication classification's mechanism of action as decreasing glucose production in the liver? 1. Biguanides 2. Meglitinides 3. Sulfonylureas 4. Alpha-glucosidase inhibitors

ANS: 1 1 Biguanides work by decreasing glucose production in the liver and increasing insulin sensitivity in skeletal muscle. 2 Meglitinides stimulate the beta cells to produce more insulin. 3 Sulfonylureas stimulate the beta cells to produce more insulin. 4 Alpha-glucosidase inhibitors slow the breakdown and absorption of sugars and starches.

The nurse correlates which clinical manifestation in a patient with type 2 diabetes mellitus (DM) with macrovascular complications? 1. Chest pain 2. Sight impairment 3. Gingival hyperplasia 4. Chronic kidney failure

ANS: 1 1 Complications from diabetes are classified as macrovascular and microvascular. Macrovascular complications involve damage to the large arteries that supply the heart and brain. Chest pain or angina is a symptom that can indicate a macrovascular complication affecting the cardiovascular system for the patient who is diagnosed with type 2 diabetes mellitus (DM). 2 Complications from diabetes are classified as macrovascular and microvascular. Macrovascular complications involve damage to the large arteries that supply the heart and brain. Microvascular complications involve damage done to the small blood vessels. Impaired sight is a microvascular, not macrovascular, complication associated with type 2 DM. 3 Complications from diabetes are classified as macrovascular and microvascular. Macrovascular complications involve damage to the large arteries that supply the heart and brain. Microvascular complications involve damage done to the small blood vessels. Gingival hyperplasia is a microvascular, not macrovascular, complication associated with type 2 DM. 4 Complications from diabetes are classified as macrovascular and microvascular. Macrovascular complications involve damage to the large arteries that supply the heart and brain. Microvascular complications involve damage done to the small blood vessels. Chronic kidney disease is a microvascular, not macrovascular, complication associated with type 2 DM.

A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further teaching? 1. "I am relieved that I can still attend concerts with my friends. " 2. "I should avoid getting the flu shot." 3. "I will use contraception to avoid pregnancy." 4. "I will report any symptoms of infection immediately."

ANS: 1 1 Crowds may increase exposure to infection. 2 Patients at risk for infections because of treatment should not receive live vaccines if on immunosuppressive therapy. Annual influenza vaccination is recommended but patients with significant immunosuppression should not receive live vaccines. 3 Immunosuppressive drugs may increase the risk of birth defects. 4 Chills, fever, sore throat, fatigue, or malaise should be reported.

The nurse prioritizes which nursing diagnosis to guide care for the patient diagnosed with diabetes insipidus? 1. Fluid Volume Deficit 2. Alteration in Comfort 3. Body Image Disturbance 4. Sensory Perceptual Alteration

ANS: 1 1 Diabetes insipidus, caused by a lack of antidiuretic hormone, results in excretion of large volumes of dilute urine. 2 The patient might be uncomfortable because of dehydration, but this is not the priority if the patient has decreased fluid volume. 3 Diabetes insipidus is not associated to changes in appearance. Body Image Disturbance may be appropriate for the patient with hyperpituitarism. 4 Sensory perception alterations related to vision changes may be seen in patients with pituitary tumors. This requires further follow-up, but the loss of fluid is a higher priority.

The nurse correlates which laboratory value to a patient diagnosed with hypoparathyroidism? 1. Serum phosphate 5.5 mg/dL 2. Serum magnesium 3.0 mg/dL 3. Serum potassium 3.2 mEq/L 4. Serum albumin 4.0 g/dL

ANS: 1 1 Diagnostic results consistent with hypoparathyroidism include low serum calcium levels, high serum phosphate levels, and low serum parathyroid hormone (PTH) levels. 2 Serum magnesium levels are often evaluated to rule out hypomagnesemia as the cause of hypoparathyroidism because low serum magnesium levels inhibit synthesis of PTH. This is an elevated magnesium. 3 Hypokalemia is not associated with hypoparathyroidism. 4 Serum albumin levels are monitored because the majority of serum calcium is plasma protein bound; however, in hypoparathyroidism the serum albumin level is low. This is a normal albumin.

A patient with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which clinical manifestation should the nurse expect to be most affected with this medication? 1. Tremors 2. Mood instability 3. Impaired balance 4. Behavioral changes

ANS: 1 1 Dopamine precursors such as carbidopa/levodopa (Sinemet) are later used and are most effective in the treatment of tremors, bradykinesia, and rigidity. 2 Dopamine precursors are not identified to target mood instability. 3 Dopamine precursors are not identified to target impaired balance. 4 Dopamine precursors are not identified to target behavioral changes.

The nurse correlates flank pain to which disorder in the patient with hyperparathyroidism? 1. Renal calculi 2. Muscle spasms 3. Adrenal gland dysfunction 4. Elevated phosphorous level

ANS: 1 1 Elevated serum calcium levels caused by hyperparathyroidism can lead to renal calculi. Manifestations of renal calculi include flank pain. 2 Muscle spasms are not typically associated with flank pain. 3 Adrenal gland dysfunction does not typically cause flank pain. 4 Elevated phosphorous levels do not cause flank pain.

A patient is admitted for treatment of Cushing's syndrome. The nurse correlates this disease process to which alteration in endocrine function? 1. Elevated glucocorticoid level 2. Elevated aldosterone secretion 3. Decreased glucocorticoid level 4. Decreased aldosterone secretion

ANS: 1 1 Excessive secretion of glucocorticoids causes Cushing's syndrome. 2 Excessive secretion of aldosterone causes Conn's syndrome. 3 Decreased glucocorticoid level causes Addison's disease. 4 Decreased aldosterone secretion causes Addison's disease.

The nurse is preparing discharge instructions for a patient being treated medically for hyperthyroidism. What should the nurse emphasize to protect the patient's eyes? 1. Use artificial tears. 2. Wear sunglasses at all times. 3. Wear eye shields at all times. 4. Tape the eyes closed at bedtime.

ANS: 1 1 Eye lubricant decreases possible eye dryness and potential for corneal irritation secondary to incomplete eyelid closure. 2 Sunglasses do not need to be worn at all times. 3 Wearing eye shields at all times severely reduces this patient's vision and would not be recommended. 4 The eyes should not be taped shut.

The nurse correlates which etiology to a diagnosed low-energy fracture in a 65-year-old patient? 1. A fall 2. Golfing 3. Bicycle accident 4. Motor vehicle collision

ANS: 1 1 Fractures in people 65 or older are generally caused by low-energy trauma such as falls. 2 Golfing is a noncontact sport but does not increase the risk of a low-energy fracture. 3 Bicycle accidents are a type of high-energy trauma. 4 Motor vehicle collisions are a type of high-energy trauma.

The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? 1. Administer gabapentin 2. Turn and reposition every 2 hours 3. Apply sequential compression devices 4. Perform passive range-of-motion exercises several times a day

ANS: 1 1 Gabapentin may be used to relieve neuropathic pain. 2 Frequent repositioning promotes comfort and prevents complications of immobility including thromboembolism and impaired skin integrity. 3 Sequential compression devices prevent venous stasis. 4 Range-of-motion exercises promote joint mobility and function.

The nurse develops the nursing diagnosis "Altered Comfort related to inflammation and pain secondary to urate crystals in the joints and tissues." For which disorder is this nursing diagnosis most relevant? 1. Gout 2. Osteoarthritis 3. Rheumatoid arthritis 4. Scleroderma

ANS: 1 1 Gout is a disease in which monosodium urate crystals are deposited in joints, bone, and soft tissues accompanied by inflammation. 2 Osteoarthritis is primarily a noninflammatory type of arthritis that results from weight-bearing, trauma, infection, and overuse. Damage occurs within the joint, which leads to the deterioration of joint function. 3 Rheumatoid arthritis is an autoimmune inflammatory disease that not only affects joints but may also affect other organ systems. Inflammation within each organ system is what causes organ or tissue damage. 4 Small-vessel vasculopathy (diseases affecting blood vessels), pathological accumulation of collagen, and autoimmunity cause the disease manifestations associated with scleroderma.

A patient with type 1 diabetes mellitus develops symptoms of hypoglycemia only when the blood glucose level drops to 40 mg/dL. What is the recommended action for this complication? 1. Raise glycemic targets. 2. Cut the insulin dose in half. 3. Add an extra snack to the meal plan. 4. Eliminate the evening dose of insulin.

ANS: 1 1 If patients have "hypoglycemia unawareness," they will not experience symptoms of low blood glucose until their blood glucose levels fall to the point where they are at risk for neurological symptoms, such as confusion or loss of consciousness. Individuals with hypoglycemia unawareness should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of further episodes. 2 Cutting the insulin dose will not reverse hypoglycemia unawareness. 3 Adding an extra snack to the meal plan will not reverse hypoglycemia unawareness. 4 Eliminating a dose of insulin will not reverse hypoglycemia unawareness.

A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? 1. Elevated protein level 2. Elevated glucose level 3. Reduction in white blood cell count 4. Increased number of red blood cells

ANS: 1 1 In GBS, cerebrospinal fluid findings include an elevated protein level. 2 In GBS, there is no evidence to suggest that glucose is elevated in the cerebrospinal fluid. 3 In GBS, the cell count in the cerebrospinal fluid is normal. 4 In GBS, the cell count in the cerebrospinal fluid is normal.

A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. The nurse correlates these clinical manifestations to which type of multiple sclerosis? 1. Relapsing-remitting 2. Primary progressive 3. Progressive relapsing 4. Secondary progressive

ANS: 1 1 In relapsing-remitting multiple sclerosis, relapses or exacerbations occur during which new symptoms appear and old ones worsen or reappear; these relapses can last days or months. 2 Primary progressive multiple sclerosis has gradual progression with no remissions. 3 Progressive relapsing multiple sclerosis has a gradual worsening of symptoms from onset, and the relapses may or may not have recovery. 4 Secondary progressive multiple sclerosis is when the patient initially had relapsing-remitting but it gradually becomes worse.

The nurse monitors for which clinical manifestation in the patient diagnosed with hyperthyroidism? 1. Insomnia 2. Bradycardia 3. Cold intolerance 4. Decreased appetite

ANS: 1 1 Insomnia is a clinical manifestation the nurse anticipates when assessing the patient who is diagnosed with hyperthyroidism. 2 Tachycardia, not bradycardia, is a clinical manifestation the nurse anticipates when assessing the patient who is diagnosed with hyperthyroidism. 3 Heat, not cold, intolerance is a clinical manifestation the nurse anticipates when assessing the patient who is diagnosed with hyperthyroidism. 4 An increased, not decreased, appetite is a clinical manifestation the nurse anticipates when assessing the patient who is diagnosed with hyperthyroidism.

A nurse is caring for a patient with systemic lupus erythematosus (SLE). Which intervention does the nurse plan to teach this patient to minimize skin infections associated with SLE? 1. Use sunscreen with an SPF of 50 or greater 2. Remain indoors on sunny days 3. Avoid swimming in a pool or the ocean 4. Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

ANS: 1 1 Nonpharmacological interventions for SLE include avoiding prolonged sun exposure and using sunscreen (SPF 50 or higher) on a daily basis. 2 The patient does not need to stay indoors on sunny days as long as prolonged sun exposure is avoided and sunscreen used. 3 The patient may swim but should reapply sunscreen after swimming. 4 The patient does not need to decrease sun exposure between 3:00 p.m. and 5:00 p.m. The key is to avoid prolonged sun exposure and using sunscreen.

The nurse provides care for a patient who is admitted to the cardiac care unit for a coronary artery bypass graft (CABG). The patient has a history of osteoarthritis. Which medication does the nurse question if prescribed by the healthcare provider? 1. Ibuprofen (Advil) 2. Fentanyl (Duragesic) 3. Morphine (MS Contin) 4. Acetaminophen (Tylenol)

ANS: 1 1 Nonsteroidal anti-inflammatory drug (NSAIDs) (e.g., ibuprofen) may cause an increased risk of serious cardiovascular thrombotic events such as myocardial infarction, stroke, and renal insufficiency, especially in a "stressed" kidney (a patient with pre-existing risk factors such as dehydration, or a patient with already compromised renal function), and serious GI-adverse events including bleeding, ulceration, and perforation of the stomach. They are contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft surgery and patients in renal failure. 2 Opioid analgesics, like fentanyl and morphine, are appropriate for moderate to severe pain and would not be questioned by the nurse. 3 Opioid analgesics, like fentanyl and morphine, are appropriate for moderate to severe pain and would not be questioned by the nurse. 4 Acetaminophen is appropriate for mild pain and would not be questioned by the nurse.

A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness. The nurse recognizes which treatment is indicated for this patient? 1. Fasciotomy 2. Skeletal traction 3. Intravenous fluids 4. Patient-controlled pain management

ANS: 1 1 Once compartment syndrome is suspected, the provider will often remove the cast or perform a fasciotomy to immediately relieve the compartment pressure. 2 This patient has clinical manifestations of compartment syndrome so establishing perfusion is the priority. There is no indication for skeletal traction until circulation is established. 3 Intravenous fluids might be indicated if the patient is hypovolemic, but treating the pulselessness is the priority. 4 Pain control is important, but establishing circulation is the priority.

Which patient statement best indicates correct understanding of the teaching regarding actions to be taken during an episode of hypoglycemia in a patient recently diagnosed with type 1 diabetes mellitus (DM)? 1. "I will eat a cracker." 2. "I will drink a diet soda." 3. "I will eat some ice cream." 4. "I will drink a cup of whole milk."

ANS: 1 1 Oral glucose (15-20 g) administration is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Juice, soda, bread, or crackers work well. This statement indicates understanding of the priority action taken during episodes of hypoglycemia. 2 Oral glucose (15-20 g) administration is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Juice, soda, bread, or crackers work well. Diet soda does not contain glucose; therefore, this statement does not indicate understanding of the action taken during episodes of hypoglycemia. 3 Oral glucose (15-20 g) administration is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Carbohydrates that contain fat, such as ice cream, are not recommended. Pure glucose is the preferred treatment because fat may retard glucose absorption, prolonging the acute hypoglycemic event. This statement does not indicate understanding of the priority action taken during episodes of hypoglycemia. 4 Oral glucose (15-20 g) administration is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Juice, soda, bread, or crackers work well. Carbohydrates that contain fat, such as whole milk, are not recommended.

The nurse monitors for which clinical manifestations in the patient diagnosed with bone cancer? 1. Limp 2. Muscle atrophy 3. Skin discoloration 4. Dependent edema

ANS: 1 1 Pain may cause the patient to limp. 2 Muscle atrophy is not a manifestation of bone cancer. 3 Skin discoloration is not a manifestation of bone cancer. 4 Although swelling is associated with bone cancer, dependent edema does not typically occur.

The nurse monitors for which clinical manifestation in the patient diagnosed with dry macular degeneration? 1. Blurred vision 2. Increased intraocular pressure 3. Loss of peripheral vision 4. Sudden onset of light flashes

ANS: 1 1 Patients with advanced dry macular degeneration have breakdown of light-sensitive cells and supporting tissue in the central retinal area, with the presence of drusen bodies also noted on examination. The breakdown can cause a blurred spot in the center of vision that will gradually get bigger and darker, taking up much of the central vision. 2 Increased intraocular pressure (IOP) is a clinical manifestation of glaucoma. 3 Loss of central vision is a clinical manifestation of dry macular degeneration. 4 Patients with retinal detachment may experience sudden onset of light flashes or the appearance of a curtain over the field of vision.

A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. The nurse monitors this patient for which complication of this treatment? 1. Septicemia 2. Flu-like symptoms 3. Aseptic meningitis 4. Acute renal failure

ANS: 1 1 Plasmapheresis increases the risk for infection. Septicemia is a complication of plasmapheresis. 2 Flu-like symptoms are associated with intravenous immunoglobulin therapy. 3 Aseptic meningitis is associated with intravenous immunoglobulin therapy. 4 Acute renal failure is associated with intravenous immunoglobulin therapy.

A patient with hyperthyroidism is prescribed propylthiouracil (PTU). The nurse includes which formation about the mechanism of action of this medication in the teaching plan? 1. Diverts iodine pathways 2. Causes formation of thyroid antibodies 3. Decreases the vascularity of the thyroid gland 4. Blocks iodine from binding with thyroglobulin

ANS: 1 1 Propylthiouracil (PTU) inhibits the synthesis of thyroid hormone by diverting iodine pathways. 2 Lithium carbonate (Lithonate) can cause thyroid antibodies. 3 Iodine decreases the vascularity of the thyroid gland. 4 Methimazole (Tapazole) blocks the combination of iodine with a protein called thyroglobulin.

A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by ethnicity. Which response by the nurse is the most appropriate? 1. "RA affects females more often than males" 2. "RA affects about 10% of the population." 3. "The onset of RA is usually in the sixth decade." 4. "RA is most prevalent in men younger than age 20 years."

ANS: 1 1 Rheumatoid arthritis (RA) is three times more prevalent in females than males. 2 Rheumatoid arthritis (RA) affects approximately 1% of the population. 3 The onset of Rheumatoid arthritis (RA) may occur at any age but is most common in the third through fifth decades, with incidence increasing after the sixth decade. 4 Rheumatoid arthritis (RA) affects women three times more than men, and the onset is usually between the ages of 20 and 40 years.

The nurse is reviewing orders written for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which order should the nurse question? 1. No added salt diet 2. Fluid restriction 1 L/day 3. Intravenous fluids 0.9% normal saline 125 mL/hour 4. Furosemide (Lasix) 20 mg by mouth every day

ANS: 1 1 SIADH results in hyponatremia secondary to excessive secretion of ADH. Medical management is primarily focused on treating the hyponatremia and the nurse should question a no added salt diet. 2 The patient is placed on a fluid restriction, usually less than 1,000 mL/day, to concentrate serum sodium. 3 Intravenous administration of a saline solution would be expected to increase serum sodium levels. 4 Diuretics may be administered to increase urine output as SIADH is associated with excessive fluid retention.

A patient is scheduled for a cochlear implant. Which patient statement indicates that teaching about this surgery has been effective? 1. "This implant will enhance my ability to understand speech." 2. "I will be able to hear perfectly after this surgery." 3. "This surgery will drain fluid from my middle ear." 4. "This surgery will rebuild my damaged tympanic membrane."

ANS: 1 1 The acoustic reflex is a test that notes the response of the stapedius muscle to the presence of loud sound. 2 The cochlear implant does not restore normal hearing. 3 A myringotomy drains fluid from the middle ear. 4 A myringoplasty reconstructs the eardrum.

Which prescribed medication for the patient recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain? 1. Gabapentin 2. Ibuprofen 3. Opioids 4. Muscle relaxants

ANS: 1 1 The administration of antidepressant and anticonvulsant medications such as gabapentin has demonstrated effectiveness in treating phantom limb pain. 2 Pain medications like NSAIDs and opioids are not indicated for the treatment of phantom limb pain. 3 Pain medications like NSAIDs and opioids are not indicated for the treatment of phantom limb pain. 4 Muscle relaxants may be prescribed, but they are not effective in the treatment of phantom pain.

