Evolve EAQ Med/Surg

Which muscle in the given figure turns the eye towards the nose?

1 2 3 4 Option 2 indicates the medial rectus muscle, which turns the eye towards the nose and helps in contraction. Option 1 indicates the superior rectus muscle, which moves the eye diagonally upward towards the side and middle of the head. Option 3 indicates the lateral rectus muscle, which holds the eye straight and turns the eye towards side of the head. Option 4 indicates the inferior rectus muscle, which moves the eye diagonally downward towards the side and middle of the head.

A client with chronic heart failure is taking a diuretic twice a day. The healthcare provider prescribes a diet that includes the intake of dietary potassium. Which foods should the nurse instruct the client to consume? Select all that apply.

1. Bananas 2. Baked Potatoes c Skins (Bananas and baked potatoes with skins are high in potassium. Although corn, strawberries and cucumber salad have some potassium, they are not high sources. )

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.

1. Vomiting 2. Muscle Weakness 3. Irregular Heart Rate (Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle, and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.)

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140mmHg (Systolic blood pressure associated with stage 1 hypertension is between 140 and 159 mm Hg. Optimal systolic blood pressure is less than 120 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg. )

The nurse is reviewing the lymphocyte count of four clients. Which does the nurse suspect to have acquired immunodeficiency syndrome (AIDS)?

3000 cells/mm3 5000 cells/mm3 7000 cells/mm3 9000 cells/mm3 The normal lymphocyte count is between 5000 and 10,000 cells/mm3. A client with AIDS is leukopenic and has a lymphocyte count less than 3500 cells/mm3. Therefore, client A has AIDS. Clients B, C, and D have normal lymphocyte counts.

Four clients with tuberculosis are prescribed medications. Which client is at risk for optic neuritis?

A Isoniazid B Rifampin C Pyrazinamide D Ethambutol Ethambutol is an antitubercular medication that causes optic neuritis. Therefore client D is at risk for optic neuritis. Client A is at risk for vitamin B deficiency. Client B is at risk for liver toxicity. Client C is at risk for sunburn.

Which client is most likely to develop IgE antibodies?

A client with pollen allergy A client undergoing a poison ivy reaction A client with bacterial infection A client undergoing a blood transfusion A client with a pollen allergy develops IgE antibodies that may result in an anaphylactic reaction. A client with poison ivy develops delayed hypersensitivity, which is mediated by T lymphocytes. A client with a bacterial infection develops IgG and IgM antibodies. A client undergoing blood transfusion may develop IgG and IgM type II hypersensitivity reactions.

How can the nurse best describe heart failure to a client?

An inability of the heart to pump blood in proportion to metabolic needs (As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.)

What is an example of a type I hypersensitivity reaction?

Anaphylaxis Serum sickness Contact dermatitis Blood transfusion reaction An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.

Which beta-adrenergic blocker is prescribed to clients with glaucoma?

Betaxolol Carbachol Brimonidine Methazolamide Betaxolol is a beta-adrenergic blocker that is prescribed for glaucoma. Carbachol is a cholinergic agent that is used to treat glaucoma. Brimonidine is an alpha-adrenergic agonist that is prescribed in glaucoma. Methazolamide is a carbonic anhydrase inhibitor that is used to treat glaucoma.

Which prostaglandin agonist is used in the treatment of clients with glaucoma?

Carteolol Bimatoprost Brinzolamide Apraclonidine Bimatoprost is the prostaglandin agonist used in the treatment of glaucoma. Carteolol is the beta-adrenergic blocker used for treatment of glaucoma. Brinzolamide is the carbonic anhydrate inhibitor used for the treatment of glaucoma. Apraclonidine is the adrenergic agonist used in the treatment of glaucoma.

Which sexually transmitted infection is caused by Chlamydia trachomatis?

Cervicitis Gonorrhea Genital warts Genital herpes Cervicitis is caused by Chlamydia trachomatis. Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae. Genital warts are caused by the Human papillomavirus. Genital herpes is caused by the Herpes simplex virus.

What is a manifestation of tertiary syphilis?

Chancre Alopecia Gummas Condylomata lata Gummas which are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

What causes condylomata acuminate?

Chlamydia Gonorrhea Herpes simplex Human papillomavirus (HPV) Condylomata acuminate are genital warts which are caused by the human papillomavirus (HPV). Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings?

Cloudy urine may be indicative of infection (Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.)

Which autoantigens are responsible for the development of Crohn's disease?

Crypt epithelial cells Thyroid cell surface Basement membranes of the lungs Basement membranes of the glomeruli Crypt epithelial cells are considered to be the autoantigens responsible for Crohn's disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto's thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome.

Which type of hypersensitivity reaction is associated with rheumatoid arthritis?

Delayed Cytotoxic IgE-mediated Immune-complex Rheumatoid arthritis is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture's syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.

What are the symptoms of tuberculosis? Select all that apply.

Diarrhea Anorexia Weight gain Hemoptysis Night sweats Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. Signs include a persistent cough, anorexia, hemoptysis, night sweats, shortness of breath, and a high body temperature. Diarrhea and weight gain are not associated with tuberculosis.

Which organs are affected by Candida albicans? Select all that apply.

Ears Lungs Vagina Mouth Intestines Candida albicans causes thrush in the mouth, vaginitis in the vagina, and candidiasis in the intestines. The fungus Aspergillus fumigatus affects the ears. Lungs are affected by Coccidioides immitis.

A client with extensive bone and soft tissue injuries to the right leg is on bed rest. How should the nurse position the client?

Elevate the entire right leg with pillows, keeping the foot higher than the knee (Elevating the entire right leg with pillows, keeping the foot higher than the knee, supports the leg and promotes venous return by gravity, which reduces edema and pain. Keeping the right leg resting straight on the bed and maintaining both legs on the bed are positions that promote edema. Although attaching a padded ankle sling to a Balkan frame to support the right foot and elevate the leg elevates the foot, it provides no support under the leg and can cause hyperextension of the knee.)

Which drug can be administered via the intramuscular route to treat anaphylaxis?

Epinephrine Methdilazine Phenylephrine Mycophenolate mofetil Epinephrine is administered through the intramuscular route to treat anaphylaxis. Methdilazine is administered to treat allergic reactions and pruritus. Phenylephrine is administered orally, not intramuscularly, to treat anaphylaxis. Mycophenolate mofetil is administered intravenously as an immunosuppressant agent.

What are the symptoms of tuberculosis? Select all that apply.

Fatigue Nausea Weight Gain Low-grade Fever Increased Appetite Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. The symptoms of tuberculosis are fatigue, nausea, low-grade fever, weight loss, and anorexia.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs (Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.)

