EAQ

A client reports feeling nervous, irritable, and extremely tired. The client states, "Although eat a lot of food, I have frequent bouts of diarrhea and am losing weight." The nurse observes a fine hand tremor, an exaggerated reaction to external stimuli, and a wide-eyed expression. Based on the assessment findings, it is likely that which laboratory tests will be prescribed? a. Partial thromboplastin time (PTT) and prothrombin time (PT) b. Thyroxin (T 3 ) triiodothyronine (T 4 ) , and thyroid-stimulating hormone (TSH) c. Venereal disease research laboratory (VDRL) test and complete blood count (CBC) d. Adrenocorticotropic hormone (ACTH) , antidiuretic hormone (ADH) , and corticotropin- releasing factor (CRF )

b

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? a. Avoid massaging the client's legs. b. Frequently reposition the client on a scheduled basis. c. Increase the fiber content in the client's food. d. Encourage the client to participate in weight-bearing exercises.

b

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? a. Atrophy of the sweat glands b. Decreased subcutaneous fat c. Stiffening of the collagen fibers d. Degeneration of the elastic fibers

b

Which client is most at risk for osteoporosis? a. A nonsmoking 60- year-old woman, body mass index (BMI) 27.1 b. A 66 year-old white woman , body mass index (BMI) 18, who is a paralegal c. A 68-year- old black woman , body mass index ( BMI) 23.3, who is a retired receptionist d. A 62-year -old woman , body mass index ( BMI 11 23.2) , who takes calcium carbonate daily

b

Which intervention would be included in the plan of care for the prevention of a pressure injury? a. Positioning a client directly on the trochanter b. Keeping the client's skin directly off plastic surfaces c. Keeping the head of the bed elevated above 30 degrees d. Placing a rubber ring or donut under the client's sacral area

b

The nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. "I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "I will advise the client to apply tale directly to the perineum" "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." "I will teach the client to refrain from eating a high-protein and calorie diet."

"I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

Which clinical manifestations would the nurse anticipate when assessing a client with hypothyroidism? Select all that apply. 1. Dry skin 2. Brittle hair 3. Weight loss 4. Resting tremors 5. Heat intolerance

1, 2

Which factors contribute to development of osteoporosis in female clients? Select all that 1. Cigarette smoking 2. Moderate exercise 3. Use of street drugs 4. Familial predisposition 5. Inadequate intake of dietary calcium

1, 4, 5

Which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Dry skin 3. Insomnia 4. Excitability 5. Weight loss 6. Intolerance to heat

1,2

A client is diagnosed with hyperthyroidism and is treated with 1-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidismsigns and symptoms would be included in the teaching? Select all that apply: 1. Fatigue 2. Dry skin 3. Insomnia 4. Intolerance to heat 5. Progressive weight gain

1,2,5

Which clinical findings would the nurse expect to find when caring for a client with hyperthyroidism? Select all that apply. 1. Lethargy 2. Tachycardia 3. Weight gain 4. Constipation 5. Exophthalmos

2, 5

A child with iron-deficiency anemia is prescribed oral iron therapy. Anticipatory guidance regarding which side effect would the nurse provide? a. Bloody stool b. Orange urine c. Greenish-black stool d. Staining of the mouth

C

Which action by a 70-year-old female client would best limit further progression of osteoporosis? a. Taking supplemental calcium and vitamin D b. Increasing the consumption of eggs and cheese c. Taking supplemental magnesium and vitamin E d. Increasing the consumption of milk products

a

Which key feature is associated with a stage 2 pressure ulcer? a. Presence of nanintact skin b. Development of sinus tracts c. Damage to the subcutaneous tissues d. Appearance of a reddened area over a bony prominence

a

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125pg / m * L . Which medication would the nurse expect to be prescribed for the client? a. Oral hydroxyurea b. Vitamin B12 injections c. Oral iron supplements d. Erythropoietin injections

b

A client has had a total gastrectomy. Which topic will the nurse include in the discharge teaching? a. Daily use of a stool softener b. Injections of vitamin B 12 for life c. Monthly injections of iron dextran d. Replacement of pancreatic enzymes

b

A thin 24-year-old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin would the nurse recommend? a. Vitamin E b.Vitamin B c. Vitamin D d. Vitamin C

c

The nurse instructs self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer. Which statement of the client shows ineffective learning? a. "use tepid rather than hot water." b. "will clean my skin as soon as soiling occurs" c. "I will apply powders and talc on the perineum." d. "will pat my skin gently rather than rubbing it dry"

c

Which ethnic group has a greater incidence of osteoporosis due to musculoskeleta differences? a. Americans b. African Americans c. Chinese Americans d. Egyptian Americans

c

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? a. Use two square gauze pads to cleanse the wound, one for each half of the wound. b. Apply new Montgomery straps each time the dressing is changed. c. Hold the wet gauze with the tips of the forceps higher than the wrist. d. Cleanse the wound with wet , sterile gauze from the center of the wound outward.

d

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia The nurse would document the assessment finding as which stage of pressure ulcer? a. Stage l b. Stage ll c. Stage lll d. Unstageable

d

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a. Red b. Black c.Green d. Yellow

d

The nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? a. A food allergy b. Noncompliance with medications c. Side effects from medications d. A nutritional deficiency

d

Which definition would the nurse use to explain osteoporosis? a. It is avascular necrosis . b.It is caused by pathological fractures . c.It is hyperplasia of osteoblasts. d. It involves a decrease in bone substance .

d

While assessing the client for a pressure injury, the nurse identifies exposed bone and tendons. Which stage would the nurse document for this pressure injury? a. Stage l b. Stage ll c. Stage lll d. Stage IV

d

When a client develops iron-deficiency anemia, which of the client's laboratory test results would the nurse expect to be decreased?

ferritin level