A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing a headache and confusion. The nurse correlates which laboratory result to this clinical presentation of SIADH? 1. Sodium 125 mEq/L 2. Calcium 8.7 mEq/L 3. Potassium 5.5 mEq/L 4. Hematocrit 50%

ANS: 1 1 The clinical presentation of the patient with SIADH is primarily related to the resultant hyponatremia. The neurological signs associated with the hyponatremia are related to osmotic fluid shifts in the brain that lead to cerebral edema and increased intracranial pressure. 2 The manifestations of SIADH are not caused by a calcium imbalance. Changes in calcium levels are associated with disorders of the parathyroid glands. 3 The manifestations of SIADH are not caused by a potassium imbalance. Changes in potassium balance are associated with adrenal disorders. 4 The manifestations of SIADH are not caused by a change in hematocrit level. Because of excessive fluid retention in SIADH, the hematocrit may be decreased, not elevated.

A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? 1. Rigidity with ambulation 2. Unremarkable electroencephalogram 3. Results of basic metabolic panel and complete blood count (CBC) 4. Integrity of cerebral vessels after a cerebral angiogram

ANS: 1 1 The diagnosis of Parkinson's disease is made when two or more cardinal symptoms with asymmetrical presentation—such as rigidity—are observed in the absence of other causes. Progressive decline in motor function accompanied by rigidity is typically how the diagnosis is made. 2 There are no specific diagnostic studies to confirm Parkinson's disease. This would not be documented in this patient's medical record. 3 There are no specific diagnostic studies to confirm Parkinson's disease. This would not be documented in this patient's medical record. 4 There are no specific diagnostic studies to confirm Parkinson's disease. This would not be documented in this patient's medical record.

A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most appropriate? 1. "The onset of OA is gradual, whereas the onset of RA may be rapid." 2. "With OA, multiple joints are symmetrically affected; RA affects one joint at a time." 3. "The affected joints in RA feel cold to the touch, whereas the joints affected by OA are warm or hot to the touch." 4. "The pain and stiffness with RA is with activity; OA pain and stiffness is predominant on arising."

ANS: 1 1 The onset of OA is gradual, whereas the onset of RA may be rapid. 2 RA affects multiple joints symmetrically, whereas OA affects one joint at a time. 3 The affected joints in OA feel cold to the touch, whereas the joints affected by RA are warm or hot to the touch. 4 Pain associated with RA is predominant on arising versus the pain in OA, which is with activity.

A patient with hyperthyroidism is placed on seizure precautions as a result of which observation? 1. Serum sodium 120 mEq/L 2. Serum glucose 200 mg/dL 3. Rapid heart rate 4. Increased T3 and T4 levels

ANS: 1 1 The patient is at an increased risk for seizure activity related to hyponatremia. 2 Hyperglycemia does not cause seizures. 3 A rapid heart rate is a manifestation of hypermetabolism but will not directly cause seizures. 4 Increased T3 and T4 levels are diagnostic for hyperthyroidism; however, they do not directly cause seizures.

The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse emphasize regarding medications? 1. Keep extra doses of medication in the car. 2. Store extra doses of medication in the refrigerator. 3. Take an extra dose of medication if a dose is missed . 4. Pack prescribed medications in a suitcase before departing to ensure they arrive.

ANS: 1 1 The patient should be instructed to keep medication available at all times. Spare doses should be kept in the car. 2 Extra doses of the medication do not need to be stored in the refrigerator. 3 The medication should be taken as prescribed. Efforts should be taken to not miss doses and not to take extra doses. 4 When the patient travels, medication should remain with the patient in carry-on luggage.

The nurse provides discharge instructions for a patient who experienced a traumatic amputation of the leg below the knee. Which patient statement indicates the need for further teaching? 1. "I will elevate my leg with a pillow." 2. "I will need to start wrapping my stump 1 to 3 days after surgery." 3. "I will eat foods high in protein and carbohydrates." 4. "I will apply ice to the area for no more than 15 to 20 minutes at a time."

ANS: 1 1 The patient should be taught to refrain from using a pillow under the remaining portion of the lower extremity because this prevents the development of flexion contractures that can occur if a pillow is left under the extremity. Therefore, this patient statement indicates a need for additional teaching. 2 This statement indicates patient understanding because the stump needs to start being wrapped with a compression dressing 1 to 3 days postoperatively. 3 Sufficient dietary intake of proteins and carbohydrates allows for adequate healing of bone, muscle, and skin. Therefore, this patient statement indicates a correct understanding of the information presented. 4 The application of ice promotes vasoconstriction and decreases painful edema. Therefore, this patient statement indicates a correct understanding of the information presented.

A patient is prescribed regular insulin 5 units subcutaneous injection now. Which syringe should the nurse use for this dose if all are readily available? 1. U-30 2. U-50 3. U-100 4. U-500

ANS: 1 1 The patient should choose the insulin syringe size according to the insulin dosage. Using the U-30 syringe allows a more accurate measurement of insulin to be administered. 2 The patient should choose the insulin syringe size according to the insulin dosage. This syringe could be used if the U-30 syringe is not available. 3 The patient should choose the insulin syringe size according to the insulin dosage. This syringe might be difficult to correctly measure 5 units of insulin because 1 mL of medication is equal to 100 units of insulin. 4 The patient should choose the insulin syringe size according to the insulin dosage. A U-500 syringe should only be used for large insulin doses.

A patient with a 20-year history of type 1 diabetes is admitted to the emergency department with changes in level of consciousness. Serum electrolytes and arterial blood gases (ABGs) are obtained. The ABG results are as follows: pH 7.28 PaO2 92 PaCO2 30 HCO3 19 O2 Sat 95% The nurse documents these results as: 1. Partially compensated metabolic acidosis 2. Fully compensated metabolic acidosis 3. Partially compensated respiratory alkalosis 4. Fully compensated respiratory alkalosis

ANS: 1 1 This is a partially compensated metabolic acidosis because the pH is acidotic (less than 7.35), the HCO3 is acidotic (matches the pH), and PaCO2 is compensating (alkalotic, less than 22 mEq/L). 2 Fully compensated acidosis would produce a pH within the normal range of 7.35 to 7.45. 3 Partially compensated respiratory alkalosis would produce an alkalotic pH. The pH in this patient is acidotic. 4 Fully compensated respiratory alkalosis would produce an alkalotic pH. The pH in this patient is acidotic.

The nurse provides education to a patient who is diagnosed with osteoporosis and prescribed ibandronate (Boniva). Which patient statement indicates the need for additional teaching? 1. "I will take my medication with food." 2. "I will take the medication once a month." 3. "My doctor told me that the medication may cause heartburn." 4. "My doctor told me that I can receive the medication by IV every 3 months."

ANS: 1 1 This medication should be taken on an empty stomach; therefore, this statement indicates a need for additional teaching. 2 When the medication is prescribed orally, it is administered once per month; therefore, this statement indicates an accurate understanding of the information presented. 3 This medication is known to cause gastrointestinal disturbance; therefore, this statement indicates an accurate understanding of the information presented. 4 This medication can be given orally, once per month, or intravenously (IV) every 3 months; therefore, this statement indicates an accurate understanding of the information presented.

The nurse provides education to a patient with rheumatoid arthritis who is prescribed methotrexate by the healthcare provider. Which patient statement indicates to the nurse the need for further teaching? 1. "I can have a glass of wine each night with dinner." 2. "I will take folic acid each day to decrease my risk of mouth ulcers." 3. "I will continue to take my oral contraception to prevent pregnancy." 4. "I didn't have to decrease my medication dose because my kidney tests came back okay."

ANS: 1 1 This patient statement indicates a need for additional teaching. The patient is taught to avoid alcohol while taking this medication because of the risk of hepatotoxicity. 2 This patient statement indicates a correct understanding of the information presented. Patients are encouraged to take folic acid daily to prevent side effects such as oral ulcers. 3 This patient statement indicates a correct understanding of the information presented. Female patients are counseled on proper birth control methods because of significant risk of teratogenicity (the capability of producing fetal malformation). 4 This patient statement indicates a correct understanding of the information presented. Patients with renal insufficiency require lower doses of methotrexate.

A patient with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement by the patient indicates that further teaching is needed about this treatment? 1. "This medication will cure my disease." 2. "This medication may delay the need to be on a ventilator." 3. "This medication works on nerve conduction." 4. "This medication may decrease the progression of my disease."

ANS: 1 1 This statement indicates the need for additional teaching because riluzole does not cure the disease. Because no cure exists, management focuses on slowing disease progression and managing clinical manifestations. Riluzole (Rilutek) is the first medication approved to slow disease progression. 2 This statement indicates patient understanding of this medication. Riluzole (Rilutek) does not repair damaged neurons but has been shown to increase survival and to extend the period without the need for ventilator support. 3 This statement indicates patient understanding of this medication. Riluzole (Rilutek) does not repair damaged neurons but has been shown to increase survival and to extend the period without the need for ventilator support. 4 This statement indicates patient understanding of this medication. Riluzole (Rilutek) is the first drug approved to slow disease progression.

Which statement by the patient with multiple sclerosis (MS) indicates the need for additional teaching? 1. "MS causes my nerves to die." 2. "There is no cure for MS." 3. "MS is caused by damage to the covering of the spinal cord." 4. "Physical therapy may help me with my MS."

ANS: 1 1 This statement indicates the need for additional teaching. MS does not cause the nerves to die. In MS, there is demyelination (loss of the myelin sheath) around the spinal cord that impacts nerve conduction. 2 This statement indicates patient understanding. There is no cure for MS. Treatment often focuses on improving the speed of recovery from attacks, reducing the number of attacks, and slowing the progression of the disease. 3 This statement indicates patient understanding. MS is caused by demyelination of the spinal cord. 4 This statement indicated patient understanding. Patients with MS are treated with physical therapy.

Which patient statement indicates to the nurse the need for further teaching regarding the new diagnosis of type 1 diabetes mellitus (DM)? 1. "I will need to take medication by mouth until my blood sugar is within normal limits again." 2. "The things that I eat may impact the dose of my medication used to control my blood glucose." 3. "If I get the flu, the dose of my insulin may need to be altered to control my blood glucose." 4. "I will monitor my blood glucose to help determine whether my medication is working as anticipated."

ANS: 1 1 This statement indicates the need for further education because lifelong insulin administration is required for cellular metabolism in patients with type 1 diabetes mellitus (DM). 2 Increased stress, infection, activity level, increased ingestion of carbohydrates, and decreased oral intake all alter insulin requirements. This patient statement indicates a correct understanding of the information presented during medication education for the new diagnosis of type 1 DM. 3 Increased stress, infection, activity level, increased ingestion of carbohydrates, and decreased oral intake all alter insulin requirements. This patient statement indicates a correct understanding of the information presented during medication education for the new diagnosis of type 1 DM. 4 Regular blood glucose checks help determine the adequacy of the medication regimen and maintain glycemic targets. This patient statement indicates a correct understanding of the information presented during medication education for the new diagnosis of type 1 DM.

The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which patient statement indicates an appropriate understanding of the plan of care? 1. "I will need to use birth control methods while I am taking cytotoxic medications." 2. "I do not need to be concerned with a fever or rash because these are expected with this disorder." 3. "I plan to go to the movies this weekend so that I get out of the house." 4. "I can take aspirin as indicated for pain."

ANS: 1 1 Treatment for SLE can include cytotoxic drugs. Immunosuppressive agents such as methotrexate may be necessary to treat joint inflammation, which does not respond to nonsteroidal anti-inflammatories or steroids. The patient is taught to avoid pregnancy by using contraceptives because these drugs can cause birth defects. 2 Because their immune system is compromised, patients with SLE should contact their primary care providers should manifestations of infection occur. 3 The patient is taught to avoid crowds because they are potential sources of infection. 4 Aspirin can cause bleeding and should be taken with extreme care.

The nurse is reviewing type 1 diabetes mellitus with a group of patients newly diagnosed with the disorder. What should the nurse explain as the major cause for the disorder? 1. Autoimmune process 2. Cancer of the pancreas 3. Alteration in lipid and protein utilization 4. Malfunction of carbohydrate metabolism

ANS: 1 1 Type 1 diabetes mellitus (DM) is typically triggered by an autoimmune process in which the insulin-producing beta cells of the pancreas are destroyed, resulting in an absolute lack of insulin. 2 If part of the pancreas is removed for cancer, the patient can develop type 1 diabetes mellitus, but this is not the primary cause of type 1 DM in adults. 3 Type 1 diabetes is not caused by an alteration in lipid and protein utilization. 4 Type 1 diabetes is not caused by a malfunction in carbohydrate metabolism.

While playing tennis a patient fell and sustained a nondisplaced fracture of the right elbow. The nurse prepares the patient for which treatment? 1. Closed reduction and cast 2. Splint 3. External fixator 4. Pressure dressing

ANS: 1 1 A nondisplaced elbow fracture is treated with closed reduction and immobilized with a cast. A displaced elbow fracture is treated with operative open reduction and internal fixation (ORIF). 2 Splints are a form of nonrigid immobilization to maintain alignment of bone fragments and would not be effective with this elbow fracture. A fractured forearm or clavicle could be immobilized with a splint. 3 External fixation is the application of a series of rods and pins to the area surrounding the fracture, creating an external frame to stabilize and align the displaced fragments. A fractured wrist may need to be immobilized with an external fixator. 4 A fractured wrist may be immobilized with a pressure dressing.

The nurse correlates which laboratory values to the patient diagnosed with primary hypothyroidism? Select all that apply. 1. Decreased T3 2. Decreased T4 3. Decreased serum calcium 4. Decreased TSH 5. Decreased serum glucose

ANS: 1, 2 1 This is correct. Primary hypothyroidism is diagnosed with decreased T3 and T4 levels. 2 This is correct. Primary hypothyroidism is diagnosed with decreased T3 and T4 levels. 3 This is incorrect. Hypocalcemia is not diagnostic for primary hypothyroidism. 4 This is incorrect. In primary hypothyroidism, the thyroid-stimulating hormone (TSH) level is elevated as a result of the feedback system to the hypothalamus and anterior pituitary gland caused by low circulating levels of thyroid hormones (T3 and T4). 5 This is incorrect. Decreased serum glucose is not associated with hypothyroidism.

A patient with hypothyroidism is recovering from orthopedic surgery. Which findings suggest that this patient is developing myxedema coma? Select all that apply. 1. Hypoxia 2. Slow heart rate 3. Low body temperature 4. Elevated blood pressure 5. PaCO2 32 mm Hg

ANS: 1, 2, 3 1 This is correct. The most severe type of hypothyroidism is myxedema coma and is characterized by hypoxia. 2 This is correct. Because of significant decreases in cardiac function, the patient with myxedema is bradycardic. 3 This is correct. The most severe type of hypothyroidism is myxedema coma and is characterized by hypothermia. 4 This is incorrect. Because of significant decreases in cardiac function, the patient is hypotensive. 5 This is incorrect. The most severe type of hypothyroidism is myxedema coma and is characterized by carbon dioxide retention (elevated PaCO2.). This value is low.

The nurse monitors for which clinical manifestations in the patient with hypothyroidism? Select all that apply. 1. Fatigue 2. Weight gain 3. Increased sleep 4. Decreased energy 5. Increased appetite

ANS: 1, 2, 3, 4 1 This is correct. The hypometabolic state is characterized by fatigue. 2 This is correct. The hypometabolic state is characterized by weight gain. 3 This is correct. The hypometabolic state is characterized by increased sleep. 4 This is correct. The hypometabolic state is characterized by decreased energy. 5 This is incorrect. The hypometabolic state is characterized by decreased, not increased, appetite.

The nurse monitors for which clinical manifestations in the patient experiencing an ischemic stroke of the basilar artery? Select all that apply. 1. Ataxia 2. Nausea 3. Dysphasia 4. Inability to swallow 5. Difficulty with speech

ANS: 1, 2, 3, 4, 5 1 This is correct. Manifestations of basilar artery syndrome include ataxia, dizziness, tinnitus, nausea and vomiting, weakness on one side of the body, difficulty with articulation, and difficulty swallowing. 2 This is correct. Manifestations of basilar artery syndrome include ataxia, dizziness, tinnitus, nausea and vomiting, weakness on one side of the body, difficulty with articulation, and difficulty swallowing. 3 This is correct. Manifestations of basilar artery syndrome include ataxia, dizziness, tinnitus, nausea and vomiting, weakness on one side of the body, difficulty with articulation, and difficulty swallowing. 4 This is correct. Manifestations of basilar artery syndrome include ataxia, dizziness, tinnitus, nausea and vomiting, weakness on one side of the body, difficulty with articulation, and difficulty swallowing. 5 This is correct. Manifestations of basilar artery syndrome include ataxia, dizziness, tinnitus, nausea and vomiting, weakness on one side of the body, difficulty with articulation, and difficulty swallowing.

The nurse is preparing information about eye health for a community health fair and includes which information related to risk factors for cataracts? Select all that apply. 1. Exposure to UV light 2. Age older than 60 3. Family history 4. Alcohol intake 5. Diabetes mellitus

ANS: 1, 2, 3, 4, 5 1 This is correct. Risk factors for cataracts include exposure to UV light, age older than 60, family history, African American and Hispanic races, history of diabetes mellitus or other chronic medical conditions, obesity, hypertension, smoking and alcohol use, and specific environmental factors, such as lead exposure. 2 This is correct. Risk factors for cataracts include exposure to UV light, age older than 60, family history, African American and Hispanic races, history of diabetes mellitus or other chronic medical conditions, obesity, hypertension, smoking and alcohol use, and specific environmental factors, such as lead exposure. 3 This is correct. Risk factors for cataracts include exposure to UV light, age older than 60, family history, African American and Hispanic races, history of diabetes mellitus or other chronic medical conditions, obesity, hypertension, smoking and alcohol use, and specific environmental factors, such as lead exposure. 4 This is correct. Risk factors for cataracts include exposure to UV light, age older than 60, family history, African American and Hispanic races, history of diabetes mellitus or other chronic medical conditions, obesity, hypertension, smoking and alcohol use, and specific environmental factors, such as lead exposure. 5 This is correct. Risk factors for cataracts include exposure to UV light, age older than 60, family history, African American and Hispanic races, history of diabetes mellitus or other chronic medical conditions, obesity, hypertension, smoking and alcohol use, and specific environmental factors, such as lead exposure.

The nurse contacts the healthcare provider with data collected from a patient admitted for a stroke. Which information indicates the patient may be experiencing central herniation? Select all that apply. 1. Posturing 2. Bradycardia 3. Positive Babinski reflex 4. Unilateral dilated pupil 5. Increased systolic blood pressure

ANS: 1, 2, 3, 5 1 This is correct. Clinical manifestations of central herniation include posturing, bilateral pupillary dilation, abnormal eye movements, positive Babinski reflex, coma, increased systolic blood pressure, bradycardia, and irregular respiratory pattern. 2 This is correct. Clinical manifestations of central herniation include posturing, bilateral pupillary dilation, abnormal eye movements, positive Babinski reflex, coma, increased systolic blood pressure, bradycardia, and irregular respiratory pattern. 3 This is correct. Clinical manifestations of central herniation include posturing, bilateral pupillary dilation, abnormal eye movements, positive Babinski reflex, coma, increased systolic blood pressure, bradycardia, and irregular respiratory pattern. 4 This is incorrect. Unilateral dilated pupil is a clinical manifestation of uncal herniation. There is bilateral pupillary dilation in central herniation syndrome. 5 This is correct. Clinical manifestations of central herniation include posturing, bilateral pupillary dilation, abnormal eye movements, positive Babinski reflex, coma, increased systolic blood pressure, bradycardia, and irregular respiratory pattern.