A nurse is discussing dietary guidelines to help reduce a client's risk for heart disease. What should the nurse teach the client?

Increase complex carbohydrates (The fiber component of complex carbohydrates helps bind and eliminate dietary cholesterol and fosters growth of intestinal microorganisms to break down bile salts and release the cholesterol component for excretion. It is what the client eats, not the amount at each meal that is important. Proteins need not be decreased; it is the type of protein that should be limited, such as fatty meat and the skin of fowl. Of the fats in the diet, saturated fats should be decreased.)

Which complication will the nurse suspect in a client with genital herpes disease?

Infertility Cold sores Reactive arthritis Bartholin's abscess Cold sores are the autoinoculation of the virus to extragenital sites, such as the fingers and lips. It is a complication of genital herpes disease. Infertility and reactive arthritis are the complications of chlamydial infection. Bartholin's abscess is a complication of gonorrhea.

A nurse is teaching a client with hypertension about a sodium-restricted diet. Which information should the nurse emphasize?

Liking the taste of table salt is learned, but it can be modified with practice. (The taste for salt is learned from habitual use and can be unlearned or reduced with health improvement motivation and creative salt-free food preparation. Substitutes do not taste the same as salt. Using salt substitutes containing potassium chloride may be unsafe; excessive use can produce abnormally high serum potassium levels. The taste for salt is learned. )

An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time?

Monitor for cardiovascular irregularities. (Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.)

Which leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply.

Monocyte Memory cell Helper T cell B-lymphocyte Cytotoxic T cell Memory cells and B-lymphocytes are involved in antibody-mediated immunity. Monocytes are involved in inflammation. Helper T cells and cytotoxic T cells are involved in cell-mediated immunity.

Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)?

Oropharyngeal candidiasis Cryptosporidiosis Toxoplasmosis encephalitis Pneumocystis jiroveci pneumonia Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is the more common in a client infected with AIDs. It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

Pain radiating to the hip and leg Stiffness in shoulders Paralysis of both lower extremities Overgrowth of tissue on the lower back Because of pressure on the sciatic nerve, pain radiating to the hip and leg is common. Although weakness (paresis) may occur, paralysis is not common. Shoulder stiffness and overgrowth of tissue on the lower back are not associated with this disorder.

Which complication is associated with Pott's disease?

Peritonitis Bacterial meningitis Generalized lymphadenopathy Destruction of intervertebral discs Pott's disease is tuberculosis (TB) of the spine, which can lead to destruction of intervertebral discs. Abdominal TB can cause peritonitis. Central nervous system TB can cause severe bacterial meningitis. Generalized lymphadenopathy can be caused by miliary tuberculosis.

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field. Teach passive range-of-motion exercises. Instill artificial teardrops into the affected eye. Reduce time client is positioned on the left side. A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response?

Reduction in circulating blood volume (Decreased intravascular volume results in hypovolemia and hypotension, which is evidenced by decreased blood pressure and decreased pulse pressure. Vasomotor stimulation to the arterial walls is increased with shock. Vasodilation resulting from diminished vasoconstrictor tone is a description of neurogenic shock, which is unlikely in this situation. Although electrolyte imbalances can precipitate cardiac decompensation, cardiogenic shock is unlikely in this situation. )

Which diseases can be transmitted by air? Select all that apply.

Scabies Measles Pediculosis Chicken pox Tuberculosis Measles, chicken pox, and tuberculosis are infectious diseases that are transmitted by air. Scabies and pediculosis are transmitted by direct contact.

Which statement is true regarding Sjögren's syndrome?

Sjögren's syndrome increases lacrimation. Sjögren's syndrome increases body secretions. Sjögren's syndrome decreases the risk for infection. Sjögren's syndrome decreases the digestion of carbohydrates. Sjögren's syndrome decreases the digestion of carbohydrates because of insufficient secretion of saliva. Sjögren's syndrome decreases lacrimation. Sjögren's syndrome also decreases body secretions and saliva, therefore increasing the risk of infection.

A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home?

Spirometry (A spirometer is a hand-held device that can be used at home. A client blows forcefully and quickly into the device after taking a deep breath. This device is used to diagnose early lung transplant rejections or infections and helps to monitor lung function. Oximetry is used for the intermittent monitoring of arterial or venous oxygen saturation. Capnography helps to assess the level of CO2 in exhaled air; this device graphically displays the amount of partial pressure of CO2. Ventilation-perfusion is used to assess the ventilation and perfusion of the lungs.)

What is the most commonly reported sexually transmitted infection (STI)?

Syphilis Chlamydia Gonorrhea Herpes simplex Chlamydial infections are the most commonly reported sexually transmitted infection. Syphilis and gonorrhea are not the most commonly reported STI. Herpes simplex is not a reportable infection.

Which disease is caused by Escherichia coli?

Tetanus Peritonitis Diphtheria Food poisoning Escherichia coli causes peritonitis. Clostridium tetani causes tetanus. Corynebacterium diphtheria causes diphtheria. Clostridium botulinum causes food poisoning.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production. (Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis. )

Which bacteria causes toxic shock syndrome in female clients?

Treponema pallidum Streptococcus faecalis Staphylococcus aureus Neisseria gonorrhoeae Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Streptococcus faecalis causes genitourinary tract infections and infection of surgical wounds. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.

Which drug treats hay fever by preventing leukotriene synthesis?

Zileuton Cromolyn Sodium Chlorpheniramine Diphenhydramine Zileuton is a leukotriene antagonist drug; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E.. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.

For which illness should airborne precautions be implemented?

Influenza Chickenpox Pneumonia RSV Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

Which conditions result in humoral immunity? Select all that apply.

Tuberculosis Atopic diseases Bacterial infection Anaphylactic shock Contact dermatitis Atopic diseases, bacterial infections, and anaphylactic shock are disease conditions that trigger humoral immunity. Tuberculosis and contact dermatitis result in cell-mediated immunity.

The nurse is caring for a client after the client's open heart surgery (coronary artery bypass grafting [CABG]). Serosanguineous fluid drains from the client's chest tube. The nurse expects what volume of drainage from the tube during the first 24 hours after the surgery?

400-500ml (During the first 24 hours after CABG surgery, 500 mL of fluid will accumulate in the intrapleural space because of trauma and the inflammatory response; gradually, this amount will decrease. Between 100 and 300 mL is less than the expected amount of drainage from the chest tube during the first 24 hours after open heart surgery. A volume of 750 mL or more is an excessive amount of drainage from the chest tube during the first 24 hours after open heart surgery; this amount may indicate a complication. )

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?

Check the clients pedal pulses (These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.)

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Frontal Parietal Occipital Temporal Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. The frontal area is the area of abstract thinking and muscular movements. The occipital area is the area where nerve impulses are translated into sight. The temporal area is the area where nerve impulses are translated into sound.