The nurse is providing care to a patient who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are appropriate? Select all that apply. 1. Assessing for an allergic reaction 2. Monitoring for signs of renal problems 3. Advising against abrupt discontinuation of drugs 4. Assuring the patient that there is no relationship between NSAIDs and heart disease 5. Encouraging the patient to take NSAIDs with water, milk, or a small snack to help avoid stomach distress

ANS: 1, 2, 3, 5 1 This is correct. When providing care to a patient who is receiving any medication, it is important to monitor the patient for signs of an allergic reaction. 2 This is correct. If you take NSAIDs in high doses, the reduced blood flow can permanently damage the kidneys, and it can eventually lead to kidney failure and require dialysis. 3 This is correct. Abrupt discontinuation can have serious side effects. 4 This is incorrect. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this patient. 5 This is correct. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer.

A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be essential for the family to receive before taking the patient home? Select all that apply. 1. Skin care 2. Aspiration precautions 3. Recognizing exacerbations 4. Lower extremity circulation 5. Strategies to lose weight

ANS: 1, 2, 4 1 This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Skin care to monitor for and prevent pressure injuries is important. 2 This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Aspiration precautions are a high priority because of impaired swallowing. 3 This is incorrect. ALS is a progressive disease and not noted to have exacerbations like those occurring in patient with multiple sclerosis. 4 This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Strategies to facilitate lower extremity circulation are important to prevent venous stasis and deep vein thrombosis development. 5 This is incorrect. Patients with ALS have weight loss secondary to loss of muscle mass and difficulty with oral intake.

The nurse monitors for which clinical manifestations in the patient being evaluated for myasthenia gravis? Select all that apply. 1. Ptosis 2. Diplopia 3. Abdominal pain 4. Dysphagia 5. Epigastric pain

ANS: 1, 2, 4 1 This is correct. Ptosis; diplopia; difficulty with phonation, chewing, and swallowing (dysphagia); and trunk and limb weakness are clinical manifestations of myasthenia gravis. 2 This is correct. Ptosis; diplopia; difficulty with phonation, chewing, and swallowing (dysphagia); and trunk and limb weakness are clinical manifestations of myasthenia gravis. 3 This is incorrect. Abdominal pain is not a manifestation of myasthenia gravis. 4 This is correct. Ptosis; diplopia; difficulty with phonation, chewing, and swallowing (dysphagia); and trunk and limb weakness are clinical manifestations of myasthenia gravis. 5 This is incorrect. Epigastric pain is not a manifestation of myasthenia gravis.

In assessing a patient admitted with diabetes insipidus (DI), which clinical manifestations does the nurse correlate with this diagnosis? Select all that apply. 1. Fatigue 2. Extreme thirst 3. Extreme hunger 4. Large amounts of urine output 5. Waking up to urinate during the night

ANS: 1, 2, 4, 5 1 This is correct. Fatigue is a sign of fluid volume deficit. 2 This is correct. Polydipsia or extreme thirst is a primary clinical manifestation of DI. 3 This is incorrect. Extreme hunger is a manifestation of diabetes mellitus. 4 This is correct. Polyuria is a primary clinical manifestation of DI. 5 This is correct. Nocturia or waking up during the night to void is a primary clinical manifestation of DI.

A patient is having testing to diagnose type 1 diabetes mellitus. Which diagnostic tests might be prescribed for this patient? Select all that apply. 1. Hemoglobin A1c 2. 2-hour postprandial 3. Serum triglycerides 4. Fasting blood glucose 5. Random blood glucose

ANS: 1, 2, 4, 5 1 This is correct. Hemoglobin A1c (HgbA1c) gives an accurate indication of long-term, time-averaged glucose levels over the 6 to 8 weeks before the HgbA1c blood draw. 2 This is correct. A 2-hour postprandial (after meals) or oral glucose tolerance test measures blood glucose levels 1 and 2 hours after consuming a high-glucose beverage. The diagnostic value is based on the blood glucose level 2 hours after consumption. 3 This is incorrect. Serum triglycerides are not specific to the diagnosis of type 1 diabetes mellitus. 4 This is correct. Fasting blood glucose measures the glucose level after no caloric intake for at least 8 hours. Normally, insulin is released, moving that glucose into the cells, preventing hyperglycemia. Without adequate insulin, hyperglycemia results. 5 This is correct. A random blood glucose level of greater than or equal to 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis may be indicative of diabetes mellitus.

The nurse monitors for which of the following clinical manifestations in the patient diagnosed with systemic lupus erythematosus? Select all that apply. 1. Alopecia 2. Fever 3. Elevated uric acid 4. Thrombocytosis 5. Leukopenia

ANS: 1, 2, 5 1 This is correct. Systemic lupus erythematosus is an autoimmune disease mostly characterized by fatigue, fever, rash, photosensitivity, oral and nasal ulcers, alopecia, arthralgia, and myalgia. 2 This is correct. Systemic lupus erythematosus is an autoimmune disease mostly characterized by fatigue, fever, rash, photosensitivity, oral and nasal ulcers, alopecia, arthralgia, and myalgia. 3 This is incorrect. Elevated uric acid levels are associated with gout. 4 This is incorrect. The platelet count is decreased (thrombocytopenia), not increased (thrombocytosis). 5 This is correct. Laboratory values in patients with SLE include a complete blood count (CBC) to check for leukopenia (decreased white blood cell count), thrombocytopenia (decreased platelet count), and anemia (decreased red blood cells).

The nurse provides care to a patient who is diagnosed with Parkinson's disease (PD). Which patient data support the implementation of fall precautions in the plan of care? Select all that apply. 1. Rigidity 2. Tremors 3. Mask-like face 4. Difficulty swallowing 5. Orthostatic hypotension

ANS: 1, 2, 5 1 This is correct. Tremors, rigidity, and orthostatic hypotension place PD patients at great risk for falls. Therefore, the implementation of fall precautions is appropriate in this patient's plan of care. 2 This is correct. Tremors, rigidity, and orthostatic hypotension place PD patients at great risk for falls. Therefore, the implementation of fall precautions is appropriate in this patient's plan of care. 3 This is incorrect. Although a mask-like face is a clinical manifestation of PD, this data does not support the implementation of fall precautions in this patient's plan of care. 4 This is incorrect. Difficulty swallowing supports the implementation of aspiration, not fall precautions, in the patient's plan of care. 5 This is correct. Tremors, rigidity, and orthostatic hypotension place PD patients at great risk for falls. Therefore, the implementation of fall precautions is appropriate in this patient's plan of care.

In reviewing orders written for a patient with myasthenia gravis, which medication order should the nurse question before administering? Select all that apply. 1. Verapamil 2. Furosemide 3. Erythromycin 4. Nicotine patch 5. Warfarin sodium

ANS: 1, 3, 4 1 This is correct. Antiarrhythmic medications such as procainamide, propranolol, timolol, verapamil, and quinidine are known to aggravate myasthenia gravis. 2 This is incorrect. Furosemide is not identified as aggravating myasthenia gravis. 3 This is correct. Aminoglycosides, ciprofloxacin, clindamycin, telithromycin, ampicillin, and erythromycin are antibiotics known to aggravate myasthenia gravis. 4 This is correct. Nicotine patches, as well as trihexyphenidyl, neuromuscular-blocking agents, magnesium preparations, carbamazepine, and oral contraceptives are known to aggravate myasthenia gravis. 5 This is incorrect. Warfarin sodium, an anticoagulant, is not identified as aggravating myasthenia gravis.

Which clinical manifestations does the nurse assess for in the patient diagnosed with gout? Select all that apply. 1. Presence of tophi 2. Raynaud's phenomenon 3. Reports of severe pain in the great toe 4. Redness and swelling of great toe 5. Ulnar deviation

ANS: 1, 3, 4 1 This is correct. Chronic tophaceous gout is characterized by repeated attacks of many years, leading to the production of tophi (uric acid deposits or nodules in the joint) and joint destruction. 2 This is incorrect. Raynaud's phenomenon results from vasospasm of the small vessels in the hands caused by exposure to cold and is associated with scleroderma. 3 This is correct. Clinical manifestations of gout are related to pain and decreased function caused by the accumulation of urate crystals and tophi nodules in the affected joints. 4 This is correct. Clinical manifestations of gout are related to pain and decreased function caused by the accumulation of urate crystals and tophi nodules in the affected joints. 5 This is incorrect. Ulnar deviation is a joint deformity seen in patients with rheumatoid arthritis that develop hyperextension of interphalangeal joints.

In reviewing laboratory results from a patient demonstrating clinical manifestations of diabetes insipidus (DI), which results does the nurse correlate with a definitive diagnosis? Select all that apply. 1. Hematocrit 52% 2. White blood cells 8000 3. Serum sodium 150 mEq/L 4. Urine specific gravity 1.002 5. Serum potassium 5.5 mEq/L

ANS: 1, 3, 4 1 This is correct. Hematocrit is increased in DI secondary to excessive urine output. 2 This is incorrect. Elevated white blood cell count is not specific to DI. 3 This is correct. Serum sodium is elevated in DI as a result of hemoconcentration caused by fluid loss. 4 This is correct. Urine specific gravity is decreased in DI secondary to lack of antidiuretic hormone (ADH) leading to excretion of dilute urine. 5 This is incorrect. Serum potassium levels are not impacted by lack of ADH.

The nurse monitors for which of the following clinical manifestations in the patient diagnosed with osteoarthritis? Select all that apply. 1. Bouchard's nodes 2. Butterfly rash 3. Crepitus 4. Heberden's nodes 5. Raynaud's phenomenon

ANS: 1, 3, 4 1 This is correct. Osteophytes are projections of new cartilage and bone growth that form along joint lines, contributing to pain in the joint and decreased range of motion. Osteophyte formations on the proximal interphalangeal joints and distal interphalangeal joints are referred to as Bouchard's nodes and Heberden's nodes, respectively. 2 This is incorrect. Malar, also known as "butterfly rash," across the cheeks is a clinical manifestation of systemic lupus erythematosus. 3 This is correct. Crepitus, a crackling, grating sound or feeling caused by air or gas under the skin, may be present in patients with osteoarthritis. This is due to cartilage breakdown in the joint. 4 This is correct. Osteophytes are projections of new cartilage and bone growth that form along joint lines, contributing to pain in the joint and decreased range of motion. Osteophyte formations on the proximal interphalangeal joints and distal interphalangeal joints are referred to as Bouchard's nodes and Heberden's nodes, respectively. 5 This is incorrect. Raynaud's phenomenon results from vasospasm of the small vessels in the hands caused by exposure to cold and is associated with scleroderma.

The nurse monitors for which clinical manifestations in the patient diagnosed with type 2 diabetes mellitus? Select all that apply. 1. Fatigue 2. Muscle cramps 3. Visual disturbances 4. Poor wound healing 5. Recurrent infections

ANS: 1, 3, 4, 5 1 This is correct. In addition to the three Ps of type 1 diabetes—polyuria, polydipsia, and polyphagia—other common clinical manifestations include fatigue. 2 This is incorrect. Muscle cramps are not identified as a manifestation of type 2 diabetes mellitus. 3 This is correct. In addition to the three Ps of type 1 diabetes—polyuria, polydipsia, and polyphagia—other common clinical manifestations include visual disturbances. 4 This is correct. In addition to the three Ps of type 1 diabetes—polyuria, polydipsia, and polyphagia—other common clinical manifestations include poor wound healing. 5 This is correct. In addition to the three Ps of type 1 diabetes—polyuria, polydipsia, and polyphagia—other common clinical manifestations include recurrent infections.

The nurse monitors for which clinical manifestations of osteomyelitis in the patient recovering from hip replacement surgery? Select all that apply. 1. Fever 2. Bone deformity 3. Pain unrelieved by rest 4. Progressive muscle weakness 5. Tenderness and warmth at the surgical site

ANS: 1, 3, 5 1 This is correct. Clinical manifestations of acute osteomyelitis include fever. 2 This is incorrect. Bone deformity is associated with Paget's disease. 3 This is correct. Clinical manifestations of acute osteomyelitis include pain relieved by rest. 4 This is incorrect. Progressive muscle weakness is associated with muscular dystrophy. 5 This is correct. Clinical manifestations of acute osteomyelitis include tenderness and warmth at the site.

The nurse is preparing a tool about macular degeneration that will be posted during a health fair. Which risk factors does the nurse include in this tool? Select all that apply. 1. Elevated cholesterol levels 2. Elevated serum glucose levels 3. Obesity 4. Opioid use 5. High blood pressure

ANS: 1, 3, 5 1 This is correct. Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. 2 This is incorrect. Elevated serum glucose levels are not a risk factor for macular degeneration. 3 This is correct. Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. 4 This is incorrect. Opioid use is associated with endogenous endophthalmitis, not macular degeneration. 5 This is correct. Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history.

The nurse monitors for which clinical manifestations in the patient with suspected compartment syndrome? Select all that apply. 1. The patient reports pain. 2. The patient's limb is red. 3. The patient reports numbness. 4. The patient's pulses are bounding. 5. The patient reports a feeling of pressure.

ANS: 1, 3, 5 1 This is correct. Pain is a symptom of compartment syndrome. 2 This is incorrect. Pallor, not erythema, is a symptom of compartment syndrome. 3 This is correct. Paresthesia, or numbness, is a symptom of compartment syndrome. 4 This is incorrect. Pulselessness, not a bounding pulse, is a symptom of compartment syndrome. 5 This is correct. Pressure is a symptom of compartment syndrome.

The nurse correlates which clinical manifestations in the patient with myasthenia gravis to bulbar manifestations? Select all that apply. 1. Dysphagia 2. Difficulty opening eyes 3. Unequal smile 4. Difficulty moving the tongue 5. Decreased gag reflex

ANS: 1, 4, 5 1 This is correct. Bulbar symptoms are the first to appear in about 16% of myasthenia gravis (MG) patients and refer to clinical manifestations involving cranial nerves (CNs) IX, X, XI, and XII) that emerge from the medulla of the brainstem. Clinical manifestations include difficulty with phonation, chewing, and swallowing. 2 This is incorrect. Bulbar manifestations relate to cranial nerves (CNs) IX, X, XI, and XII. Eye opening is controlled by CN VII. 3 This is incorrect. Bulbar manifestations relate to cranial nerves (CNs) IX, X, XI, and XII; CN VII controls the muscles involved in smiling and facial expression. 4 This is correct. Bulbar symptoms are the first to appear in about 16% of MG patients and refer to clinical manifestations involving cranial nerves (CNs) IX, X, XI, and XII) that emerge from the medulla of the brainstem. Clinical manifestations include difficulty with phonation, chewing, and swallowing. 5 This is correct. Bulbar symptoms are the first to appear in about 16% of MG patients and refer to clinical manifestations involving cranial nerves (CNs) IX, X, XI, and XII that emerge from the medulla of the brainstem. Clinical manifestations include difficulty with phonation, chewing, and swallowing. CN X controls gag reflex.

A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). The nurse recognizes which factors as contraindications to this treatment? Select all that apply. 1. Age 83 years 2. Symptoms present for 45 minutes 3. Computed tomography (CT) scan demonstrates area of ischemia 4. 10-year history of type 2 diabetes mellitus 5. Takes warfarin sodium for atrial fibrillation

ANS: 1, 4, 5 1 This is correct. Exclusion criteria for rt-PA include age greater than 80 years. 2 This is incorrect. Inclusion criteria for re-PA include symptoms present for at least 30 minutes. 3 This is incorrect. Inclusion criteria for re-PA include a CT scan consistent with an ischemic stroke. 4 This is correct. Exclusion criteria for rt-PA include a history of diabetes. 5 This is correct. Exclusion criteria for rt-PA include receiving anticoagulants.

A patient with a seizure disorder is prescribed a 1,900-calorie ketogenic diet of which 80% should be consumed as fat. How many calories should the patient consume as fat? Record your answer as a whole number. _____

ANS: 1520 To calculate the number of fat calories, the total number of calories per day should be multiplied by 80%, or 1,900 80% = 1,520. The client should consume 1,520 calories per day of fats.

A patient who weighs 176 lbs. is prescribed intravenous immunoglobulin 2 g/kg to be infused over 3 days. How many grams of the medication should the nurse have sent from the pharmacy? Record your answer as a whole number. ______

ANS: 160 grams First determine the patient's weight in kilograms by dividing the weight in pounds by 2.2 or 176 / 2.2 = 80 kg. Then multiply the ordered dose by the weight or 2 g 80 = 160 g. The nurse needs to have 160 g of the medication available to be infused over 3 days.

The nurse is providing care to a patient diagnosed with diabetic ketoacidosis. The following laboratory results are available: Serum sodium 147 mEq/L Serum potassium 3.0 mEq/L Serum chloride 110 mEq/L Serum bicarbonate 20 mEq/L Serum glucose 275 mg/dL The nurse calculates the anion gap. What is the value? Record as a whole number

ANS: 17 The anion gap is calculated using three laboratory values: positively charged sodium, negatively charged chloride, and negatively charged HCO3. Anion gap = Na+ - (Cl- + HCO3-) 147 - (110 + 20) = 17

The nurse correlates an increased risk of developing Ménière's disease based upon which information in the patient's health record? 1. Follows a gluten-free diet 2. Allergic to house dust and pet dander 3. Works as a computer science technician 4. Treated for a pinched nerve in the lower back

ANS: 2 1 A gluten-free diet is not a risk factor for Ménière's disease. 2 Risk factors for Ménière's disease include allergies. 3 Vocation is not identified as a risk factor for Ménière's disease. 4 Lower spinal cord disorders are not identified as risk factors for Ménière's disease.

During a home visit, the nurse suspects that a patient recovering from an amputation is not complying with prescribed postoperative care. The nurse makes this clinical determination based on what observation? 1. Suture line pink and slightly edematous 2. Evidence of a developing hip contracture 3. Stump wrapped with a compression bandage 4. Taking opioid medication every 8 to 10 hours

ANS: 2 1 A pink and slightly edematous suture line indicates healing. 2 A developing hip contracture indicates that the patient is not complying with postoperative exercises and actions to prevent the development of a contracture. 3 Wrapping the stump with a pressure bandage decreases edema and aids in the correct fitting of the prosthesis. 4 Taking pain medication as prescribed indicates adherence to postoperative teaching and care.

A patient comes into the emergency department with clinical manifestations of retinal detachment. What action by the nurse is the priority to minimize this patient's eye movements? 1. Provide a sedative 2. Loosely cover both eyes 3. Elevate the head of the bed 45 degrees 4. Apply an eye patch over the affected eye

ANS: 2 1 A sedative might help with anxiety; however, it will not minimize eye movements. 2 Movement of either eye can exacerbate internal eye injury. Because eyes move together, both eyes must be covered to minimize injury. 3 Elevating the head of the bed helps decrease intraocular pressure; however, this is not a problem with retinal detachment. 4 A single eye patch is not recommended, as movement of the uncovered eye causes the affected eye to move. Both eyes should be covered.

What does the nurse teach the patient with type 1 diabetes mellitus to do in advance of playing tennis? 1. Drink 1 L of fluid. 2. Measure blood glucose level. 3. Eat one serving of carbohydrate. 4. Take a dose of prescribed medication.

ANS: 2 1 Although adequate hydration is important, it is not required for this patient. 2 In individuals taking insulin, physical activity can cause hypoglycemia if medication dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if pre-exercise blood glucose levels are less than 100 mg/dL. The blood glucose needs to be measured before ingesting a carbohydrate. 3 A carbohydrate should be ingested only if the blood glucose level is less than 100 mg/dL. 4 An additional dose of medication could cause hypoglycemia and should not be taken.

Which statement best describes the pathophysiology of type 2 diabetes mellitus? 1. There is an absolute lack of insulin. 2. The cells resist glucose from entering. 3. Pancreatic cells stop producing insulin. 4. An autoimmune disorder damages pancreatic cells.

ANS: 2 1 An absolute lack of insulin describes type 1 diabetes mellitus. 2 Type 2 diabetes mellitus involves defects at the cell membrane that prevent the normal action of insulin. Even though insulin is present, the cell "resists" its effect in transporting glucose into the cell. 3 Pancreatic cells stop producing insulin in type 1 diabetes mellitus. 4 Type 1 diabetes mellitus is considered an autoimmune disorder that damages pancreatic cells.

The nurse provides education to a patient who is prescribed latanoprost (Xalatan) for the treatment of glaucoma. Which patient statement indicates that the teaching was effective? 1. "I will take over-the-counter antihistamines for my allergies." 2. "It increases the outflow of aqueous humor, which decreases the pressure in my eye." 3. "It reduces the production of aqueous humor, which decreases the pressure in my eye." 4. "I will apply pressure to the corner of my eye for 10 sec to decrease systemic absorption."

ANS: 2 1 Anticholinergic medications can cause worsening of glaucoma by constricting the drainage of aqueous humor; therefore, this statement indicates a need for additional teaching. 2 This is the mechanism of action for the prescribed medication; therefore, this statement indicates a correct understanding of the information presented. 3 This is not the mechanism of action for the prescribed medication; therefore, this statement indicates a need for additional teaching. 4 Pressure is applied for 30 to 60 seconds, not 10 seconds, to decrease systemic absorption; therefore, this statement indicates a need for additional teaching.

During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do? 1. Ask the patient to explain. 2. Prepare for a seizure to begin. 3. Turn on the overhead room lights. 4. Document visual hallucinations.

ANS: 2 1 Asking the patient to explain is not the priority because this may be a clinical manifestation of an impending seizure. 2 Seizures can be preceded by a preictal phase that may include an aura. An aura can be a visual hallucination like the room color changing to green. 3 Turning on the overhead rooms lights indicates that the nurse is unaware of the patient experiencing an aura, which is a precursor to a seizure in many patients. 4 The nurse should not stop to document at this time. Further patient assessment is a priority because of the risk of a seizure.

A patient has been experiencing a tonic-clonic seizure for 5 minutes. What should the nurse do first? 1. Assess carotid pulse. 2. Prepare to insert an airway. 3. Provide rescue breathing. 4. Insert an intravenous access line.

ANS: 2 1 Assessing circulation might be required but only after establishing an airway and providing rescue breathing. 2 In the case of status epilepticus, which is a seizure lasting longer than 5 minutes, emergency actions should be taken. The first is to establish an airway. 3 Providing rescue breathing might be required but only after establishing an airway. 4 Inserting an intravenous access line is essential but only after the ABCs of emergency care are completed.

The nurse correlates the new onset of back pain radiating down the left leg to which neurological disorder? 1. Meningitis 2. Spinal cord tumor 3. Multiple sclerosis 4. Amyotrophic lateral sclerosis

ANS: 2 1 Back pain radiating down the leg is not a manifestation of meningitis. 2 Many of the symptoms of a spinal cord tumor are the same as a low back injury or herniated disk. 3 Although spinal cord tumors can mimic the manifestations of multiple sclerosis, the patient's symptoms are limited to low back pain radiating down the leg. Multiple sclerosis has many additional manifestations that this patient is not experiencing. 4 Manifestations of back pain radiating down the leg are not associated with amyotrophic lateral sclerosis.

In providing care to a patient who is being evaluated for a possible connective tissue disease, the nurse correlates which finding to the definitive diagnosis of gout? 1. Boutonniere deformity 2. Crystals in synovial fluid 3. Elevated uric acid levels 4. Joint erosions

ANS: 2 1 Boutonniere deformity is seen in patients with rheumatoid arthritis and is caused by abnormal flexion of the proximal interphalangeal joints. 2 A presumptive diagnosis of gout may be achieved by combining objective, subjective, and laboratory data, but the definitive diagnosis can be made only by observing crystals in synovial fluid or tophaceous material. 3 Elevated uric acids are associated with gout, but the definitive diagnosis requires observation of uric acid crystals in the joint fluid. 4 Joint erosions and soft tissue nodules are radiographically consistent with chronic gouty arthritis but not diagnostically definitive.

A patient contemplating cataract surgery asks if there are any risk factors. What is the nurse's best response? 1. "Blindness is a risk factor of cataract surgery." 2. "Detached retina is a risk factor of cataract surgery." 3. "Corneal abrasion is a risk factor of cataract surgery." 4. "Macular degeneration is a risk factor of cataract surgery."

ANS: 2 1 Cataract removal does not increase the risk of blindness. 2 Cataract removal increases the risk of retinal detachment. 3 Cataract removal is not associated with a corneal abrasion. 4 Cataract removal does not increase the risk of macular degeneration.

The nurse is reviewing discharge instructions with a patient being treated with desmopressin (DDAVP) for diabetes insipidus (DI). What should the nurse direct the patient to do regarding changes in body weight? 1. Decrease intake of fluids for a day. 2. Notify the healthcare provider. 3. Increase the intake of salty foods. 4. Take an extra dose of medication.

ANS: 2 1 DDAVP works like antidiuretic hormone (ADH) and should promote fluid retention, and decreasing fluid intake is not indicated. 2 Weight is directly associated with water loss or gain, and changes of more than 2 lbs. per day should be reported to the healthcare provider. If the DDAVP is not working, the patient will demonstrate signs of DI. If the patient is receiving too much DDAVP, the patient will present with signs of syndrome of inappropriate antidiuretic hormone (SIADH). 3 Salty foods may cause more water weight gain and are not indicated if the DI is well managed with DDAVP. 4 The patient should not modify the medication schedule unless directed by the healthcare provider. Skipping a dose of DDAVP could increase signs of DI.

In providing care to a patient with multiple sclerosis who is developing speech difficulties, the nurse correlates this new finding to which factor? 1. Depression 2. Medications 3. Nerve regeneration 4. Mental status changes

ANS: 2 1 Depression is an adverse effect of the disease. It does not cause speech deficits. 2 Speech defects due to muscle weakness may be due to medications. 3 Nerve regeneration would improve speech. 4 Mental status changes is an adverse effect of the disease. It does not cause speech deficits.

During a home visit by the nurse with a patient with type 2 diabetes mellitus, which observation of the patient indicates the need for further teaching? 1. Exercising with a treadmill 2. Walking barefoot in the backyard 3. Eating one-half apple and cheese for a snack 4. Stated a weight loss of 2 lbs. over the last month

ANS: 2 1 Exercise is encouraged. 2 The patient with type 2 diabetes mellitus should never walk barefoot. 3 The snack of apple and cheese is balanced and appropriate for this patient. 4 A weight loss of 2 lbs. in 1 month is appropriate for this patient.

The nurse is evaluating teaching provided to a patient with type 1 diabetes mellitus. Which patient observation indicates that medication teaching has been effective? 1. Uses a 1 mL syringe to measure insulin dose 2. Places a new injection an inch away from previous injection site 3. Inserts the needle at a 25-degree angle before injecting the medication 4. Provides an injection in the thigh after an abdominal injection in the morning

ANS: 2 1 Insulin syringes should be used to measure insulin doses. 2 Rotating sites within one area rather than moving from area to area helps decrease absorption variability from day to day. This can be done by injecting a new shot at least an inch away from the last injection site. 3 The needle should be injected at a 90-degree angle. A 45-degree angle can be used if the patient is very thin. 4 Rotating sites does help reduce lipohypertrophy; however, absorption will be variable between injections if another body part and not a similar area is used.

In providing care to a patient diagnosed with osteoporosis, the nurse correlates which pathophysiological mechanisms to this disease process? 1. Osteoclasts break down bone with acids and enzymes. 2. Osteoclastic activity is greater than osteoblastic activity. 3. Osteoblastic activity is greater than osteoclastic activity. 4. Osteoblasts synthesize and add minerals to the bony matrix.

ANS: 2 1 Osteoclasts breaking down bone with acids and enzymes is part of the process of building new bone. 2 Bone loss osteopenia occurs when bone resorption or osteoclastic activity is greater than bone rebuilding or osteoblastic activity, which ultimately results in decreased bone mineral density (BMD). 3 Osteoclastic activity is greater than bone rebuilding or osteoblastic activity in patients with osteoporosis. The resulting bone loss causes changes in the skeletal structure and results in an increased risk for fracture. 4 Osteoblasts rebuild bone by synthesis and mineralization of the new bony matrix within the bone cavity.

The nurse monitors for which assessment data in the patient diagnosed with obstructive hearing loss? 1. The patient has visible blood upon otoscope examination. 2. The patient has a visible lesion upon otoscope examination. 3. The patient reports pain and states, "My ear feels plugged." 4. The patient reports, "The hearing in my right ear comes and goes ever since my MS diagnosis."

ANS: 2 1 Pain, bloody drainage, and visible blood upon otoscope examination are expected for the patient with hearing loss caused by trauma, not obstruction. 2 Hearing loss caused by a tumor often presents with a visible lesion. 3 Pain, along with feeling as if the ear is "plugged" or has something in it, are both clinical manifestations anticipated for the patient with obstructive hearing loss. 4 This statement is anticipated for the patient experiencing a demyelinating disease such as multiple sclerosis (MS) causing unilateral hearing loss that comes and goes.

The nurse is caring for a patient admitted for treatment of a subarachnoid hemorrhage caused by a cerebral aneurysm who has a wide neck and tortuous vascular anatomy. The patient is hemodynamically stable with Glasgow Coma Scale of 14. Based on this data, the patient is most likely to have which procedure? 1. Aneurysm coiling 2. Aneurysm clipping 3. Reinforcing aneurysm wall 4. Evacuation of the hematoma

ANS: 2 1 Patients with high-grade Hunt and Hess scores (grade 4 or 5), as well as patients with multiple comorbid conditions and with hemodynamic instability at baseline, may be better candidates for aneurysm coiling. 2 Aneurysms with a wide neck and tortuous vascular anatomy may be better candidates for aneurysm clipping. 3 In cases where neither clipping nor coiling the aneurysm is feasible, reinforcement of the aneurysmal wall by wrapping the outside of the aneurysm with synthetic material or muscle during the surgery may be accomplished. 4 Surgical management of intracranial hemorrhage above the tentorium cerebelli has not been shown to improve outcomes unless a hematoma is superficial in location.

A patient recovering from surgery to repair a fractured hip is placed in skin traction. The nurse correlates which data to the effectiveness of the traction? 1. Strong peripheral pulses 2. Reduction in muscle spasms 3. Improved mobility of the foot 4. Reduction of lower extremity edema

ANS: 2 1 Peripheral pulses are important to assess but do not relate to effectiveness of skin traction. 2 Skin traction uses a flexible harness, boot, or belt to secure the extremity while 5 to 10 lbs. of weight is applied to relieve muscle spasms and maintain the length of the bone. 3 The effectiveness of skeletal traction is not assessed with foot mobility. 4 It is important to monitor for lower extremity edema in the patient in skeletal traction, but this is not a parameter to measure the effectiveness of this treatment.

The nurse provides care to a patient who is admitted to confirm a suspected diagnosis of myasthenia gravis (MG). Which medication prescription does the nurse question for this patient? 1. Prednisone 2. Erythromycin 3. Edrophonium 4. Pyridostigmine

ANS: 2 1 Prednisone is a corticosteroid that is anticipated when providing care to the patient who is diagnosed with MG. 2 Erythromycin, an antibiotic, is a medication that is known to exacerbate MG; therefore, it is appropriate for the nurse to question this medication prescription. In addition to other antibiotics, select antiarrhythmics and neuropsychiatric medications are known to exacerbate MG. 3 Edrophonium is used for the Tensilon test to diagnose MG. 4 Pyridostigmine is a medication that is a reversible inhibitor of acetylcholinesterase (AChE). It improves neuromuscular transmission by increasing acetylcholine (ACh) stimulation of the ACh receptors that are available.

A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with the prescribed medication? 1. Renal toxicity 2. Retinal toxicity 3. Cushingoid effects 4. Pulmonary fibrosis

ANS: 2 1 Renal toxicity is not the primary concern with hydroxychloroquine (Plaquenil). 2 Hydroxychloroquine is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. 3 Cushingoid effects are a concern with corticosteroid therapy. 4 Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil.

The nurse correlates which pathophysiological mechanism to the development of detached retina? 1. Blood vessels in the eye spasm 2. Inner layers of the retina separate 3. Overgrowth of vessels damages vision 4. Drainage of aqueous humor is blocked

ANS: 2 1 Retinal detachment is not caused by vessel spasms. 2 Retinal detachment occurs when there is a separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE; choroid). 3 Macular degeneration is associated with growth of abnormal blood vessels. 4 Glaucoma is associated with overproduction or blocked drainage of aqueous humor

During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a patient with Parkinson's disease with breakfast. Which observation requires an immediate intervention? 1. Patient sitting out of bed in a chair 2. Head of the bed raised to 30 degrees 3. Thickener added to liquid menu items 4. Oral suction catheter equipment turned on

ANS: 2 1 Sitting out of bed for meals facilitates swallowing. 2 The patient's head of the bed should be elevated higher than 30 degrees when eating and drinking. Impaired swallowing associated with Parkinson's disease increases the risk of aspiration. Elevating the head facilitates the swallow reflex. 3 Adding thickener to liquids improves swallowing and reduces the risk of aspiration. 4 Oral suction equipment is a safety precaution and would be appropriate.

A patient with myasthenia gravis has lost 6 kg of weight over the last 2 months. What should the nurse suggest to improve this patient's nutritional status? 1. Eat three large meals per day. 2. Plan medication doses to occur before meals. 3. Restrict drinking fluids before and during meals. 4. Increase the amount of fat and carbohydrates in meals.

ANS: 2 1 Small, frequent meals will help maintain calorie intake. 2 Plan meals when medications are at peak levels. Often patients take pyridostigmine an hour before meals to minimize difficulty with chewing and swallowing. 3 The patient does not have difficulty with digestion. Fluids do not need to be restricted before or during meals. 4 It is not recommended to alter the amount of fat and carbohydrates in the diet of a patient with myasthenia gravis.

Which statement by the patient after laser trabeculoplasty indicates the need for follow-up by the nurse for additional teaching? 1. "I should take a daily laxative." 2. "I can't wait to be able to hold and play with my a 3-year-old grandchild." 3. "I should not bend at the waist." 4. "I need to apply pressure to the lacrimal duct after applying eye drops."

ANS: 2 1 Straining at a bowel movement is contraindicated and can increase the chance of postoperative bleeding within the eye. A laxative would avoid this potential complication. 2 Lifting heavy objects (anything over 25 pounds) such as a grandchild increases intraocular pressure, which should be avoided after having this surgery. It is important for the nurse to make sure the patient understands lifting restrictions. 3 Lifting heavy objects, bending at the waist, and strenuous activities can increase intraocular pressure (IOP) and cause damage to the newly repaired eye. 4 Applying pressure to the lacrimal duct after applying eye drops reduces the risk of systemic absorption of the medication, and indicates understanding of postoperative instructions.

The nurses uses which diagnostic tool to assess a patient experiencing a gradual loss of central vision? 1. Jaeger card 2. Amsler grid 3. Snellen chart 4. Ishihara chart

ANS: 2 1 The Jaeger card assesses near vision. 2 The Amsler grid is used to determine if a matrix of black lines appear straight or are wavy, which could indicate macular degeneration. 3 The Snellen chart is used to assess for visual acuity. 4 The Ishihara chart is used to assess color vision.

The nurse correlates which assessment findings to a patient experiencing diabetic ketoacidosis? 1. Slow heart rate 2. Deep rapid respirations 3. Decreased urine output 4. Increased blood pressure

ANS: 2 1 The heart rate would be rapid because of dehydration. 2 The patient develops Kussmaul's respirations, which are rapid, deep respirations that occur as a compensatory mechanism for the acidosis. 3 The urine output would be increased because of osmotic diuresis. 4 The blood pressure would be low because of dehydration.

A patient is diagnosed with myasthenia gravis. What information does the nurse include in an explanation of this disease process? 1. "Your nerve endings are no longer functional and that leads to muscle weakness." 2. "Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction." 3. "Your body does not make enough of the neurotransmitter needed for movement." 4. "Your nerves have lost their protective covering and impulses are not as smooth."

ANS: 2 1 The issue is related not to the nerves but to impairment at the neuromuscular junction with decreased acetylcholine receptor (AChR) sites. 2 In myasthenia gravis, circulating anti-AChR antibodies bind with the AChR, resulting in complement-mediated destruction of receptor sites. 3 The amount of neurotransmitter is not altered in myasthenia gravis. 4 The nerves in myasthenia gravis have not lost their protective covering or myelin sheath. Demyelination develops in multiple sclerosis and Guillain-Barré Syndrome.

What is the priority action by the nurse in providing care to a patient diagnosed with thyrotoxicosis? 1. Monitoring heart rate 2. Managing the airway 3. Assessing blood pressure 4. Administering intravenous fluids

ANS: 2 1 The nurse follows the ABCs (airway, breathing, circulation) to prioritize patient care. Although it is an appropriate nursing action to monitor the patient's heart rate, this is not the priority because circulation is not prioritized over airway. 2 Thyrotoxicosis is a medical emergency requiring definitive treatment to prevent respiratory compromise and cardiac collapse. The nurse follows the ABCs to prioritize patient care; therefore, the priority nursing action is to protect and manage the airway because intubation may be required. 3 The nurse follows the ABCs to prioritize patient care. Although it is an appropriate nursing action to monitor the patient's blood pressure, this is not the priority because circulation is not prioritized over airway. 4 The nurse follows the ABCs to prioritize patient care. Although it is an appropriate nursing action to administer intravenous fluids, this is not the priority because circulation is not prioritized over airway.

In the immediate post-operative period after tympanoplasty, how does the nurse position the patient? 1. Head of bed elevated 60 degrees 2. Flat with operative ear facing up 3. Flat on the affected side 4. Supine with eyes toward ceiling

ANS: 2 1 The patient needs to be placed flat with operative site facing up. 2 Position the patient flat, turned on the side with the operative side facing up after tympanoplasty. 3 The patient needs to be placed flat with operative site facing up. 4 The patient needs to be placed flat with operative site facing up.

A patient with Paget's disease is demonstrating manifestations of a fracture. The results of which diagnostic test is most effective in confirming the fracture? 1. X-ray 2. Bone scan 3. Arthroscopy 4. Bone density test

ANS: 2 1 The patient will need more than an x-ray to definitively diagnosis a fracture caused by the Paget's disease. 2 If a chronic illness, like Paget's disease, is suspected as having a major role in the injury, a bone scan may be needed to confirm the diagnosis. 3 Arthroscopy is a surgical procedure that allows a practitioner to view the inside of a joint through an instrument called an arthroscope and is not indicated in the diagnosis of fracture. 4 A bone density test is not indicated in the diagnosis of a fracture.

A patient with type 1 diabetes mellitus is scheduled for a hemoglobin A1c level. What information does the nurse include in the patient teaching about this diagnostic test? 1. "You need to schedule this test for first thing in the morning." 2. "You can have this test drawn at any time during the day." 3. "Avoid eating and drinking anything after midnight the day before the test." 4. "Restrict the intake of red meat for 3 days before having the test."