Identify the location of the aortic valve.

Image of the heart The marked area in the given image indicates the aortic valve. The aortic valve separates the left ventricle from the aorta. It prevents blood from flowing back into the ventricle during diastole.

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client?

Increases the cardiac workload (Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure. Anxiety does not directly interfere with respirations; an increase in cardiac workload will increase respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen used and leads to an increased respiratory rate.)

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

Pulse 50 bpm and BP 140/60 mm Hg Pulse 56 bpm and BP 130/110 mm Hg Pulse 60 bpm and BP 126/96 mm Hg Pulse 120 bpm and BP 80/60 mm Hg Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate. Pulse 56 bpm and BP 130/110 mm Hg, pulse 60 bpm and BP 126/96 mm Hg, and pulse 120 bpm and BP 80/60 mm Hg do not meet these criteria.

Which cytokine increases growth and maturation of myeloid stem cells?

Interleukin-2 Thrombopoietin Granulocyte colony-stimulating factor Granulocyte-macrophage colony-stimulating factor Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T-lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils.

Which medications are useful to treat psoriasis? Select all that apply.

Psoralen Anthralin Isotretinoin Clindamycin Calcipotriene Psoriasis is a chronic autoimmune dermatitis treated with a systemic photosensitizer such as psoralen and topical agents such as calcipotriene and anthralin. Isotretinoin and clindamycin are used to treat acne vulgaris.

Which organism causes smallpox?

Variola virus Yersinia pestis Bacillus anthracis Clostridium botulinum Smallpox is an infectious disease caused by the Variola virus. Yersinia pestis causes plague. Bacillus anthracis causes anthrax. Clostridium botulinum causes botulism.

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis?

Interleukin 2 Interleukin 11 Beta interferon Alpha interferon Beta interferon is an immunomodulator that is administered in the treatment of multiple sclerosis. Interleukin 11 is used in the prevention of thrombocytopenia after chemotherapy. Interleukin 2 is used for the treatment of metastatic renal cell carcinoma and metastatic melanoma. Alpha interferon is administered for the treatment of hairy cell leukemia, chronic myelogenous leukemia, and malignant melanoma.

Which is a leukotriene modifier used to manage and prevent allergic rhinitis?

Zileuton Ephedrine Scopolamine Cromolyn sodium Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing drug used to prevent mast cell membranes from opening when an allergen binds to IgE.

A client has a low hemoglobin level that is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? Select all that apply.

1. Eggs 2. Spinach (Eggs and spinach are high in iron. Although squash and apricots contain some iron, they are not the best source. Carrots are high in vitamin A. )

Which malnutrition condition may predispose a client to secondary immunodeficiency?

Cachexia Cirrhosis Diabetes mellitus Hodgkin's lymphoma Cachexia is a nutrition disorder that may occur due to wasting of muscle mass and weight, resulting in secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin's lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders.

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene?

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles) (Cottage cheese, crackers, and a relish dish (celery, olives, sweet pickles) have the highest sodium content. Meals consisting of soft-cooked egg, toast, jelly, and skim milk; baked chicken, boiled potatoes, broccoli, and coffee; and fillet of sole, baked potato, and fresh fruit cup (berries and melons) are low in sodium. )

The nurse suspects that a client with inhalation anthrax is in the fulminant stage of the disease. Which symptom supports the nurse's conclusion?

Fever Dry cough Hematemesis Mild chest pain Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. This disease has two stages of illness, the prodromal stage and the fulminant stage. The symptom of the fulminant stage is hematemesis. The symptoms of the prodromal stage are fever, dry cough, and mild chest pain.

A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment?

Tender mass in the left upper abdomen (Splenomegaly usually accompanies chronic myelogenous leukemia; the spleen usually is gross, palpable, and tender and necessitates removal. The spleen is located high in the abdomen on the left side and usually is not palpable unless it is enlarged. The urinary output is not affected with these conditions. With leukemia and splenomegaly there is increased destruction of blood cells; the erythrocyte count will be low. Polydipsia, increased appetite, and urinary frequency are not associated with leukemia or splenomegaly, but rather diabetes.)

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding?

Unifocal (A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.)

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply.

1. Tell a staff member to get the ECG machine 2. Notify the x-ray department that a CXR is needed stat 3. Have a staff member notify the nursing supervisor of the change in status 4. Notify the MRP of the change in the oxygen sat and ask for advice 5. Increase supplemental oxygen without a prescription from 2L NP to 4L NP and notify MRP (A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role. )

A client develops epistaxis and seeks treatment at a first aid station. Which action should the nurse take?

Apply direct lateral pressure to the nose (Apply direct lateral pressure to the nose for 10 minutes and apply ice or cool compresses to the nose and face if possible. Tilting the head back will cause the blood to be swallowed, which can result in vomiting and aspiration. Packing the bleeding nostril with tissue may cause further damage if done too firmly; some of the tissue may be left in the nose, causing an additional problem. Gauze or nasal tampons are used for packing. Blowing the nose can prevent clotting, which can result in prolonged bleeding.)

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?

Increased total iron-binding capacity (TIBC) (TIBC may be elevated from 350 to 500 mcg/dL (82 µmol/L) (expected range is 250 to 460 mcg/dL [45-82 mcmol/L]) because the RBCs are compensating for the iron deficiency. The RBCs are microcytic, not macrocytic, because of their low iron content. A low platelet count is not associated with iron deficiency anemia. Decreased folate levels often are noted in vitamin B12 anemias, such as occur with sprue and celiac diseases, as well as in folate deficiency anemia, but not in iron deficiency anemia.)

Which type of immunity is acquired through the transfer of colostrum from the mother to the child?

Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next?

Perform a head-to-toe assessment, including vital signs. (Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary issues (crackles) associated with left-sided heart failure. Checking the record for code status is not a priority and should have been established and known on an elderly client. Increasing intake will make the problem of fluid retention worse. Continuing to monitor daily weights without an assessment may miss worsening symptoms.)

Why is a Neisseria gonorrhoeae infection particularly troublesome for a female client?

The medication is expensive. It is difficult to treat with antibiotics. Symptoms are often overlooked. Treatment has many adverse effects. Many female clients who contract gonorrhea are asymptomatic or have minor symptoms that are often overlooked, making it possible for them to remain a source of infection. There is no evidence to support that the medication to treat the infection is expensive. The infection can be treated with one intramuscular injection of ceftriaxone. There is no evidence to support that the medication to treat this infection has many adverse effects.

Why would a client with acquired immunodeficiency syndrome (AIDS) be prescribed diphenoxylate hydrochloride?

To manage pain To manage diarrhea To manage candidal esophagitis To manage behavioral problems Diphenoxylate hydrochloride is an antidiarrheal drug prescribed to clients with AIDS to manage frequent diarrhea experienced by a client with AIDS. Opioid analgesics such as tramadol are used to manage pain. Ketoconazole can be used to treat candidal esophagitis associated with AIDS. Behavioral problems are managed with psychotropic drugs.

Which sexually transmitted disease is caused by the human papilloma virus?

Gonorrhea Genital herpes Chlamydia infection Condylomata acuminata Condylomata acuminata is a sexually transmitted disease caused by the human papilloma virus. Gonorrhea is caused by Neisseria gonorrhoeae. Genital herpes is causes by the herpes simplex virus. Chlamydia infection is caused by Chlamydia trachomatis.

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing?

Right ventricular failure (The failing right ventricle fails to contract effectively, which causes a backup of blood into the right atrium and venous circulation, causing peripheral edema and hepatomegaly. Left-sided heart failure results from left ventricular dysfunction, which prevents normal forward blood flow and causes blood to back up into the left atrium and pulmonary veins, causing pulmonary congestion. Although dyspnea on exertion is associated with obstructive and restrictive pulmonary disease, hypertension and pedal edema are related to cardiac, not respiratory, problems.)

What should the nurse suggest for a client with right ventricular failure?

"Avoid emotionally stressful situations." (Stressful situations increase the body's oxygen demands. Clients with a low cardiac reserve cannot tolerate extremes of temperature; a hot bath increases the body's oxygen demands. Hot, humid weather is detrimental for those with heart disease; these individuals should use an air conditioner. The heart of a client with low cardiac reserve cannot tolerate a pulse rate this high.)

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply.

1. Boiled Spinach 2. Roasted Potatoes (Spinach and potatoes are high in iron. Although carrots, brussels sprouts, and asparagus spears contain some iron, they are not considered high sources of iron. )

The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-gram sodium diet. Which statement from the client indicates that further teaching is needed?

"I can use a little table salt on my food as long as I do not use it when cooking food." (The response "I can use a little table salt on my food as long as I do not use it when cooking" demonstrates that the client did not understand the discharge teaching. Table salt and foods high in sodium should be avoided. Sodium intake causes fluid retention, which can precipitate a fluid volume excess, which contributes to heart failure. Digoxin should be withheld if the client's pulse is less than a preset rate (i.e., 60 beats per minute) because this is a sign of digoxin toxicity; the risk of digoxin toxicity is increased if the client develops hypokalemia as a result of receiving furosemide. Slowly increasing activities while ensuring rest periods limits the stress on the heart and is desirable. Orthopnea is a sign of pulmonary edema related to heart failure, and the healthcare provider should be notified.)

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse?

"I don't know. I will ask the health care provider for a prescription." "Antibiotics are used to treat viruses and you have a bacterial infection." "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics." Generally, upper respiratory infections are viral; therefore antibiotics should not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.

A registered nurse is educating a client with acquired immune deficiency syndrome about safe sexual practices. Which statement made by the client indicates a need for further education?

"I should use a dental dam during oral sex." "I can participate in anal intercourse safely without using condoms." "I should ask my partner to use a female condom while engaging in sexual activity." "I should use condoms even while receiving highly active antiretroviral therapy (HAART)." Having anal intercourse indicates the client needs more teaching because this statement is incorrect. The client should wear a condom or use other genital barriers to prevent the transmission of human immunodeficiency virus (HIV). Anal intercourse is a risky sexual practice that allows contact between the seminal fluid and the rectal mucous membranes. Anal intercourse also tears the mucous membranes, making an infection more likely. All the other statements are correct and do not indicate further education is needed. Barriers such as female condoms and dental dams are recommended while participating in sexual activity. Though the viral load may decrease with the use of HAART, the risk for transmission still exists. Therefore the client should use condoms during sexual contact.

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. What is the nurse's best reply?

"I suggest that you buy a commode exclusively for your child's use." "Your child may use the bathroom, but you need to use disposable toilet covers." "You will need to clean the bathroom from top to bottom every time a family member uses it." "All family members, including your child, need to wash their hands after using the bathroom." Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. It is not feasible to clean "from top to bottom" each time the bathroom is used. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

The nurse is teaching a post-radiation therapy client regarding proper skin care to the radiation treatment area. Which statement made by the client indicates the nurse needs to follow up?

"I will avoid wearing tight-fitting clothing." "I will avoid using adhesive bandages." "I will avoid exposing the area to cold temperatures." "I will avoid rinsing the area with the saline solution." A client who underwent radiation therapy should rinse the radiation treatment area with saline solution to prevent infection. Therefore the nurse should follow up to correct the misconception of not using saline. Tight-fitting clothing such as brassieres and belts should be avoided in the area of the treatment field. The use of adhesive bandages should be avoided and should not be used unless permitted by the radiation therapist. The radiation treatment area should not be exposed to cold temperatures.

A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement?

"I'll cut back to a half pack a day." (The response "I'll cut back to a half pack a day" is a positive step in reducing smoking [1] [2]; it is the first step toward stopping. The response "I'll just finish the carton that I have at home" is postponing the decision to quit. The response "I find that smoking is the only way I can relax" is rationalizing why quitting smoking is too difficult. The response "I should find this easy" is unrealistic because giving up smoking is difficult regardless of whether the client smokes when alcoholic beverages are consumed. )

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse?

"Tell me about your concerns as of the moment." (The response "Tell me about your concerns as of the moment" encourages the client to review facts and provides an opportunity to talk about feelings. The response "Let me ask your primary healthcare provider for you" suggests the nurse does not want to discuss the subject; it abdicates the nurse's responsibility to explore the issue with the client. Although it is an empathic answer, the response "I can understand why you are worried" does not encourage the client to explore feelings; it may increase anxiety. Although the statement "It depends on whether the tumor has spread" is true, the response does not encourage the client to examine feelings.)

A nurse is planning to provide discharge teaching to the family of a client with acquired immunodeficiency syndrome (AIDS). Which statement should the nurse include in the teaching plan?

"Wash used dishes in hot, soapy water." "Let dishes soak in hot water for 24 hours before washing." "You should boil the client's dishes for 30 minutes after use." "Have the client eat from paper plates so they can be discarded." A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client's dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 35 mm Hg, and HCO3 is 20 mEq/L (20 mmol/L). Which client should the nurse consider is most likely to exhibit these results?

A 24yo with DKA (The low pH and bicarbonate levels are consistent with metabolic acidosis, which can be caused by excess ketones, a result of diabetic ketoacidosis. A 54-year-old with vomiting most likely will experience metabolic alkalosis from loss of gastric hydrochloric acid. A 17-year-old with panic attacks most likely will experience metabolic alkalosis from hyperventilation. A 65-year-old with advanced emphysema most likely will experience respiratory acidosis.)