ANS: 2 1 The test can be done at any time of the day. 2 On the day the hemoglobin A1c (HgbA1c) sample is collected, eating, physical activity, or acute stresses do not affect the result, and the test can be done at any time of day and does not require fasting. 3 The test does not require fasting. 4 Eating does not affect the result.

A patient who suffered a thrombotic stroke has residual left lower extremity motor deficit and dysphagia. The nurse identifies which of the following as the priority nursing diagnosis? 1. High Risk for Impaired Skin Integrity 2. High Risk for Aspiration 3. High Risk for Injury: Falls 4. High Risk for Impaired Verbal Communication

ANS: 2 1 This patient is at risk for impaired skin integrity, but potential for aspiration as a result of difficulty swallowing is the priority. 2 The risk for aspiration is the priority because of swallowing difficulty. 3 This patient is at risk for impaired injury from falls, but potential for aspiration because of difficulty swallowing is the priority. 4 Dysphasia is impaired speech. Although this patient may be at risk for impaired verbal communication, preventing aspiration and maintaining the airway are the priorities.

The nurse reinforces teaching for a patient who is scheduled for a left-sided tympanoplasty. Which patient statement indicates a need for additional teaching? 1. "I might experience temporary hearing loss due to the packing in my ear after the procedure." 2. "I will turn and cough after the procedure to decrease my risk for developing pneumonia." 3. "I will keep my ear clean and dry after the procedure to decrease my risk for infection." 4. "I won't use cotton swabs to clean my ear as this pushes the wax further into the ear."

ANS: 2 1 This statement indicates a correct understanding of the information presented. 2 The patient should be taught to avoid forceful coughing, because this places increased pressure on the middle ear; therefore, this statement indicates the need for additional teaching. 3 This statement indicates a correct understanding of the information presented. 4 This statement indicates a correct understanding of the information presented.

The nurse teaches a patient who is prescribed carbamazepine (Tegretol) for the treatment of seizure activity. Which patient statement indicates a need for additional teaching? 1. "I will have blood drawn to monitor my liver function." 2. "I can crush the pill and eat it in applesauce because it is so big." 3. "I might experience blurred vision because of this medication." 4. "I will get up slowly if I experience dizziness while on this medication."

ANS: 2 1 This statement indicates a correct understanding of the information presented. Hepatitis is a known side effect to the prescribed medication; therefore, the patient will have blood drawn to monitor liver function. 2 Sustained-released pills cannot be crushed or chewed; therefore, this patient statement indicates the need for additional teaching. 3 This statement indicates a correct understanding of the information presented. Blurred or double vision is a known side effect for the prescribed medication. 4 This statement indicates a correct understanding of the information presented. Dizziness is a known side effect for the prescribed medication; therefore, the patient is taught to change positions slowly to decrease the risk for falls.

Which statement by the patient scheduled for an open reduction and internal fixation (ORIF) of a compound fracture of the femur indicates the need for further teaching? 1. "The surgeon will put rods and nails into my leg to align the fracture." 2. "I will have to be in traction after this surgery." 3. "The pins do not have to be removed; they will stay in my body." 4. "I will need to monitor for infection as I heal."

ANS: 2 1 This statement indicates patient understanding. An open reduction requires a surgical incision that enables the surgeon to accurately visualize the wound and ensure proper realignment. Internal fixation requires the use of plates, screws, rods, and other hardware to realign the fractured bone segments. 2 This statement indicates the need for further teaching. Traction is the nonsurgical approach to management of fractures. Once the ORIF is completed, the patient will not be placed in traction. 3 This statement indicates patient understanding because the hardware does stay in the patient. It is only removed in case of osteomyelitis. 4 This statement indicates patient understanding because after ORIF the patient is still at risk of infection, particularly as a result of the initial compound fracture.

Which statement by the patient with myasthenia gravis indicates the need for further teaching? 1. "My weakness will get worse when I exercise too much." 2. "It is important that I take my medications 30 minutes before or after eating." 3. "My eyes will get tired if I read too much." 4. "I need to wait for 30 minutes after taking medication to eat or drink."

ANS: 2 1 This statement indicates patient understanding. Muscle activity gets progressively weaker because of decreased acetylcholine receptor (AChR) sites at the neuromuscular junction. Activities requiring strength need to be timed with peak effectiveness of medications. 2 This statement indicates the need for additional teaching. Medications need to be taken 30 to 60 minutes before (not after) eating or drinking, or other activities that impact swallowing, like brushing teeth. 3 This statement indicates patient understanding. Because of the eye movements, reading will make the eyes tire. 4 This statement indicates patient understanding. Medications need to be taken 30 to 60 minutes before eating or drinking, or other activities that impact swallowing, like brushing teeth.

A patient undergoes a total thyroidectomy, leaving one lobe of the parathyroid gland intact. Which laboratory value would provide the nurse the most accurate assessment of parathyroid function? 1. TSH 2. Ionized calcium 3. Serum calcium 4. Serum potassium

ANS: 2 1 Thyroid-stimulating hormone (TSH) is not part of the diagnostic evaluation for hypoparathyroidism. 2 Ionized calcium is the free and active form of calcium. 3 Because serum calcium levels are influenced by albumin levels, in hypoparathyroidism the ionized calcium is most accurate. 4 Serum potassium is not part of the diagnostic evaluation for hypoparathyroidism.

A patient with hearing loss is wearing headphones as a part of a diagnostic test. What test is being completed with this patient? 1. Tympanometry 2. Pure-tone threshold 3. Acoustic reflex test 4. Speech reception threshold

ANS: 2 1 Tympanometry is a test that measures the impedance of the middle ear to the acoustic energy. 2 Pure-tone threshold is an audiological test conducted with air and bone conduction assessment to quantify hearing loss. To complete this test, the patient wears headphones. 3 The acoustic reflex is a test that notes the response of the stapedius muscle to the presence of loud sound. 4 Speech reception threshold is used to measure the intensity at which speech is recognized by a patient. This test is used to determine the softest level at which the patient is able to recognize speech.

A patient with thyroid cancer is receiving high-dose radiation to the thyroid gland. In assessing the patient, which clinical manifestations would be consistent with hypoparathyroidism? 1. Voice changes 2. Tetany 3. Absent deep tendon reflexes 4. Periorbital edema

ANS: 2 1 Voice changes are related to damage to the laryngeal nerve. 2 Clinical manifestations of hypoparathyroidism are related to hypocalcemia and include tetany, muscle cramps, positive Chvostek's sign, positive Trousseau's sign, paresthesias of the hands and feet, and circumoral tingling. 3 Reflexes are not absent in hypoparathyroidism. 4 Periorbital edema may occur in with patients with myxedema, not hypoparathyroidism.

A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1. Improved muscle strength 2. Fasciculations 3. Strong hand grasps 4. Equal shoulder shrugs

ANS: 2 1 When Tensilon is administered, if the patient demonstrates muscle strength improvement, it is determined to be a myasthenic crisis. 2 If Tensilon is administered and the patient demonstrates fasciculations and muscle weakness, including respiratory muscles, it is a cholinergic crisis. 3 When Tensilon is administered, if the patient demonstrates strong hand grasp, it is determined to be a myasthenic crisis. 4 When Tensilon is administered, if the patient demonstrates equal shoulder shrugs, it is determined to be a myasthenic crisis.

A patient who takes pyridostigmine (Mestinon) 30 mg 4 times a day is scheduled for surgery. To determine the conversion dose for intravenous (IV) medication, how many milligrams of IV neostigmine (Prostigmin) should be prescribed for an entire day? Record your answer as a whole number. ______

ANS: 2 The patient should receive 1 mg intravenous neostigmine (Prostigmin) for every 60 mg of pyridostigmine (Mestinon). This patient should receive 0.5 mg for every 30 mg. Because the patient takes 4 doses of oral pyridostigmine (Mestinon), 0.5 mg 4 or 2 mg of pyridostigmine (Mestinon) should be prescribed.

The nurse correlates which assessment findings as modifiable risk factors for developing type 2 diabetes mellitus? Select all that apply. 1. Serum triglycerides 200 mg/dL 2. Sedentary lifestyle 3. Body mass index 29 4. Blood pressure 140/90 mm Hg 5. HDL less than 25 mg/dL

ANS: 2, 3, 4 1 This is incorrect. Modifiable risk factors for type 2 diabetes mellitus (DM) include triglyceride level greater than or equal to 250 mg/dL. 2 This is correct. Modifiable risk factors for type 2 DM include body mass index (BMI) greater than 26 kg/m2, physical inactivity, and high-density lipoprotein (HDL) cholesterol greater or equal to 35 mg/dL or triglyceride level greater than or equal to 250 mg/dL. 3 This is correct. Modifiable risk factors for type 2 DM include BMI greater than 26 kg/m2, physical inactivity, and HDL greater or equal to 35 mg/dL or triglyceride level greater than or equal to 250 mg/dL. 4 This is correct. Modifiable risk factors for type 2 DM include BMI greater than 26 kg/m2, physical inactivity, and HDL greater or equal to 35 mg/dL or triglyceride level greater than or equal to 250 mg/dL. 5 This is incorrect. Modifiable risk factors for type 2 DM include HDL greater or equal to 35 mg/dL.

The nurse monitors for which clinical manifestation in the patient diagnosed with multiple sclerosis (MS)? Select all that apply. 1. Paralysis 2. Dizziness 3. Double vision 4. Unsteady gait 5. Radicular pain

ANS: 2, 3, 4 1 This is incorrect. Patients with MS develop numbness and weakness but not paralysis 2 This is correct. Depending on the location of the affected nerve fibers, manifestations of MS include dizziness. 3 This is correct. Depending on the location of the affected nerve fibers, manifestations of MS include double vision. 4 This is correct. Depending on the location of the affected nerve fibers, manifestations of MS include unsteady gait. 5 This is incorrect. Patients with multiple sclerosis develop numbness and weakness but not radicular pain. Radiculopathy is related to nerve root compression, and MS is caused by demyelination.

The nurse correlates which findings in a 40-year-old patient's health history as secondary risk factors for osteoporosis? Select all that apply. 1. Cigarette smoking 2. Corticosteroid therapy for more than 3 months 3. Inflammatory bowel disease 4. Premature menopause 5. Sedentary lifestyle

ANS: 2, 3, 4 1 This is incorrect. Primary risk factors are those that are nonmodifiable, such as age or race, and lifestyle choices such as sedentary lifestyle, not enough calcium intake, or smoking. 2 This is correct. Secondary risk factors include other disease states that are associated with an increased risk such as Cushing's disease, inflammatory bowel disease, and premature menopause, or medication use such as steroids. 3 This is correct. Secondary risk factors include other disease states that are associated with an increased risk such as Cushing's disease, inflammatory bowel disease, and premature menopause, or medication use such as steroids. 4 This is correct. Secondary risk factors include other disease states that are associated with an increased risk such as Cushing's disease, inflammatory bowel disease, and premature menopause, or medication use such as steroids. 5 This is incorrect. Primary risk factors are those that are nonmodifiable, such as age or race, and lifestyle choices such as sedentary lifestyle, not enough calcium intake, or smoking.

The nurse correlates which laboratory results in the patient diagnosed with metastatic bone cancer? Select all that apply. 1. Decreased serum calcium 2. Increased serum alkaline phosphatase 3. Increased serum lactate dehydrogenase (LD) 4. Increased erythrocyte sedimentation rate (ESR) 5. Increased serum aspartate aminotransferase (AST)

ANS: 2, 3, 4 1 This is incorrect. With metastasis from the breast, kidney, or lung to the bone, elevated calcium levels are frequently noted. 2 This is correct. Serum alkaline phosphatase is frequently elevated with osteosarcomas due to the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. 3 This is correct. LD is often elevated with osteosarcomas because of the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. 4 This is correct. ESR is often elevated with osteosarcomas due to the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. 5 This is incorrect. AST is often elevated with muscular dystrophy (MD), not metastatic bone cancer. The AST level is monitored to assess for muscle wasting and deterioration in MD.

A victim of a motor vehicle crash has a partially severed lowered extremity. What are the priority actions the nurse needs to implement when the patient arrives in the emergency department? Select all that apply. 1. Administering antibiotics 2. Preparing for blood transfusions 3. Preparing for emergency surgery 4. Assessing for active hemorrhaging 5. Monitoring effectiveness of tourniquet

ANS: 2, 3, 4, 5 1 This is incorrect. Antibiotics are important, but not part of emergency care for a traumatic amputation. 2 This is correct. To prevent hemorrhagic shock after a traumatic amputation, the patient should be prepared for blood transfusions. 3 This is correct. The patient with a traumatic amputation should be prepared for emergency surgery. 4 This is correct. The patient with a traumatic amputation should be assessed for active hemorrhaging. 5 This is correct. The tourniquet or pressure bandage placed over the site of a traumatic amputation should be assessed for effectiveness.

A patient is being discharged after treatment for an ischemic stroke. Which medications does the nurse correlate with this management of this neurological disorder? Select all that apply. 1. Antibiotics 2. Anticoagulants 3. Antihypertensives 4. Antiplatelet therapy 5. Lipid-lowering agent

ANS: 2, 3, 4, 5 1 This is incorrect. Antibiotics are not routinely prescribed in the treatment of an ischemic stroke. 2 This is correct. According to stroke center accreditation guidelines, after a stroke, patients should be discharged with antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for atrial fibrillation, and a blood pressure control strategy in patients with hypertension. 3 This is correct. According to stroke center accreditation guidelines, after a stroke, patients should be discharged with antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for atrial fibrillation, and a blood pressure control strategy in patients with hypertension. 4 This is correct. According to stroke center accreditation guidelines, after a stroke, patients should be discharged with antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for atrial fibrillation, and a blood pressure control strategy in patients with hypertension. 5 This is correct. According to stroke center accreditation guidelines, after a stroke, patients should be discharged with antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for atrial fibrillation, and a blood pressure control strategy in patients with hypertension.

The nurse correlates which clinical manifestations to the patient diagnosed with Guillain-Barré syndrome (GBS)? What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply. 1. Decreased level of consciousness 2. Hypotension 3. Difficulty breathing 4. Dysphagia 5. Numbness and tingling

ANS: 2, 3, 4, 5 1 This is incorrect. In patients with GBS, level of consciousness and cognitive function remain intact throughout the course of the illness. 2 This is correct. Clinical manifestations of GBS include paresthesias and pain that involve the shoulders, back, buttocks, and upper legs; diminished or absent deep tendon reflexes; difficulty smiling or frowning; dysphagia; and autonomic dysfunction with possible cardiac dysrhythmias, paroxysmal hypotension, orthostatic hypotension, paralytic ileus, urinary retention, and potential syndrome of inappropriate secretion of antidiuretic hormone (SIADH). 3 This is correct. Up to 40% of patients with GBS develop respiratory impairment. Respiratory failure is caused by weakness of the diaphragm and intercostal muscles, and the patient may require intubation and mechanical ventilation to provide respiratory support. 4 This is correct. Clinical manifestations of GBS include paresthesias and pain that involve the shoulders, back, buttocks, and upper legs; diminished or absent deep tendon reflexes; difficulty smiling or frowning; dysphagia; and autonomic dysfunction with possible cardiac dysrhythmias, paroxysmal hypotension, orthostatic hypotension, paralytic ileus, urinary retention, and potential syndrome of inappropriate secretion of antidiuretic hormone (SIADH). 5 This is correct. Clinical manifestations of GBS include paresthesias and pain that involve the shoulders, back, buttocks, and upper legs; diminished or absent deep tendon reflexes; difficulty smiling or frowning; dysphagia; and autonomic dysfunction with possible cardiac dysrhythmias, paroxysmal hypotension, orthostatic hypotension, paralytic ileus, urinary retention, and potential syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

The nurse monitors for which clinical manifestations in the patient diagnosed with hyperthyroidism? Select all that apply. 1. Anorexia 2. Heart rate 150 bpm 3. Hyperactive bowel sounds 4. Thinning hair 5. 10 pound weight loss over the last month

ANS: 2, 3, 4, 5 1 This is incorrect. Increased appetite, not anorexia, is associated with hyperthyroidism. 2 This is correct. Clinical manifestations of hyperthyroidism include elevated heart rate. 3 This is correct. Clinical manifestations of hyperthyroidism include increased gastric activity. 4 This is correct. Clinical manifestations of hyperthyroidism include hair loss. 5 This is correct. Clinical manifestations of hyperthyroidism include weight loss.

The nurse is preparing teaching materials for a group of older adults. What information does the nurse include as risk factors for hearing loss? Select all that apply. 1. Smoking history 2. Heredity 3. Medications 4. Recreational noise 5. Occupational noise

ANS: 2, 3, 4, 5 1 This is incorrect. Smoking history is not identified as placing a person at higher risk for developing hearing loss. 2 This is correct. Heredity is identified as placing a person at higher risk for developing hearing loss. 3 This is correct. Specific medications are identified as placing a person at higher risk for developing hearing loss. 4 This is correct. Recreational noise is identified as placing a person at higher risk for developing hearing loss. 5 This is correct. Occupational noise is identified as placing a person at higher risk for developing hearing loss.

The nurse correlates which assessment data to a diagnosis of Cushing's syndrome in a female patient? Select all that apply. 1. Leg cramps 2. Amenorrhea 3. Breast atrophy 4. Menstrual pain 5. Deepening of the voice

ANS: 2, 3, 5 1 This is incorrect. Leg cramping is not a manifestation of Cushing's syndrome. 2 This is correct. In female patients, clinical manifestations include virilization (male sexual characteristics developing in females), breast atrophy, vocal changes (deepening), and amenorrhea. 3 This is correct. In female patients, clinical manifestations include virilization (male sexual characteristics developing in females), breast atrophy, vocal changes (deepening), and amenorrhea. 4 This is incorrect. Menstrual pain is not specifically linked to Cushing's syndrome. 5 This is correct. In female patients, clinical manifestations include virilization (male sexual characteristics developing in females), breast atrophy, vocal changes (deepening), and amenorrhea.

The nurse correlates which clinical manifestations to the diagnosis of rheumatoid arthritis? Select all that apply. 1. Bouchard's nodes 2. Boutonniere deformity 3. Swan-neck deformity 4. Tophi 5. Ulnar deviation

ANS: 2, 3, 5 1 This is incorrect. Osteophytes are projections of new cartilage and bone growth that form along joint lines in patients with osteoarthritis and lead to pain in the joint and decreased range of motion. Osteophyte formations on the proximal interphalangeal joints and distal interphalangeal joints are referred to as Bouchard's nodes and Heberden's nodes, respectively. 2 This is correct. Rheumatoid arthritis leads to irreversible joint damage and disability. Common joint deformities include swan-neck deformity caused by hyperextension of the proximal interphalangeal joints, boutonnière deformity caused by abnormal flexion of the proximal interphalangeal joints, and ulnar deviation caused by the lateral deviation of the phalanges. 3 This is correct. Rheumatoid arthritis leads to irreversible joint damage and disability. Common joint deformities include swan-neck deformity caused by hyperextension of the proximal interphalangeal joints, boutonnière deformity caused by abnormal flexion of the proximal interphalangeal joints, and ulnar deviation caused by the lateral deviation of the phalanges. 4 This is incorrect. Chronic tophaceous gout is characterized by repeated attacks of many years, leading to the production of tophi (uric acid deposits or nodules in the joint) and joint destruction. 5 This is correct. Rheumatoid arthritis leads to irreversible joint damage and disability. Common joint deformities include swan-neck deformity caused by hyperextension of the proximal interphalangeal joints, boutonnière deformity caused by abnormal flexion of the proximal interphalangeal joints, and ulnar deviation caused by the lateral deviation of the phalanges.