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results?

A 65-year-old with pulmonary fibrosis (The low pH and elevated Pco2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.)

A nurse is reviewing the laboratory reports of four clients. Which client's laboratory report indicates acquired immunodeficiency syndrome (AIDS)?

A 750 cells/mm B 550 cells/mm C 175 cells/mm D 450 cells/mm The diagnosis of AIDS requires that the person should be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/uL) or less than 14% or an opportunistic infection. Therefore client 3, with a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/uL) and who is HIV positive, is having AIDS-defining illness. A healthy client usually has at least 800 to 1000 CD4+ T-cells per cubic millimeter (mm 3) of blood. This number is reduced in the client with HIV disease. Client 1, with a CD4+ T-cell count of 750 cells/mm 3 and HIV positive, does not have AIDS. Client 2, with a CD4+ T-cell count of 550 cells/mm 3 and HIV positive, does not have AIDS. Client 4, having a CD4+ T-cell count of 450 cells/mm 3 and HIV positive does not have AIDS.

A nurse in the emergency department is assigned to care for four clients. Which client should the nurse see first?

A client V-fib (Ventricular fibrillation will cause irreversible brain damage and then death within minutes because the heart is not pumping blood to the brain. Defibrillation, or CPR until defibrillation is possible, must be initiated immediately. Although head injury, fractured femur, and penetrating abdominal wound require prompt treatment, death is not as imminent as with ventricular fibrillation.)

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

1. Check primary healthcare provider's prescription. 2. Obtain vital signs and history of transfusions. 3. Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Change main line solution to normal saline. 5. Check client identification before hanging unit of blood (The nurse should first check the primary healthcare provider's prescription to notify the blood bank of what product will be needed. The next step is to obtain the client's baseline vital signs and ask whether the client has had previous transfusions and whether there were any untoward effects. Ascertaining the intravenous catheter size is at least 18 gauge will prevent hemolysis of red blood cells. The main line solution must be normal saline 0.9% to flush the line and use as a main line if the blood administration must occur because of a reaction. Other solutions can affect blood, causing it to clot. Checking the client identification and verification of blood product is necessary before proceeding.)

A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply

1. Crackles 2. Dyspnea on exertion (Pressure in the pulmonic circulation increases when the left ventricle fails; fluid moves from the intravascular compartment into the alveoli, causing crackles. Pressure in the pulmonic circulation increases when the left ventricle fails; fluid in the alveoli impairs gas exchange, which causes dyspnea on exertion. Ascites, a sign of right ventricular failure, results from an increased hydrostatic pressure in the systemic circulation; fluid moves out of the intravascular compartment into the abdominal cavity. Peripheral edema, a sign of right ventricular failure, results from an increased hydrostatic pressure in the systemic circulation. Fluid moves out of the intravascular compartment into the interstitial compartment. Jugular vein distention, a sign of right ventricular failure, results from hypervolemia.)

A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply.

1. Headache 2. Dizziness when standing up 3. Crackles on lung auscultation (Cerebral edema caused by hypervolemia may cause a headache. Crackles on lung auscultation indicate the presence of fluid in the alveoli (pulmonary edema). Increased fluid volume in the intravascular compartment (overhydration) will cause the pulse to feel full and bounding. The blood pressure will increase, not decrease, with hypervolemia. Dizziness when standing up occurs when pooling of blood in the peripheral vessels causes orthostatic (postural) hypotension.)

An older client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply.

1. Occasional cocaine use 2. African-American heritage (Cocaine is a stimulant that causes tachycardia and hypertension. Hypertension is more prevalent in African-Americans in the United States. Aspirin decreases platelet aggregation, thus reducing the risk for cardiovascular disease. Lowered hemoglobin may increase the heart rate, not the blood pressure. Increased HDL reduces the risk for cardiovascular disease because it helps to remove excess cholesterol from the blood, thereby preventing atheromas.)

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

1. Shock 2. Abd distention 3. Pulmonary complications (Because of its great blood supply and general fragility, the spleen may hemorrhage, causing shock and abdominal distention. Pulmonary complications may occur because the spleen is close to the diaphragm, resulting in defensive shallow breathing and the effects of anesthesia. The immediate postoperative period is too soon for the client to exhibit signs of infection. An intestinal obstruction is not associated with a splenectomy.)

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

1. Weight 2. Smoking (Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity. )

The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram?

Absence of the pedal pulse (Absence of the left pedal pulse indicates inadequate circulatory status of the left lower extremity. Mottling of the left leg may indicate impaired circulation, but observation of both extremities for comparison is necessary. Coolness of the left foot is a less significant indication of arterial occlusive disease than the absence of a pulse. Thickening of the toenails on the left foot is not as significant as the pulse; this can occur because of inadequate circulation, aging, or fungal infection.)

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client?

An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.

A nurse is assessing the needs of a client who just learned that a tumor is malignant and has metastasized to several organs and that the illness is terminal. What behavior does the nurse expect the client to exhibit during the initial stage of grieving?

Asking for a second opinion (Seeking other opinions to disprove the inevitable is a form of denial employed by individuals who have illnesses with a poor prognosis. If the client is crying, the client is aware of the magnitude of the situation and is past the stage of denial. Criticism that is unjust often is characteristic of the stage of anger. Refusing to receive visitors is most common during the depression experienced as one moves toward acceptance or during the acceptance stage. )

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

Aspiration Dehydration Nutritional imbalance Impaired communication Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life. While nutrition and fluid intake will be adversely affected by dysphagia, dehydration and nutritional imbalance are not the priority. Dysphagia is difficulty swallowing and does not affect communication.

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation?

Begin active exercises. Make a referral to the physical therapist. Position the client to prevent contractures. Avoid moving the affected extremities unless necessary. To prevent contractures after a brain attack, the client should be positioned in functional alignment, and passive range-of-motion exercises should be performed. Active exercises are impossible with paralyzed limbs. The healthcare provider must request a consult with the physical therapist. Avoiding moving the affected extremities unless necessary will increase contractures and atrophy.

What should be used to clean needles and syringes between intravenous drug users (IDUs)?

Bleach Hot water Ammonia Rubbing alcohol Intravenous drug users (IDUs) should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol are not used to disinfect used syringes.

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response?

Brief exaggeration of symptoms Prolonged symptomatic improvement Rapid but brief symptomatic improvement Symptomatic improvement of only the ptosis Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do?

Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. (Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider. )

Which test is used to specifically detect intracranial aneurysms in clients?