Which questions does the nurse ask when conducting an expanded assessment to determine patient orientation? Select all that apply. 1. "What is your name?" 2. "What state are you in right now?" 3. "What is today's date?" 4. "What are names of your children?" 5. "What kind of place are we in right now?"

ANS: 2, 4, 5 1 This is incorrect. This is an example of an assessment question to determine person, place, and time. It is not an example of an expanded assessment question to determine orientation. 2 This is correct. This is an example of an expanded assessment to determine orientation. A series of questions that go beyond the basic elements of orientation to person, place, and time help to establish a functional baseline and include specifics of place or location and specifics about the patient's current state or situation. 3 This is incorrect. This is an example of an assessment question to determine person, place, and time. It is not an example of an expanded assessment question to determine orientation. 4 This is correct. This is an example of an expanded assessment to determine orientation. A series of questions that go beyond the basic elements of orientation to person, place, and time help to establish a functional baseline and include specifics of place or location and specifics about the patient's current state or situation. 5 This is correct. This is an example of an expanded assessment to determine orientation. A series of questions that go beyond the basic elements of orientation to person, place, and time help to establish a functional baseline and include specifics of place or location and specifics about the patient's current state or situation.

A patient has an injury where one side of the bone is bent and the other is fractured. How does the nurse document this fracture? 1. Spiral 2. Oblique 3. Greenstick 4. Comminuted

ANS: 3 1 A spiral fracture wraps around the shaft of the bone. 2 An oblique fracture line occurs usually at a 45-degree angle across the cortex of the bone. 3 A greenstick fracture is an incomplete disruption where one side of the bone is bent and the other is fractured. 4 A comminuted fracture has several disruptions producing shattered bone fragments within the fracture site.

The nurse recognizes that the patient with dysfunction of the posterior pituitary gland is at risk for which disorder? 1. Acromegaly 2. Osteoporosis 3. Diabetes insipidus 4. Type 1 diabetes mellitus

ANS: 3 1 Acromegaly is caused by oversecretion of growth hormone. 2 Osteoporosis is an adverse effect of hypopituitarism. 3 Central diabetes insipidus is caused by a decreased secretion of antidiuretic hormone (ADH) from the posterior pituitary gland. 4 Type 1 diabetes mellitus is caused by a malfunction of the cells within the pancreas.

The nurse is evaluating dietary teaching provided to a patient recovering from osteomyelitis. Which meal choice indicates that additional teaching is required? 1. Green salad, meat loaf, brown rice, and broccoli 2. Caesar's salad, pork loin slices, sauerkraut, baked potato, and sautéed carrots 3. Tossed salad, spaghetti with marinara sauce, Italian bread, and creamed spinach 4. Iceberg lettuce wedge, baked chicken breast, parsley red potatoes, and green beans

ANS: 3 1 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice is adequate. 2 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice is adequate. 3 This meal choice has no protein. It may have adequate zinc and folic acid; however, protein is missing, which is required for wound healing. 4 Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice is adequate.

A patient is prescribed alendronate (Fosamax). What instruction does the nurse provide to the patient about this medication? 1. Take at bedtime. 2. Take with a full meal. 3. Take on an empty stomach. 4. Take 2 hours after breakfast.

ANS: 3 1 Alendronate (Fosamax) should not be taken at bedtime. 2 Alendronate (Fosamax) is not to be taken with a full meal. 3 Alendronate (Fosamax) should be taken on an empty stomach. 4 Alendronate (Fosamax) is not to be taken 2 hours after breakfast.

The nurse correlates which finding in a patient's history as the highest risk for a stroke? 1. Body mass index 24.8 2. Heart rate 90 bpm 3. Blood pressure 182/90 mm Hg 4. Pulse oximetry 90% on room air

ANS: 3 1 Although hypercholesterolemia is a risk factor for a stroke, being overweight is not identified as a risk factor for stroke. 2 A heart rate of 90 bpm is within normal limits and is not a risk factor for stroke. 3 A significant risk factor for stroke is hypertension. 4 A pulse oximeter reading of 90% on room air is low but not a risk factor for stroke.

A patient recently diagnosed with amyotrophic lateral sclerosis is having difficulty with swallowing and has been choking and coughing excessively at mealtimes. The nurse implements which action first? 1. Initiating low-flow oxygen therapy 2. Suctioning the oropharynx 3. Auscultating breath sounds 4. Assessing neurological status

ANS: 3 1 Although the patient may require supplemental oxygen, confirming airway and breathing are the priorities. 2 Although the patient may require suctioning, an assessment of airway and breath sounds is required. 3 The priority is to assess airway and breathing. Because motor weakness involves muscles of the face, mouth, and neck, maintaining an intact airway is compromised. Airway compromise is greater as the patient demonstrates weakened cough and impaired swallowing. 4 Assessing the neurological status is important, but in this situation, airway and breathing are the priorities.

In providing care to the patient with an aseptic nonunion of a fracture, the nurse correlates which prescribed medication as a potential cause of this complication? 1. Antibiotics 2. Muscle relaxants 3. NSAIDs 4. Opioids

ANS: 3 1 Antibiotics are indicated to treat infection and are not a factor for the development of aseptic nonunion. 2 Muscle relaxants may be used to treat muscle spasms associated with fractures but are not a factor in the development of aseptic nonunion. 3 Aseptic nonunion can be due to older age, anemia, use of tobacco and nicotine, diabetes, and medications that suppress healing such as NSAIDs, steroids, and aspirin. 4 Opioids are used for pain management in patient with fracture but are not a factor in the development of aseptic nonunion.

The nurse correlates which mechanism of action for the administration of parathyroid hormone in the patient with osteoporosis? 1. Inhibits osteoclastic activity 2. Increases calcium absorption in the gastrointestinal tract 3. Protects against gonadotropin-releasing hormone agonist related to bone loss 4. Promotes calcium phosphate absorption in the bone

ANS: 3 1 Bisphosphonate, calcitonin, dual-acting bone agents, and monoclonal activity agents inhibit osteoclastic activity. 2 Vitamin D increases calcium reabsorption in the gastrointestinal tract. 3 Parathyroid hormone (PTH) protects against gonadotropin-releasing hormone agonist-related bone loss. 4 Bisphosphonate promotes calcium phosphate absorption in the bone.

In administering pilocarpine to a patient, the nurse correlates which mechanism of action to this medication? 1. Decreases production of aqueous humor 2. Suppresses the inflammatory response 3. Increases outflow of aqueous humor 4. Vasoconstricts blood vessels

ANS: 3 1 Carbonic anhydrase inhibitors, like dorzolamide and brinzolamide, decrease the production of aqueous humor. 2 Glucocorticoids/steroids suppress the inflammatory response. 3 Miotics, or cholinergic agents, like pilocarpine and carbachol, increase the outflow of aqueous humor. 4 Anti-vascular endothelial growth factor (VEGF) therapy uses injections directly into the eye and is used to treat wet macular degeneration. This medication blocks the effects of the growth factor.

Which medication does the nurse correlate to the treatment of severe nausea and vomiting in the patient diagnosed with Ménière's disease? 1. Diazepam (Valium) 2. Meclizine (Antivert) 3. Promethazine (Phenergan) 4. Dimenhydrinate (Dramamine)

ANS: 3 1 Diazepam (Valium) depresses all levels of the central nervous system and thereby decreases symptoms. 2 Meclizine (Antivert) decreases excitability of the inner ear labyrinth and blocks conduction of the inner ear vestibular cerebellar pathways. 3 Promethazine (Phenergan) blocks histamine at the site to decrease symptoms of nausea and vomiting. 4 Dimenhydrinate (Dramamine) decreases the exaggerated sense of motion.

It is documented in the health record that a patient has a rhegmatogenous detached retina. The nurse correlates which underlying pathophysiology to this diagnosis? 1. Eye trauma causes the retinal to detach from the retinal pigment epithelium (RPE). 2. Eye inflammation causes vitreous fluid leaks into the area under the retina. 3. Vitreous fluid moves under the retina and separates the retina from the pigmented cell layer. 4. Scar tissue on the retina causes the retina to separate from the retinal pigment epithelium (RPE).

ANS: 3 1 Exudative retinal detachment can occur with eye trauma. 2 Exudative retinal detachment can occur with eye inflammation. 3 Rhegmatogenous is the most common form of retinal detachment and occurs when a tear or break in the retina allows vitreous fluid to move under the retina and separate it from the pigmented cell layer that nourishes the retina. 4 Tractional is the least common type of detachment and occurs when scar tissue on the retina's surface contracts and causes the retina to separate from the retinal pigment epithelium (RPE).

The nurse correlates which clinical manifestation to the patient being evaluated for Ménière's disease? 1. Facial pain 2. Nasal drainage 3. Positive Romberg test 4. Decreased deep tendon reflexes

ANS: 3 1 Facial pain is not associated with Ménière's disease. 2 Nasal drainage is not a primary symptom of Ménière's disease. 3 In Ménière's disease, patients may exhibit a positive Romberg test on examination (meaning they have a disturbance in balance) and may also have nystagmus. 4 Changes in deep tendon reflexes do not occur in Ménière's disease.

A patient is diagnosed with secondary hyperparathyroidism. Which additional health problem does the nurse assess for in this patient's history? 1. Diabetes insipidus 2. Hyperaldosteronism 3. Chronic renal failure 4. Parathyroid adenoma

ANS: 3 1 Hyperparathyroidism is not associated with diabetes insipidus. 2 Hyperparathyroidism is not associated with hyperaldosteronism. 3 Secondary hyperparathyroidism is most often observed in patients with chronic renal failure or chronic calcium malabsorption. 4 Parathyroid adenomas account for 85% of the cases of primary hyperparathyroidism.

A patient is admitted with a stroke/brain attack. The nurse correlates which predisposing factor in the patient's history places as placing this patient at greatest risk for embolic stroke? 1. Immobility as a result of back injury 2. Seizure history 3. Carotid plaque 4. Deep vein thrombus (DVT) in subclavian vein

ANS: 3 1 Immobility increases the risk of venous thrombi that would travel to the heart and lungs, not the brain. 2 A history of seizures is not a risk factor for embolic stroke. 3 Occlusion of large cerebral blood vessels (e.g., carotid arteries, vertebral arteries) by atherosclerotic plaque occurs when the plaque ruptures, causing a blood clot to form and block the vessel, or when atherosclerotic plaque accumulates to a point that it critically narrows and then completely obstructs blood flow. 4 A DVT would not travel to the carotid arteries; it would travel to the right side of the heart and pulmonary circulation.

The nurse prioritizes which nursing diagnosis as the highest in the patient with Guillain-Barré syndrome (GBS)? 1. Risk for Aspiration related to related to loss of sensation in oropharynx secondary to progressive neuronal degeneration 2. Ineffective Airway Clearance related to decreased cough secondary to decreased acetylcholine at neuromuscular junction 3. Ineffective Breathing Pattern related to skeletal muscle weakness secondary to destruction of myelin sheath 4. Impaired Gas Exchange related to loss of respiratory muscle secondary to nerve root compression

ANS: 3 1 In GBS, there is destruction of myelin of the peripheral nerves, not neuronal degeneration. 2 In GBS, there is destruction of myelin of the peripheral nerves, not decreased acetylcholine at neuromuscular junction. 3 In GBS, the patient's own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that impairs saltatory (jumping) conduction and results in slowing of impulses or conduction block. 4 In GBS, there is destruction of the myelin of the peripheral nerves, not nerve root compression.

The nurse provides care to a patient diagnosed with myasthenia gravis (MG) who is prescribed corticosteroid therapy. Which data require immediate notification of the healthcare provider? 1. Insomnia 2. Weight gain 3. Hyperglycemia 4. Truncal obesity

ANS: 3 1 Insomnia is an expected side effect for patients who are prescribed corticosteroid therapy. This does not require immediate notification of the healthcare provider; however, it may require an additional medication prescription. 2 Weight gain is an expected side effect for patients who are prescribed corticosteroid therapy. This does not require immediate notification of the healthcare provider. 3 When providing care to the patient who is diagnosed with MG, it is essential to monitor blood glucose levels closely. The patient may require insulin coverage. Hyperglycemia requires immediate notification of the healthcare provider. 4 Truncal obesity is an expected side effect for patients who are prescribed corticosteroid therapy. This does not require immediate notification of the healthcare provider.

The nurse administers which medication to the patient diagnosed with hypoparathyroidism? 1. Lithium 2. Synthroid 3. Vitamin D 4. Propylthiouracil (PTU)

ANS: 3 1 Lithium can be used to treat hyperthyroidism. 2 Synthroid is used to treat hypothyroidism. 3 Vitamin D is needed for calcium absorption from the bowel. 4 Propylthiouracil (PTU) is used to treat hyperthyroidism.

A patient with type 1 diabetes mellitus will be self-monitoring blood glucose levels at home. What is the minimum number of measurements that this patient should make each day? 1. 1 2. 3 3. 4 4. 8

ANS: 3 1 One measurement would not be sufficient to achieve tight glycemic control. 2 Three measurements would not provide a total picture of glycemic control. 3 Generally, patients with type 1 diabetes are advised to check their blood glucose a minimum of before meals and at bedtime or four times a day. 4 Eight measurements might be needed if another health problem affecting blood glucose levels is occurring with the patient.

The nurse monitors for which clinical manifestations in the patient diagnosed with Parkinson's disease? 1. Photophobia 2. Nuchal rigidity 3. Bradykinesia 4. Decreased level of consciousness

ANS: 3 1 Photophobia occurs with migraine headaches, meningitis, and encephalitis. 2 Nuchal rigidity occurs with meningitis and encephalitis. 3 Four discernible symptoms of Parkinson's disease are resting tremors, muscle rigidity, slowness of movement (bradykinesia) or loss of movement (akinesia), and postural instability (impaired balance and frequent falls). 4 Patients with Parkinson's disease may experience mood, cognitive, and behavioral alterations but not a decreased level of consciousness.

The nurse recognizes which patient is at highest risk for the development of macular degeneration? 1. 45-year-old woman with body mass index of 36 2. 55-year-old man with hypertension 3. 65-year-old woman with elevated cholesterol levels 4. 70-year-old man with history of smoking for 50 years

ANS: 3 1 Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. This patient has two risk factors—gender and obesity. 2 Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. This patient has one risk factor—hypertension. 3 Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. This patient has three risk factors—age, gender, and elevated cholesterol. 4 Risk factors for macular degeneration include hypertension, high cholesterol, obesity, decreased zinc levels, smoking, age older than 60, female gender, Caucasian race, and family history. This patient has two risk factors—age and smoking history.

The nurse correlates an increased risk of osteoarthritis in which of the following patients? 1. 40-year-old obese female who works as an administrative assistant 2. 45-year-old obese male who is a construction worker 3. 55-year-old obese female with works as a machine operator 4. 60-year-old obese male who works as an accountant

ANS: 3 1 Risk factors include obesity, age older than 55, female gender, and working in occupations that involve repetitive motions. This patient has two risk factors (obesity and female gender). 2 Risk factors include obesity, age older than 55, female gender, and working in occupations that involve repetitive motions. This patient has two risk factors (obesity and occupation). 3 Risk factors for osteoarthritis include obesity (the single most modifiable risk factor contributing to osteoarthritis), age older than 55 years (aging is one of the most prevalent risk factors for developing osteoarthritis, because only 0.1% of those aged 25 to 34 years are affected compared with 80% of individuals older than age 55), female gender, and occupations involving repetitive motions. This patient has four risk factors (age, obesity, female gender, and occupation). 4 Risk factors include obesity, age older than 55, female gender, and working in occupations that involve repetitive motions. This patient has two risk factors (age older than 55 and obesity).

A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress checkup. The nurse is reviewing the patient's plan of care and determines that the patient has met a goal of treatment when the patient makes which statement? 1. "I sleep for 10 hours at night." 2. "My joint pain is still severe in the morning." 3. "I get help with household tasks from my children and spouse." 4. "I try not to be too active because of the pain."

ANS: 3 1 Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. 2 Persistent joint pain would indicate that goals have not been met. 3 One technique for reducing stress on the joints is to get assistance from family members with household tasks. 4 The patient does not need to refrain from all activities to control pain.

The nurse prepares the patient diagnosed with a primary bone tumor for which treatment first? 1. Surgery 2. Amputation 3. Radiotherapy 4. Chemotherapy

ANS: 3 1 Surgery may occur after radiotherapy. 2 The goal of therapy is to prevent limb amputation. 3 In the case of primary bone tumors, radiotherapy is used to destroy or to reduce the size of the tumor so that chemotherapy and/or surgical excision can be used for treatment. 4 Chemotherapy may occur after radiotherapy.

A patient with type 1 diabetes mellitus is experiencing elevated blood glucose levels in the morning. Which action is indicated to address this complication? 1. Change the evening insulin dose. 2. Restrict oral fluids after 1800 hours. 3. Measure blood glucose at 0200 hours. 4. Limit carbohydrate intake to 45 g with evening meal.

ANS: 3 1 The cause of the elevated morning serum glucose levels needs to be determined before the healthcare provider changes the insulin dose. 2 Restricting oral fluids after 1800 hours will not impact the morning serum glucose levels. 3 The cause of elevated glucose levels needs to be determined. To determine what is causing the increased blood glucose levels in the morning, the blood glucose levels need to be checked in the early morning hours, 2 or 3 a.m., for several nights. If the blood glucose level is low at that early morning time, the high glucose levels later in the morning most likely are due to the Somogyi effect. If the blood glucose level is high or normal at that early morning hour, the increased levels later in the morning most likely are due to the dawn phenomenon. 4 The cause of the elevated morning serum glucose levels needs to be determined before the healthcare provider makes diet modifications.

A patient with osteoarthritis develops syndrome of inappropriate antidiuretic hormone (SIADH). What information in the patient's history does the nurse correlate to the development of this disorder? 1. Male gender 2. Age 70 years 3. Use of NSAIDs 4. Use of diuretics

ANS: 3 1 The epidemiology of SIADH is not related to gender. 2 The epidemiology of SIADH is not related to age. 3 Causes of SIADH vary and include side effects of medications such as NSAIDs. 4 The epidemiology of SIADH is not related to the use of diuretics, and they may be indicated in the treatment of this disorder.

The nurse correlates a husky voice in the patient with hypothyroidism to which assessment finding? 1. Chronic fatigue 2. Enlarged thyroid gland 3. Edema of the tongue and larynx 4. Dry mucous membranes from dehydration

ANS: 3 1 The husky voice is not caused by chronic fatigue. 2 The husky voice is not caused by an enlarged thyroid gland. 3 Edema of the tongue and around the larynx causes changes in speech resulting in a husky tone. 4 The husky voice is not caused by dry mucous membranes or dehydration.

Which patient receiving levothyroxine requires close monitoring of vital signs during medication titration? 1. The patient with a history of anxiety 2. The patient with a history of depression 3. The patient with a history of cardiovascular disease 4. The patient with a history of inflammatory bowel disease

ANS: 3 1 The patient with a history of anxiety does not require close monitoring of vital signs during levothyroxine medication titration. 2 The patient with a history of depression does not require close monitoring of vital signs during levothyroxine medication titration. 3 In patients with a history of cardiovascular disease, the increases in dosage of levothyroxine are made cautiously because sudden increases in cardiac rate and contractility secondary to the medication may lead to angina or congestive heart failure. 4 The patient with a history of inflammatory bowel disease does not require close monitoring of vital signs during levothyroxine medication titration.

The nurse monitors for which clinical manifestation in the patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Hematocrit 40% 2. Serum sodium 148 mEq/L 3. Urine specific gravity 1.035 4. Serum potassium 3.9 mEq/L

ANS: 3 1 This hematocrit level is within normal limits. In patients with SIADH, the hematocrit may be low secondary to hemodilution. 2 This serum sodium level is elevated. Serum sodium is decreased in SIADH secondary to fluid retention from excess secretion of ADH. 3 The urine specific gravity is elevated, which is seen in patients with SIADH. In patients with SIADH, because of excessive ADH secretion, they present with scant urine output and elevated urine specific gravity. 4 The serum potassium level is within normal limits, and this electrolyte is not used in the diagnosis of SIADH.

Which statement by the patient diagnosed with gout indicates the need for further teaching by the nurse related to dietary guidelines? 1. "I should drink at least 8 glasses of water daily." 2. "I need to avoid red meats." 3. "I am not allowed to drink wine but can drink beer." 4. "It is okay to eat chicken."

ANS: 3 1 This is a correct statement and does not indicate the need for further teaching because consuming adequate fluids can minimize the risk of developing uric acid kidney stones. 2 This statement indicates understanding of teaching because patients with gout should avoid high-purine foods such as red meat, liver, and fish. 3 This statement indicates the need for further teaching because the patient needs to avoid alcoholic beverages, especially beer, because alcohol is high in purines, which metabolize into uric acid, increasing serum uric acid levels. 4 This statement indicates understanding teaching because there is no restriction on chicken; patients with gout are taught to avoid high-purine foods such as red meat, liver, and fish.

The nurse provides care for a patient diagnosed with myasthenia gravis (MG). Which is the priority when administering the prescribed dose of pyridostigmine (Mestinon)? 1. Administering the medication on awakening in the morning 2. Monitoring the patient for increased secretions 3. Administering the medication 30 to 60 minutes before each meal 4. Teaching the patient not to crush or chew the sustained-release form of medication

ANS: 3 1 This medication is the accepted initial treatment of choice for MG. The standard dosage is 30 to 60 mg by mouth every 4 hours while the patient is awake. 2 Although this medication may cause increased secretions, this is not the priority nursing action when administering the prescribed dose. 3 Pyridostigmine must be administered exactly at the prescribed hour to maintain optimal muscle strength. Additionally, it is important to adhere to the patient's medication schedule followed at home. Patients need to take pyridostigmine 30 to 60 minutes before meals to minimize difficulty with chewing and swallowing. This is the priority nursing action to decrease the patient's risk for aspiration. 4 Although the sustained-release form of the medication should not be crushed or chewed and this information should be taught to the patient before discharge, this is not the nurse's priority before administering the prescribed dose.

A patient with macular degeneration is being treated with verteporfin (Visudyne). The nurse emphasizes which information regarding actions to reduce the risk of complications from this treatment? 1. Apply lotion to the skin for 2 weeks after the treatment. 2. Increase the intake of water for 3 days after the treatment. 3. Avoid indoor and outdoor light for 5 days after treatment. 4. Wear sunglasses when outdoors for 1 week after treatment.

ANS: 3 1 This treatment does not affect the skin. 2 Increased fluid intake is not required after this treatment. 3 It is important to instruct the patient to avoid exposing skin and eyes to direct sunlight or bright indoor light for 5 days after treatment with verteporfin (Visudyne) because the medication is activated by light. 4 The patient should avoid indoor and outdoor bright light for 5 days. Sunglasses would not be needed because bright light is avoided.

The nurse correlates that the patient with which type of musculoskeletal trauma has the highest risk of developing rhabdomyolysis? 1. Traumatic amputation 2. Compound fracture of the femur 3. Crush injury of the pelvis 4. Compression fracture of the lumbar spine

ANS: 3 1 Traumatic amputation is not a risk factor for rhabdomyolysis. The patient with traumatic amputation is at risk for hemorrhage and infection. 2 Compound fractures are not a risk factor for rhabdomyolysis. The patient with this injury is at risk for hemorrhage, infection, and malunion. 3 Traumatic rhabdomyolysis is a potential complication from injuries that result in compression and tissue ischemia, such as crush injuries. Crush injuries produce continued compression of muscle tissue that restricts blood flow and precipitates tissue ischemia. Tissue ischemia catalyzes a vicious cycle of further inflammation, increased capillary permeability, and the release of more fluid and intracellular contents into the compartment and circulatory system. 4 Compression fractures of the lumbar spine are not a risk factor for rhabdomyolysis. The patient with this injury is at risk for nerve root compression and pain.

A 40-year old patient is surprised to learn of the diagnosis of type 1 diabetes mellitus. What is the nurse's best response? 1. "It is odd because it is usually a disease of childhood." 2. "It means that something has destroyed your pancreas." 3. "Type 1 diabetes mellitus can occur at any stage of life." 4. "It usually means that another disease process is present."

ANS: 3 1 Type 1 diabetes mellitus (DM) can occur at any stage of life. 2 The pancreas is not destroyed in type 1 DM; the beta cells are secreting insufficient insulin to control serum glucose. Once beta-cell destruction has progressed to the point of total insulin deficiency, patients with type 1 diabetes require externally delivered insulin (provided via a pump or injection) for the remainder of their lives. 3 Type 1 diabetes can occur at any stage of life. 4 Type 1 diabetes does not mean that another disease process is present or occurring in the patient.

The nurse determines which patient is at highest risk for the development of osteoporosis? 1. 48-year old Hispanic female with a body mass index (BMI) of 35 and a history of hyperparathyroidism 2. 52-year old African American male with history of inflammatory bowel disease 3. 55-year old Caucasian patient with a BMI of 17 and history of hyperthyroidism 4. 60-year old Asian male who works as a tailor

ANS: 3 1 This patient's risk factors include female gender, obesity, and hyperparathyroidism. 2 This patient's risk factors include age and history of inflammatory bowel disease. 3 This patient has the highest number of risk factors, including female gender, age older than 50, low body weight, and history of hyperthyroidism. 4 This patient's risk factors include age and race.

The nurse provides education to a patient who is newly diagnosed with multiple sclerosis (MS). Which patient statements indicate the need for additional teaching? Select all that apply. 1. "I may experience visual disturbances." 2. "I may experience urinary incontinence." 3. "I should not exercise because this may trigger an exacerbation." 4. "I should alternate the eye patch every other day to help with the double vision." 5. "I need to check the water temperature before I take a bath."

ANS: 3, 4 1 This is incorrect. This patient statement indicates a correct understanding of the information presented regarding MS because visual disturbances may develop. 2 This is incorrect. This patient statement indicates a correct understanding of the information presented regarding MS because urinary incontinence may develop. 3 This is correct. Range-of-motion exercises are encouraged for the patient diagnosed with MS because they increase venous return, prevent stiffness, and help maintain muscle strength and endurance; therefore, this patient statement indicates a need for additional teaching. 4 This is correct. This patient statement indicates a need for additional teaching because the eye patches need to be alternated several times throughout the day, not every other day. 5 This is incorrect. This patient statement indicates a correct understanding of the teaching because the patient is at risk for burn injuries as a result of decreased sensation associated with MS.

The nurse provides education to a patient who is diagnosed with type 1 diabetes mellitus (DM). Which patient statements indicate the need for additional teaching regarding self-monitoring of blood glucose? Select all that apply. 1. "I will check my blood glucose daily before meals and at bedtime." 2. "I will monitor my blood glucose levels more frequently when I have the flu." 3. "I don't need to document the results of my blood glucose if it is within the normal limits." 4. "Because I am using an insulin pump, I don't need to check my blood glucose as often as before." 5. "Because my fasting blood glucose levels are consistent with my A1c, I don't need to increase the frequency of monitoring my glucose."

ANS: 3, 4 1 This is incorrect. This statement indicates a correct understanding regarding self-monitoring of blood glucose. Minimum requirements for self-monitoring of blood glucose for the patient diagnosed with type 1 diabetes mellitus are to check blood glucose before each meal and at bedtime. 2 This is incorrect. This statement indicates a correct understanding regarding self-monitoring of blood glucose. The patient is taught to monitor blood glucose levels more frequently when experiencing acute illness. 3 This is correct. This statement indicates the need for additional teaching. It is essential that patients document their blood glucose levels so that trends can be identified. 4 This is correct. This statement indicates the need for additional teaching. Patients who use an insulin pump for glycemic control often monitor their blood glucose levels more frequently. 5 This is incorrect. This statement indicates a correct understanding regarding self-monitoring of blood glucose. An increased frequency of monitoring blood glucose levels is required if fasting blood glucose levels are inconsistent (not consistent) with A1c levels.

The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which data are included in this presentation? Select all that apply. 1. Absence seizures usually last 1 to 3 hours. 2. Atonic seizures are loss of motor tone after a few seconds of clonic activity. 3. Myoclonic seizures involve sudden brief, involuntary contractions. 4. Tonic seizures are sustained muscle contractions lasting a few seconds to minutes. 5. Tonic-clonic seizures include rigidity followed by jerking movements.

ANS: 3, 4, 5 1 This is incorrect. Absence seizures typically last 5 to 10 seconds. 2 This is incorrect. Atonic seizures involve a sudden loss or diminution of muscle tone without apparent preceding myoclonic or tonic event lasting approximately 1 to 2 seconds, involving head, trunk, jaw, or limb musculature. 3 This is correct. Myoclonic seizures are sudden brief, involuntary single or multiple contraction(s) of muscles(s) or muscle groups. 4 This is correct. Tonic seizures are a sustained increase in muscle contraction lasting a few seconds to minutes. 5 This is correct. Tonic-clonic seizures are a sequence consisting of a tonic followed by a clonic phase.

The nurse monitors for which clinical manifestations in the patient diagnosed with type 1 diabetes mellitus? decision? Select all that apply. 1. Weight gain 2. Sweating 3. Extreme hunger 4. Excessive thirst 5. Large volume of urine output

ANS: 3, 4, 5 1 This is incorrect. Weight gain is not a manifestation of type 1 diabetes mellitus. 2 This is incorrect. Sweating is seen in patients who are hypoglycemic. 3 This is correct. Extreme hunger or polyphagia is a manifestation of type 1 diabetes mellitus. 4 This is correct. Excessive thirst or polydipsia is a manifestation of type 1 diabetes mellitus. 5 This is correct. Large volumes of urine output or polyuria are a manifestation of type 1 diabetes mellitus.

A patient with hypothyroidism asks why the neck has become so large. What should the nurse respond to this patient? 1. "The growth is cancer." 2. "The sluggish thyroid caused fat to be deposited around the neck." 3. "The growth is the body's attempt to wall off the infection in your thyroid." 4. "The gland got larger because it was trying to make more thyroid hormone."

ANS: 4 1 A goiter is not cancer. 2 A goiter is not fat deposits. 3 A goiter does not develop because of an infection of the thyroid gland. 4 Hypothyroidism is a major cause of goiter and develops secondary to thyroid gland hypertrophy in an attempt to produce normal amounts of T3 and T4.

The patient enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the patient and finds a butterfly rash over the bridge of nose and on the cheeks. Then nurse correlates this data with the clinical manifestations of which disorder? 1. Gout 2. Lyme disease 3. Fibromyalgia 4. Systemic lupus erythematosus

ANS: 4 1 Although fibromyalgia, Lyme disease, and gout share some symptoms of systemic lupus erythematosus (SLE), they do not cause a rash over the nose and cheeks. 2 Although fibromyalgia, Lyme disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 3 Although fibromyalgia, Lyme disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 4 The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE).

The nurse provides care to a patient diagnosed with type 1 diabetes mellitus (DM) whose hemoglobin A1c level remains elevated despite the use of the prescribed sliding scale insulin. The healthcare provider prescribes an insulin pump. The patient asks, "Why did my doctor prescribe a pump?" Which response by the nurse is best? 1. "The pump is worn continuously." 2. "The pump is more convenient for you." 3. "The pump provides more precise dosages of insulin." 4. "The pump provides better control of your blood sugar."

ANS: 4 1 Although the insulin pump is worn continuously, this is considered a disadvantage for this therapy. 2 Although the insulin pump does offer convenience, this is not the best response from the nurse regarding why the healthcare provider prescribed this therapy for the patient. 3 Although the insulin pump does provide more precise dosages of insulin, this is not the best response from the nurse regarding why the healthcare provider prescribed this therapy for the patient. 4 The use of the subcutaneous insulin pump has been found to provide better glycemic control, especially in patients with higher hemoglobin A1c levels, indicating poor glycemic control with traditional methods. This is the best response because this patient has an elevated A1c level despite the implementation of a sliding scale insulin prescription.

A patient with type 2 diabetes mellitus is being evaluated for hyperosmolar hyperglycemic state (HHS). The nurse correlates which finding with this medical diagnosis? 1. pH 7.31 2. Diaphoresis 3. Blood glucose 250 mg/dL 4. Serum bicarbonate 28 mEq/L

ANS: 4 1 An acidotic pH is associated with diabetic ketoacidosis (DKA). 2 Diaphoresis is associated with hypoglycemia. Skin is usually dry in hyperosmolar hyperglycemic state (HHS), and the patient develops dehydration. 3 Blood glucose level of 250 mg/dL is associated with DKA. 4 An elevated serum bicarbonate level greater that 15 mEq/L is associated with HHS.

The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? 1. Place on a cooling blanket. 2. Notify the healthcare provider. 3. Monitor body temperature every 2 hours. 4. Change linen and gown and keep comfortable.

ANS: 4 1 Autonomic dysfunction is causing the sweating. The patient does not have a temperature. 2 The healthcare provider does not need to be notified. 3 The patient does not have a fever. Autonomic dysfunction is causing the sweating. 4 Patients with GBS may perspire because of autonomic manifestations, and the patient's clothing and linens require frequent changes.

The nurse recognizes which disorder as the most common cause of hyperthyroidism? 1. Cancer 2. Toxic medications 3. Radiation exposure 4. Autoimmune disorder

ANS: 4 1 Cancer is not identified as a common cause for hyperthyroidism. 2 Toxic medications are not identified as common causes for hyperthyroidism. 3 Radiation exposure is not identified as a common cause for hyperthyroidism. 4 Graves's disease is the most common cause of hyperthyroidism and is an autoimmune disorder involving antibodies (thyroid-stimulating immunoglobulins) that bind to the thyroid gland, resulting in the enlargement of the thyroid gland and subsequent hypersecretion of thyroid hormone.

The nursing diagnosis "Impaired visual sensory perception related to abnormal blood vessel growth behind the retina" is most relevant to the patient with which eye disorder? 1. Cataracts 2. Dry macular degeneration 3. Glaucoma 4. Wet macular degeneration

ANS: 4 1 Cataracts involve a clouding of the eye's lens that decreases vision as a result of interference with light reaching the retina secondary to the cloudiness. 2 Dry macular degeneration occurs when the light-sensitive cells in the macula slowly start to break down. 3 Glaucoma is an eye disease that develops secondary to increases in intraocular pressure that results in damage to the optic nerve, leading to loss of vision. 4 Wet macular degeneration occurs when abnormal blood vessels located behind the retina start to grow under the macula. These new networks of blood vessels are known to be very fragile and often leak blood and fluid. This blood and fluid raise the macula from its usual position at the back of the eye, and damage to the macula occurs rapidly.

The nurse correlates which clinical manifestation to a definitive diagnosis of multiple sclerosis? 1. Onset of double vision 2. Loss of bowel and bladder control 3. Numbness and tingling of one limb 4. Magnetic resonance imaging (MRI) changes in two separate locations

ANS: 4 1 Double vision is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 2 Loss of bowel and bladder control is a manifestation of a herniated disk. 3 Numbness and tingling of one limb is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 4 For a definitive diagnosis multiple sclerosis, the patient must have MRI changes in at least two separate locations.

In planning care for a patient admitted for treatment of a connective tissue disorder, the nurse formulates the nursing diagnosis, "Self-care deficit related to decreased joint mobility secondary to an autoimmune response resulting in Boutonniere deformities" is most relevant for which disorder? 1. Fibromyalgia 2. Gout 3. Osteoarthritis 4. Rheumatoid arthritis

ANS: 4 1 Fibromyalgia is a chronic pain disorder of soft connective tissues that is characterized by widespread pain and other symptoms such as insomnia, fatigue, stiffness, and cognitive dysfunction; inability to focus or concentrate on tasks. The etiology and pathophysiology of this disorder are unclear, but current theories include the abnormal processing of stimuli by the central nervous system causing normal pain signals to be amplified. 2 Gout is a disease in which monosodium urate crystals are deposited in joints, bone, and soft tissues accompanied by inflammation. 3 Osteoarthritis is primarily a noninflammatory type of arthritis that results from weight-bearing, trauma, infection, and overuse. Damage occurs within the joint, which leads to the deterioration of joint function. 4 Rheumatoid arthritis is an autoimmune inflammatory disease that not only affects joints but may also affect other organ systems. Inflammation within each organ system is what causes organ or tissue damage.

The nurse is caring for a patient recovering from cataract removal surgery. Which action does the nurse take to reduce intraocular pressure (IOP)? 1. Restricting fluids 2. Positioning on the operative side 3. Administering mydriatic eye drops 4. Elevating the head of the bed 45 degrees

ANS: 4 1 Fluids do not need to be restricted after cataract surgery. This does not decrease intraocular pressure. 2 Positioning on the operative side would increase intraocular pressure (IOP). 3 Mydriatic eye drops dilate the pupil and would be provided preoperatively. These drops do not affect IOP in the patient after cataract surgery. 4 Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any increase in IOP.

An older adult patient diagnosed with type 1 diabetes mellitus has poor oral intake. The nurse takes which action to ensure adequate blood glucose control? 1. Holding all prandial doses 2. Considering increasing longer-acting insulin 3. Increasing the frequency of correctional doses 4. Administering prandial and correctional insulin together

ANS: 4 1 Holding prandial doses would not be appropriate because this is administered before eating. The nurse needs to assess intake before administration of insulin or there is a risk of hypoglycemia. 2 Increasing longer-acting insulin could cause early morning hypoglycemia. 3 Increasing the frequency of correctional doses would not be appropriate because the patient has poor oral intake. 4 In patients with questionable or minimal oral intake, prandial and correctional insulins may be administered together after meals after adequate carbohydrate intake has been confirmed.

The nurse correlates which data as placing a patient at risk for experiencing a metabolic seizure? 1. Serum magnesium 3.2 mg/dL 2. Serum calcium 14 mg/dL 3. Serum potassium 3.2 mEq/L 4. Serum sodium 115 mEq/L

ANS: 4 1 Hypomagnesemia increases the risk of metabolic seizures. This is an elevated magnesium level; normal range is 1.6 to 2.2 mg/dL. 2 Hypocalcemia increases the risk of metabolic seizures. This is an elevated calcium level; the normal range is 8.2 to 10.2 mg/dL. 3 Serum potassium is not associated with seizure disorders. 4 Hyponatremia and hypernatremia are associated with metabolic seizures. This is a decreased sodium level; the normal range is 135 to 145 mEq/L.