Diffusion imaging Magnetic resonance imaging Magnetic resonance angiography Magnetic resonance spectroscopy Magnetic resonance angiography is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations. Magnetic resonance spectroscopy is indicated in epilepsy, Alzheimer disease, and stroke to assess abnormalities in the brain's biochemical processes. Diffusion imaging is indicated for evaluation of ischemia in the brain to determine the location and severity of a stroke. Magnetic resonance imaging is taking multiple sets of images to determine normal and abnormal anatomy.

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli associated with atrial fibrillation (Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits. Hypertension may cause spasm of the arteries, but it does not cause anatomic occlusion. A developmental defect of the arterial wall is associated with a saccular aneurysm. A seizure is caused by an inappropriate paroxysmal discharge, not a complete occlusion of the branches of the middle cerebral artery. )

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis (Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus. )

A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)?

Enzyme-linked immunosorbent assay (ELISA) (The ELISA is the first screening test done to detect serum antibodies that bind to HIV antigens on test plates. The CD4 T cell count is not a screening test; it is done to monitor the progression of HIV infection and response to treatment. The Western blot test is not done first; the Western blot is done to validate repeatedly reactive ELISA results. The polymerase chain reaction test is not an initial screening test; it is done when there are consistently inconclusive test results with previous screening tests.)

A nurse is caring for a client who has a prescription for a 2-gram sodium diet and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) 42 mg/dL (15.2 mmol/L) and creatinine 1.1 mg/dL (97 mcmol/L). Considering the assessment findings, what is the most appropriate intervention by the nurse?

Expecting an increase in the oral fluid intake (Diuretics cause dehydration, increasing the BUN; increasing fluid intake will result in a decrease in the BUN level. Although sending the client's urine for analysis should be done, it will not change the client's hydration status. Although the client should be on strict intake and output, it will not change the client's hydration status. Sodium restriction will not lower the BUN level; in addition, nutritionists only make suggestions to the primary healthcare provider regarding interventions. The primary healthcare provider is the professional legally responsible for prescribing a sodium-restricted diet.)

The medical-surgical nurse called the code team for a client who is unresponsive and not breathing. Cardiopulmonary resuscitation and an ambu bag have been initiated. What is the next most appropriate action for the nurse to take?

Get the client's record and have it available in the room. (The client's nurse must be in the room to give information on the client's condition, history, and medical data to the arriving code team. Other healthcare providers need to be assigned to contact the client's primary healthcare provider, move other clients or visitors out of the room, and contact religious ministry.)

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse notifies the surgeon. What is the rationale for the nurse's action?

Graft is leaking (Hypertension increases pressure on the suture lines, which can affect the integrity of the graft or the graft causing leaking or rupture. A compromised venous return is evidenced by lower extremity edema, not an increase in blood pressure. Compartment syndrome is associated with circulatory, sensory, and motor alterations related to excessive interstitial fluid, the presence of which is not indicated in the question. Occluded femoropopliteal arteries were the reason that the client had the surgery; the graft bypasses the occluded area.)

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client?

Hematoma Formation (Because the femoral artery is large, it has the potential for hematoma formation and hemorrhage after surgery. The client should not be in pain after this procedure. Although the leg used for circulatory access must be kept extended and immobile for several hours, this is not the priority. The ability to swallow is not affected because conscious sedation, not general anesthesia, is used. )

A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved?

Histamine Cytokine Neutrophil Macrophage Histamine is one of the mediators of injury involving IgE-mediated injury that may cause pruritus. Cytokines are the mediators of injury in delayed hypersensitivity reaction. Neutrophils are involved in immune complex-mediated hypersensitivity reactions. Macrophages in tissues are involved in cytotoxic reactions.

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition?

I have abnormal hemoglobin (The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.)

Which type of immunoglobulin is present in tears, saliva, and breast milk?

IgE IgA IgG IgM IgA immunoglobulin is present in tears, saliva, and breast milk. IgE and IgG immunoglobulins are present in plasma and interstitial fluids. IgM immunoglobulin is present in plasma.

Which immunoglobulin crosses the placenta?

IgE IgA IgG IgM IgG is the only immunoglobulin that crosses the placenta. IgE is found in the plasma and interstitial fluids. IgA lines the mucous membranes and protects body surfaces. IgM is found in plasma; this immunoglobulin activates due to the invasion of ABO blood antigens.

Which age-related effects on the immune system are seen in the older client?

Increased autoantibodies Increased expression of IL-2 receptors Increased delayed hypersensitivity reaction Increased primary and secondary antibody responses The effects of aging on the immune system include increased autoantibodies. Expression of IL-2 receptors, delayed hypersensitivity reaction, and primary and secondary antibody responses decrease in older adults because of the effects of aging on the immune system.

A nurse is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

Inspecting the skin daily Providing a rubber cushion on which to sit Massaging body lotion over reddened areas Applying a heating pad to bony prominences Because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas [1] [2] or lesions is necessary so that treatment can be initiated quickly. Providing a rubber cushion on which to sit may contribute to circumscribed pressure, which can lead to skin breakdown. Rubber promotes perspiration, which increases the risk of pressure ulcers. Massage of reddened areas may cause further damage and should be avoided. Because sensation may be compromised, a heating pad should not be used.

Which cytokine stimulates the liver to produce fibrinogen and protein C?

Interleukin-1 Interleukin-6 Thrombopoietin Tumor necrosis factor Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.

A primary healthcare provider prescribes verapamil to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil?

Keep the client in the recumbent position for 1 hour after administration (Hypotension is a common side effect of intravenously administered verapamil. Keeping the client in the recumbent position for 1 hour after administration provides for the safety of the client. A prolonged PR interval may occur during extended therapy, not on initial administration of verapamil. Verapamil should be administered undiluted when given intravenously. It is administered over 2 minutes for adults and over 3 minutes for older adults. The client's heart rate and blood pressure should be assessed before administration to provide a baseline for comparison. Verapamil will decrease the blood pressure and dysrhythmias.)

Which diseases may occur due to rickettsial infections? Select all that apply.

Leprosy Lyme disease Epidemic typhus West Nile fever Rocky Mountain spotted fever Typhoid fever and Rocky Mountain spotted fever are caused by rickettsial infections. Spirochetes and Mycobacterium leprae cause leprosy. Borrelia burgdorferi cause Lyme disease. The West Nile virus causes West Nile fever.

Which laboratory test will be elevated in a client with inflammatory arthritis?

Leukocyte count Hemoglobin and hematocrit Blood urea nitrogen and creatinine Erythrocyte sedimentation rate (ESR) The erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. An elevated ESR (>20 mm/hr) indicates inflammation or infection somewhere in the body. The ESR is chronically elevated with inflammatory arthritis. Leukocytes will be elevated when a bacterial infection is present. Hemoglobin and hematocrit are not used to determine the presence of inflammation. Blood urea nitrogen and creatinine levels are used to determine renal function.

Which type of immunity will clients acquire through immunizations with live or killed vaccines?

Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrums from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension?

Occipital headache in the morning (Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect; it is not specific to hypertension. )

The echoviruses can cause which diseases in clients? Select all that apply.

Parotitis Gastroenteritis Mononucleosis Aseptic Meningitis Burkitts Lymphoma Echoviruses cause gastroenteritis and aseptic meningitis. Parotitis is caused by mumps. Burkitt's lymphoma and mononucleosis are caused by the Epstein-Barr virus.

What does the nurse explain to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is based on?

Performance of high-risk sexual behaviors Evidence of extreme weight loss and high fever Identification of an associated opportunistic infection Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the HIV. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Centers for Disease Control and Prevention surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.

Which disease is caused by Coronaviruses?

Pertussis Inhalation anthrax Coccidioidomycosis Severe acute respiratory syndrome Severe acute respiratory syndrome is a respiratory infection caused by Coronaviruses. Pertussis is caused by the bacterium Bordetella pertussis. Inhalation anthrax is caused by Bacillus anthracis. Coccidioidomycosis is caused by Coccidioides.

Which viral infection will cause the nurse to observe for warts?

Pox Virus Rhabdovirus Epstein-Barr Virus Papillomavirus Warts are caused by papillomavirus. Pox viruses cause smallpox. Rhabdovirus causes rabies. Epstein-Barr causes mononucleosis and Burkitt's lymphoma.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure?

Pulmonary capillary wedge pressure (Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility. Right atrial pressure measures only the function of the right side of the heart and indirectly its ability to receive blood. Cardiac output by thermodilution does not measure intracardiac pressures. Pulmonary artery diastolic pressure may not be as accurate an indicator of left ventricular pressure if chronic obstructive pulmonary disease or pulmonary hypertension exists.)

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?

Reduced peripheral pulses (Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.)

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves?

Removing the dilated superficial veins (The saphenous vein is ligated at its juncture with the femoral vein; injection sclerotherapy is used as the method of choice, but in chronic venous insufficiency and recurrent thrombophlebitis, surgery may be necessary. A bypass is unnecessary; the deep veins compensate for the removed saphenous vein. Cholesterol plaques are characteristic of atherosclerosis, an arterial, not venous, disease. Communicating veins normally exist between the superficial and deep veins; they are ligated to prevent further engorgement and varicosities.)

Which virus can cause encephalitis in adults and children?

Rubella virus Parvovirus Rotaviruses West Nile virus The West Nile virus causes encephalitis. German measles is caused by rubella. Gastroenteritis is caused by parvovirus. Rotavirus also causes gastroenteritis.

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip?

Second degree AV block Mobitz II (Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout, with the exception of the dropped beat(s). In first degree AV block, a P wave precedes every QRS complex, and the PR interval is prolonged. Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse, and it is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. Also called Mobitz I or Wenckebach phenomenon, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex.)

What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply.

Septic shock Harsh cough Mild chest pain Pleural effusion Body temperature of 104 °F Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Manifestations such as septic shock, pleural effusion, and body temperature above 103°F indicate the fulminant stage of inhalation anthrax. The prodromal stage is the early stage of inhalation anthrax; clinical manifestations include a harsh cough and mild chest pain.

Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test?

Serum potassium level (Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.)

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?

Sinus tachycardia (The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.)

Which medications are administered to inhibit purine synthesis and suppress cell-mediated and humoral immune responses? Select all that apply.

Sirolimus Azathioprine Cyclophosphamide Methylprednisolone Mycophenolate mofetil Azathioprine and mycophenolate mofetil are administered to inhibit purine synthesis and suppress cell-mediated and humoral immunity. Sirolimus binds to a mammalian target of rapamycin (mTOR), which suppresses T-cell activation and proliferation. Cyclophosphamide is administered to treat cancers, autoimmune disorders, and amyloidosis. Methylprednisolone is a corticosteroid that inhibits cytokine production.

A client presents to the emergency department with severe epistaxis. Which client position is most beneficial?

Sitting with head tilted slightly forward (The sitting position will reduce bleeding and allow for assessment of the quantity of bleeding; leaning forward will prevent blood from entering the stomach and possible aspiration. Placing the client in the Trendelenburg position will increase pressure to the area of the nosebleed. Semi-Fowler position is better than flat but may lead to blood draining down the throat. Sitting upright is appropriate, but tilting the head back increases the risk of swallowing blood and possible aspiration.)

Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm3 be classified?

Stage 1 Stage 2 Stage 3 Stage 4 Stage 2 describes a client with a CD4+ T-cell count between 200 and 499 cells/mm3. Stage 1 describes a client with a CD4+ T-cell count of greater than 500 cells/mm3. Stage 3 describes a client with a CD4+ T-cell count of less than 200 cells/mm3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T-cell counts is available.

A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client?

Stop smoking (Smoking is the single most important risk factor for peripheral arterial diseases, and cessation should be encouraged. Although hyperglycemia is a contributing factor, it is not the primary risk factor for LEAD. Although a sedentary lifestyle is a contributing factor, it is not the primary risk factor for LEAD. Although a high-fat, high-cholesterol diet is a contributing factor, it is not the primary risk factor for LEAD. )

Which sexually transmitted infection (STI) is caused by Treponema pallidum?

Syphilis Gonorrhea Genital warts Vulvovaginitis Staphylococcus aureus causes toxic shock syndrome. Treponema pallidum causes syphilis. Streptococcus faecalis causes genitourinary tract infections and infection of surgical wounds. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease.

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit?

Tachycardia (The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurologic problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress. )

A client has a tuberculin purified protein derivative test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. What does the nurse conclude about the client based on this response?

The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus. Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive tuberculin purified protein derivative indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?

This is a way of getting attention that should be ignored. The client can remember only depressing events from the past. The client feels guilty about the demands being placed on the family. This behavior is a common response over which the client has very little control. If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions. Attention-getting behavior requires cognitive thinking, and lability of mood is unrelated to this. The client may have remote memory, but there is no selective process that determines which events are remembered. There are no data to come to the conclusion that the client is experiencing feelings of guilt.

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?

To visualize the disease process in the coronary arteries (Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.)

Which type of hypersensitivity reaction will occur when the client's T cytotoxic cells are involved as the mediators of injury?

Type I Type II Type III Type IV Type IV hypersensitivity reaction will occur when the T cytotoxic cells are involved as the mediators of injury. Type I IgE-mediated reaction will occur when histamine is involved as the mediators of injury. Type II cytotoxic reaction will occur when complement lysis is the mediator of injury. Type III immune complex reaction will occur when neutrophils are involved as the mediators of injury.