The nurse is caring for a patient with multiple sclerosis. What actions does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance? 1. Administer interferon 2. Administer corticosteroids 3. Turn and reposition every 2 hours 4. Encourage range-of-motion exercises

ANS: 4 1 Interferon decreases exacerbations and slows disease progression. 2 Corticosteroids decreases the inflammatory processes associated with the flare. 3 Turning and repositioning every 2 hours prevents skin breakdown. 4 Range-of-motion exercises increase venous return, prevent stiffness, and maintain muscle strength and endurance.

The nurse monitors for which clinical manifestation in the patient diagnosed with a cataract? 1. Itching of the right eye 2. Tearing of the right eye 3. Redness of the sclera of the right eye 4. Double vision in the right eye

ANS: 4 1 Itching eyes is not a manifestation of cataracts. 2 Eye tearing is not a manifestation of cataracts. 3 Reddened sclera is not a manifestation of cataracts. 4 Double vision is a manifestation of cataracts.

The nurse monitors for which clinical manifestation in the patient being treated for Ménière's disease? 1. Muscle cramps 2. Drop in blood pressure 3. Capillary glucose 60 mg/dL 4. Uncontrollable eye movements

ANS: 4 1 Muscle cramps are not associated with Ménière's disease. 2 Hypotension is not a manifestation of Ménière's disease. 3 Hypoglycemia is not typically associated with Ménière's disease. 4 Uncontrollable eye movements are manifestations of Ménière's disease.

A patient with type 2 diabetes mellitus is prescribed a glucagon-like peptide-1 agonist. The nurse teaches the patient to monitor for which side effects of this medication? 1. Nausea 2. Diarrhea 3. Dry mouth 4. Decreased appetite

ANS: 4 1 Nausea is not identified as an adverse effect of this medication. 2 Diarrhea is not identified as an adverse effect of this medication. 3 A dry mouth is not identified as an adverse effect of this medication. 4 Glucagon-like peptide-1 (GLP-1) agonists are injected subcutaneously twice a day, an hour before breakfast and an hour before dinner. They lower glucose levels by slowing glucose absorption from the intestine, increasing insulin secretion when blood glucose levels are high, and lowering high glucagon levels sometimes found in diabetics after meals. A side benefit of GLP-1 agonists is the action of decreasing appetite by attaching to an appetite receptor on the hypothalamus, ultimately helping with weight loss.

The nurse is evaluating care provided to a patient with hypothyroidism. Which finding indicates that additional care is needed? 1. Warm skin 2. Heart rate 72 3. Blood pressure 118/68 mm Hg 4. Weight increase 2 kg over a month

ANS: 4 1 Normal skin turgor and texture are indicative of thyroid health in this patient population. 2 Vital signs within normal limits indicates thyroid health. 3 Vital signs within normal limits indicates thyroid health. 4 Stable weight indicates thyroid health. A weight gain indicates a sluggish thyroid in this patient population.

The nurse notes that a patient is diagnosed with Hashimoto's thyroiditis. What is the most likely cause of this patient's health problem? 1. Congenital 2. Iodine deficiency 3. Tyrosine deficiency 4. Autoimmune response

ANS: 4 1 One cause of primary hypothyroidism is a congenital thyroid disorder; however, this does not cause Hashimoto's thyroiditis. 2 Hypothyroidism can be caused by an iodine deficiency; however, this is rare because of iodized salt. 3 Hypothyroidism can be caused by a tyrosine deficiency; however, this is rare because of iodized salt. 4 Hashimoto's thyroiditis is the most common type of hypothyroidism and is caused by an autoimmune response that leads to destruction of the thyroid gland by immunological processes.

The nurse correlates the action of which medication to the treatment of diabetes insipidus (DI)? 1. Pitocin 2. Synthroid 3. Vitamin D 4. Desmopressin (DDAVP)

ANS: 4 1 Pitocin is used to induce or enhance labor in pregnancy. 2 Synthroid is a replacement for hypothyroidism. 3 Vitamin D is appropriate for a patient with osteoporosis caused by low growth hormone levels. 4 Desmopressin (DDAVP), a synthetic analog of antidiuretic hormone (ADH), is the drug of choice in patients with DI.

The nurse is providing health education to a diverse group at a neighborhood community center. The nurse includes information about signs and symptoms of systemic lupus erythematosus (SLE) for which of the following reasons? 1. The neighborhood is composed of many young female children. 2. The neighborhood has a large number of older adult women. 3. The audience is mainly composed of Caucasian women. 4. The audience is mainly females of Asian-American descent.

ANS: 4 1 SLE affects individuals of childbearing age. 2 Age of onset varies according to gender and ethnicity, but overall 65% of patients are diagnosed between the ages of 16 to 55. 3 Among women who are of childbearing age, SLE is more common in African-Americans, Hispanics, and Asian-Americans than Caucasians. 4 Among women who are of childbearing age, SLE is more common in African-Americans, Hispanics, and Asian-Americans than Caucasians.

The nurse correlates decreased peripheral vision in both eyes to which eye disorder? 1. Secondary glaucoma 2. Acute angle glaucoma 3. Normal-tension glaucoma 4. Primary open-angle glaucoma

ANS: 4 1 Secondary glaucoma usually results from an eye injury, inflammation, tumor, advanced cases of cataracts, or diabetes. Medications such as steroids, when used chronically, are also noted to cause this type of glaucoma. 2 Acute angle glaucoma is characterized by severe eye pain, nausea and vomiting, sudden onset of visual disturbance (often in low light), blurred vision, halo vision, and reddening of the eye. 3 Normal-tension glaucoma (also referred to as low-tension glaucoma) is a condition where optic nerve damage and vision loss occur despite having a normal intraocular pressure (IOP) between 10 to 21 mm Hg. 4 In primary open-angle glaucoma, clinical manifestations include gradual loss of peripheral vision, usually in both eyes.

A patient is in skeletal traction secondary to a fracture of the left femur. When the patient's spouse asks about the purpose of traction, which response by the nurse is best? 1. "This type of traction prevents movement of any part of the left leg." 2. "This type of traction decreases the chance of bone infection." 3. "This type of traction is used to treat muscle spasms in the left leg." 4. "This type of traction aids in realigning the bone."

ANS: 4 1 Skeletal traction does not prevent movement; it is used to align the bone. 2 Skeletal traction does not decrease infection as it uses instrumentation into the bone. 3 Skin traction uses a flexible harness, boot, or belt to secure the extremity while 5 to 10 lbs. of weight is applied to relieve muscle spasms and maintain the length of the bone. 4 In skeletal traction, pins, tongs, screws, and wires are surgically secured to the bone, and weight is then applied to provide realignment.

Which parameter does the nurse use to guide the effectiveness of intravenous fluid replacement in the patient with diabetes insipidus? 1. Skin turgor 2. Urine output total 3. Hemoglobin level 4. Serum sodium level

ANS: 4 1 Skin tenting indicates insufficient fluid replacement in the patient with diabetes insipidus (DI) but is not as specific as the serum sodium level. 2 Because DI is caused by excessive secretion of antidiuretic hormone (ADH), there is increased excretion of dilute urine, and this is not an indication of actual fluid volume status. 3 Hemoglobin level is not used to guide intravenous fluid replacement therapy. 4 The solution ordered is based on serum sodium level, which is typically elevated secondary to secretion of ADH.

The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year who has a history of type 2 diabetes mellitus. The patient has recently been placed on prednisone for treatment. Which patient statement indicates that the medication teaching was successful? 1. "I can eat canned vegetables." 2. "I can take this medication on an empty stomach." 3. "I do not need to monitor my blood sugar more frequently while on this medication because I take pills for my diabetes." 4. "I will take the ordered dose at the same time every day."

ANS: 4 1 Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. 2 Steroids are taken with food to minimize gastrointestinal distress. 3 Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen. 4 Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day.

The nurse monitors for which clinical manifestations in the patient diagnosed with hypoparathyroidism? 1. Low heart rate 2. Muscle weakness 3. Respiratory rate 20 and shallow 4. Hand spasm

ANS: 4 1 The heart rate is not impacted by parathyroid hormone. 2 Muscle weakness is not associated with hypoparathyroidism. 3 A respiratory rate of 20 and shallow is not associated with hypoparathyroidism. 4 A hand spasm when measuring blood pressure indicates Trousseau's sign.

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? 1. "An infection destroys the nerve endings." 2. "An infection enters the spinal cord and erodes the nerves at the roots." 3. "The nerves are killed by infiltration of your body's white blood cells used to fight an infection." 4. "The covering of nerves that help conduct impulses is damaged."

ANS: 4 1 The myelin is damaged in GBS, not the nerve endings. 2 An infection does not enter the spinal cord and erode the nerves at the roots in GBS. 3 The nerves are not killed by the body's white blood cells in GBS. 4 In GBS, the patient's own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in slowing of impulses or conduction block. There is infiltration of lymphocytes into the peripheral nervous system, which attracts macrophages; the macrophages penetrate the Schwann cells and invade the myelin, resulting in demyelination.

A patient with chronic renal failure is diagnosed with hyperparathyroidism. Which treatment approach is most effective in this patient? 1. Increased oral fluid intake 2. Oral thiazide diuretics twice a day 3. High-volume normal saline infusions 4. Discontinued calcium and vitamin D supplements

ANS: 4 1 The patient has chronic renal failure and will most likely have a fluid restriction. 2 Thiazide diuretics increase reabsorption of calcium in the kidney. 3 The patient has chronic renal failure and will most likely have a fluid restriction. 4 Patients with hyperparathyroidism are also taught to decrease consumption of calcium-containing antacids and vitamin D. Calcium and vitamin D supplements will most likely be discontinued.

A patient with a seizure disorder asks the purpose of staying awake all night before having an electroencephalogram (EEG) in the morning. What should the nurse explain to this patient? 1. "You will be expected to sleep during the test." 2. "Most people with seizure disorders receive too much sleep." 3. "This is the only way to confirm that you really have a seizure disorder." 4. "Sleep deprivation can cause a seizure, which will be helpful during the test."

ANS: 4 1 The patient will not be expected to sleep during a sleep-deprived EEG. 2 Saying that people with seizure disorders sleep too much is not related to the pathophysiology of this disorder. 3 A sleep-deprived EEG is not the only way to confirm that the patient really has a seizure disorder. When sleep is deprived, cortical activity may be increased, triggering a seizure. 4 A sleep-deprived EEG may be performed. Stress, such as that found when the individual is deprived of sleep, causes an increase in cortical activity and is a key trigger for seizures.

A patient experiencing diabetic ketoacidosis (DKA) is receiving a normal saline infusion and intravenous insulin. What additional medication does the nurse expect to be prescribed for this patient? 1. Diuretic 2. Calcium 3. Antibiotic 4. Potassium

ANS: 4 1 The patient will not need a diuretic because of osmotic diuresis occurring with the diabetic ketoacidosis (DKA). 2 There is no need to supplement calcium in the patient with DKA. 3 Antibiotics are not routinely prescribed in the treatment of DKA. 4 Care must be taken to monitor potassium levels before treating the hyperglycemia with insulin. As insulin is administered to decrease hyperglycemia, potassium will also move back into the cell, worsening hypokalemia. If hypokalemia is present, potassium replacement is a priority.

A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history? 1. "Have you been around any small children?" 2. "When was the last time you had anything to eat?" 3. "When was the last time you traveled out of the country?" 4. "Have you recently experienced any lung or stomach infections?"

ANS: 4 1 There is no evidence to suggest that Guillain-Barré syndrome (GBS) is transmitted from small children. 2 Recent ingestion of food most likely did not cause the patient's symptoms. 3 Traveling out of the country is not directly linked to the development of Guillain-Barré syndrome (GBS). 4 About two-thirds of patients who develop Guillain-Barré syndrome (GBS) demonstrate clinical manifestations of an infection 3 weeks before onset. Respiratory or gastrointestinal infections are the most common sources.

The nurse provides care to a patient who experienced a femur fracture. Which clinical manifestation requires immediate notification of the healthcare provider? 1. Pain 2. Edema 3. Nausea 4. Restlessness

ANS: 4 1 This is an anticipated clinical manifestation for the patient with a femur fracture and does not require immediate notification of the healthcare provider. 2 This is an anticipated clinical manifestation for the patient with a femur fracture and does not require immediate notification of the healthcare provider. 3 Nausea can be the result of the opioid pain medication that is used to treat the pain associated with this injury. Although this may require the administration of anti-nausea medication, it does not require immediate notification of the healthcare provider. 4 Patients may experience symptoms of respiratory distress, acute confusion, and restlessness with fat emboli, which is a medical emergency requiring immediate notification of the healthcare provider. If not treated, it can lead to respiratory failure and patient death.

The nurse provides care to a patient diagnosed with osteoarthritis who is prescribed daily acetaminophen. Which patient statement requires an intervention? 1. "I am not experiencing as much pain as I was before." 2. "I joined a gym to learn muscle-strengthening exercises." 3. "I lost 10 lbs. since my last visit by modifying my diet." 4. "I only drink a couple of beers when I get home from work."

ANS: 4 1 This patient statement indicates the current treatment regimen is effective. 2 This patient statement indicates the current treatment regimen is effective. 3 This patient statement indicates the current treatment regimen is effective. 4 The patient who is prescribed daily acetaminophen is at increased risk for hepatic toxicity because of almost daily consumption of alcohol. This patient statement requires the nurse to contact the healthcare provider.

In reviewing education for the patient who is receiving a cochlear implant, which statement indicates the need for additional teaching? 1. "The microphone retrieves sound from the environment." 2. "The electrodes send the impulses to different regions of the auditory nerve." 3. "The speech processor selects and arranges sounds received from the microphone." 4. "The transmitter receives signals from the microphone and converts them into impulses."

ANS: 4 1 This statement indicates a correct understanding. 2 This statement indicates a correct understanding. 3 This statement indicates a correct understanding. 4 This statement indicates the need for additional teaching. The transmitter and receiver stimulator receive signals from the speech processor (not the microphone) and convert them into electrical impulses.

The nurse is evaluating teaching provided to a patient with hyperparathyroidism. Which statement by the patient indicates the need for further teaching? 1. "I should expect to have a poor appetite." 2. "I should eat raw vegetables and fruits every day." 3. "I should expect to have muscle cramping and pain." 4. "I should consume dairy products with breakfast and lunch."

ANS: 4 1 This statement indicates patient understanding as anorexia is a manifestation of hyperparathyroidism. 2 The patient should be instructed to increase roughage to reduce constipation caused by an elevated calcium level. 3 This statement indicates patient understanding of the teaching. Muscle cramping and pain are manifestations of hyperparathyroidism. 4 This statement indicates the need for further teaching. The patient should be instructed to restrict the intake of calcium-rich foods.

Which statement by the patient with suspected osteomyelitis indicates that teaching was effective? 1. "Osteomyelitis increases my risk of bone cancer." 2. "I will have to be on antibiotics for about 7 to 14 days." 3. "This can be cured with radiation therapy." 4. "A bone biopsy is the best way to diagnose this disease."

ANS: 4 1 This statement indicates the need for additional teaching because osteomyelitis is not a risk factor for bone cancer. 2 This statement indicates the need for additional teaching because the initial line of treatment is antibiotic intravenous infusions over a course of 4 to 6 weeks from the time of the final surgical debridement or surgical cleaning of the wound. 3 This statement indicates the need for additional teaching because antibiotics, not radiation therapy, is the treatment for osteomyelitis. 4 This statement indicates that teaching was effective because a bone biopsy is the gold standard for conclusive diagnosis for osteomyelitis. An open (preferred) approach or needle aspirate can be used for this procedure. A positive biopsy (infectious bone) is conclusive for both acute and chronic osteomyelitis.

Which statement by the patient with neural hearing loss indicates understanding of teaching about this disorder? 1. "My hearing loss is caused by perforation of my eardrum." 2. "My hearing loss affects both of my ears." 3. "My hearing should return to normal after the surgery." 4. "My hearing loss is permanent."

ANS: 4 1 This statement indicates the need for further teaching because conductive hearing loss may be caused by eardrum perforation. 2 This statement indicates the need for further teaching as neural hearing loss is unilateral. 3 This statement indicates the need for further teaching as neural hearing loss is permanent. 4 This statement indicates effective teaching as neural hearing loss is permanent.

Which statement by the patient with rheumatoid arthritis indicates the need for further teaching? 1. "I can use analgesics to help decrease the pain." 2. "It is okay to take ibuprofen for the pain." 3. "I may have to take steroids if I have a rheumatoid arthritis (RA) flare." 4. "My immunosuppressive medications need to be increased if I get an infection."

ANS: 4 1 This statement indicates understanding of teaching because analgesics, including acetaminophen and narcotic agents, provide pain relief for rheumatoid arthritis (RA). 2 This statement indicates understanding of teaching because anti-inflammatory medications provide pain relief and some reduction in inflammation in patients with RA. 3 This statement indicates understanding of teaching because glucocorticoids decrease pain by suppressing the inflammatory process and may alter the course of the disease. 4 This statement indicates the need for further teaching because immunosuppressive therapy should be discontinued while patients have an active infection as it puts patients at a higher risk for developing infections and complications from infections.

A patient with severe Ménière's disease is considering a labyrinthectomy. What potential complication does the nurse include in the preoperative teaching? 1. Long-term tinnitus 2. Chronic otitis media 3. Rupture of the tympanic membrane 4. Complete hearing loss of the affected ear

ANS: 4 1 Tinnitus is not a complication after a labyrinthectomy. 2 Chronic otitis media is not a complication after a labyrinthectomy. 3 Tympanic membrane rupture is not a complication after a labyrinthectomy. 4 Labyrinthectomy is a more radical surgery reserved for very severe cases of Ménière's disease that includes removal of part of the inner ear. Although this surgery also improves the vertigo symptoms, complete hearing loss in the ear on the affected side is a potential result of the procedure.

A patient recovering from an ischemic stroke is prescribed verapamil (Calan). The nurse teaches the patient that this medication works by which action? 1. Increases urination 2. Slows the heart rate 3. Lowers blood lipids 4. Decreases blood pressure

ANS: 4 1 Verapamil (Calan) is a calcium channel blocker and not a diuretic. 2 Verapamil (Calan) is a calcium channel blocker and not a beta blocker. 3 Verapamil (Calan) is a calcium channel blocker and not a lipid-lowering agent. 4 Verapamil (Calan) is a calcium channel blocker used to reduce blood pressure to prevent long-term damage from excessive shear stress and reduce the chance for complications of hypertension such as intracerebral hemorrhage.

The nurse prepares the patient with suspected osteoporosis for which diagnostic test? 1. Magnetic resonance imaging (MRI) 2. Computed tomography (CT) scan 3. Bone scan 4. Dual-energy x-ray absorptiometry (DEXA) scan

ANS: 4 1 An MRI is not used to diagnose osteoporosis. 2 A CT scan is not used to diagnose osteoporosis. 3 A bone scan is not used to diagnose osteoporosis. 4 The gold standard assessment for osteoporosis is bone mineral density measurements. They are obtained through a DEXA scan.

The nurse is reviewing the results of a patient's recent hemoglobin A1c level drawn to evaluate type 1 diabetes management. Which result indicates that treatment has been successful? 1. Less than or equal to 8% 2. Less than or equal to 6.5% 3. Greater than or equal to 6.5% 4. Greater than or equal to 8.5%

ANS:2 1 A hemoglobin A1c level less than or equal to 6.5% indicates good glycemic control. 2 A hemoglobin A1c result less than or equal to 6.5% indicates good glycemic control. 3 A hemoglobin A1c result less than or equal to 6.5% indicates good glycemic control. 4 A hemoglobin A1c result less than or equal to 6.5% indicates good glycemic control.