A nurse is caring for a client with a negative-pressure wound treatment device. When should the nurse tell the client to call the wound center about this system?

When the negative pressure seal is broken When the tubing coming from the wound has no kinks When the drainage chamber is one-third full of exudate When the dressing has a small amount of exudate under the seal With negative pressure wound therapy, the client should understand that when the seal is broken, the wound center should be contacted immediately. There should be a tight seal covering the foam and an air-tight seal covering the wound and vacuum.

A client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair asks the nurse what to do in light of this result. How should the nurse respond?

Your cholesterol is elevated slightly. A diet low in saturated fats should be followed. (A level more than 200 mg/dL (5 mmol/L) is considered elevated, and foods high in cholesterol and saturated fats should be limited in the diet. A level of 240 mg/dL (6.2 mmol/L) or more is considered high. Levels between 140 and 200 mg/dL (2 mmol/L to 5 mmol/L) are considered desirable. A low level is less than 140 mg/dL (2.0 mmol/L). Medical attention should be sought, because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.)

A client diagnosed with osteomyelitis is being discharged. Which statement indicates a need for further teaching?

"I will take the antibiotic at the same time every day." "I will take the antibiotic regularly until my symptoms subside." "I will take the antibiotic with food if I develop gastric distress when on the antibiotic." "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath." The antibiotic should be taken as prescribed for the full length of treatment. The client should not discontinue the medication when symptoms subside. The statements "I will take the antibiotic at the same time every day," "I will take the antibiotic with food if I develop gastric distress when on the antibiotic," and "I will notify my healthcare provider and stop taking the medication if I develop a rash or shortness of breath" demonstrate understanding of the discharge instructions.

A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse?

"The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." (Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance. )

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

1. Pain in the calf 2. Redness in the affected area 3. Localized warmth in the lower extremity (Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease. Although some localized edema occurs, pitting edema does not occur in thrombophlebitis. Ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot. )

Four near-drowning victims are admitted to the emergency department. Which victim does the nurse determine to be at greatest risk for hypovolemia?

50yo rescued from the ocean (The high osmotic pressure of the saltwater from the ocean draws fluid from the vascular space into the alveoli, causing hypovolemia. The others involve aspiration of freshwater, which causes fluid to move rapidly into the capillary bed and circulation, leading to fluid overload. A lake, backyard pool, and bathtub don't use saltwater, so there is less risk.)

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the most appropriate nursing action?

Applying cold compresses to the affected area Ensuring the client keeps the skin clean and dry Monitoring for neurological and cardiac symptoms Advising the client to launder all clothes with bleach A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurologic manifestations. Therefore the nurse has to monitor for these symptoms. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure that the client's clothes are bleached to prevent the transmission of the infection.

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?

Approaching the client from the left side Keeping the client's head turned to the right Teaching the client to use head movements to scan the left field of vision Arranging the furniture in the client's room so that the door is in the right visual field The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. The client should be approached from the right side because the left visual field is impaired. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. Although it may help to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse (The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.)

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. What is the primary reason that the nurse pursues more information about the roommate?

Death from tuberculosis is on the increase The roommate is causing the client to be anxious Older adults with chronic illness are affected adversely by tuberculosis The roommate most likely is preventing the client from getting proper sleep The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from tuberculosis is declining because of improved drug therapy. (Canada: According to the Public Health Agency of Canada, 1,607 new active and re-treatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?

Elevate the legs (Elevation of extremities promotes venous and lymphatic drainage by gravity. Restricting fluids and applying elastic bandages are dependent functions of the nurse. Doing range-of-motion exercises may have little effect on edema. )

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first?

Leave the individual lying on the back with instructions not to move, and seek additional help. Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution. The individual should be moved only with a backboard to avoid additional spinal cord damage. Moving a person whose spinal cord has been injured may cause irreversible paralysis. A back injury precludes changing the person's position. A back injury is suspected; therefore the person should not be moved. A flat board is indicated; however, one rescuer should not move the person without help.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to prevent malaria?

Mosquito Bites Untreated Water Undercooked Food Overpopulated Areas Malaria is caused by the protozoan Plasmodium falciparum, which is carried by mosquitoes. Avoiding untreated water, undercooked food, and overpopulated areas will not prevent protozoa from entering the bloodstream.

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency?

Practice relaxation techniques. (Research has shown that decreasing stress will slow the rate of atherosclerotic development. Exercise is thought to decrease atherosclerosis and the formation of lipid plaques. Saturated fats in the diet are contraindicated because they increase the risk for atherosclerosis.)

Which sexually transmitted disease is treated with antiviral drugs?

Syphilis Gonorrhea Genital herpes Chlamydial infection Genital herpes is a sexually transmitted disease caused by herpes simplex virus. Therefore antiviral drugs are used to treat this condition. Bacteria cause syphilis, gonorrhea, and chlamydial infections.

What type of hypersensitivity reaction is the cause of systemic lupus erythematosus?

Type I Type II Type III Type IV Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

Use standard precautions. Employ airborne precautions. Plan interventions to limit direct contact. Discourage long visits from family members. The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact and discouraging long visits from family members will unnecessarily isolate the client.

A client expresses concern that because of supply and demand there is no vaccine available for the annual flu vaccine. What is the nurse's best reply?

"It's unfortunate, but there was such a limited supply available." "There are many others who also were unable to get a flu vaccine." "It doesn't matter because the vaccine is for just one particular strain." "There are other things you can do to prevent the flu, such as hand washing." The statement "There are other things you can do to prevent the flu, such as hand washing" is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response "It's unfortunate, but there was such a limited supply available" is empathic, but it does not address the client's concern of vulnerability. The response "There are many others who also were unable to get a flu vaccine" belittles the client for being concerned. The response "It doesn't matter because the vaccine is for just one particular strain" may be true, but it belittles the client's concern.

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply.

1. Pallor 2. Tachycardia (Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.)

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?

Activated partial thromboplastin time (APTT) is double the control value (Activated partial thromboplastin time should be 1.5 to 2.5 for the control of heparin therapy. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels.)

The nurse suspects that a client is in the chronic persistent stage of Lyme disease. Which symptoms support the nurse's suspicion? Select all that apply.

Arthritis Dyspnea Dizziness Chronic fatigue Erythema migrans Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi. The symptoms of the chronic persistent stage are arthritis and chronic fatigue. Dyspnea and dizziness are the symptoms of the early disseminated stage. Erythema migrans is observed in the localized stage.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level?

Asking the client's parent Using Wong's "Pain Faces" Observing the client's body language Explaining the use of a 0 to 10 pain scale An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication?

Avoid traumatic injury and exposure to infection. (Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection. Beginning a program of meticulous mouth care is helpful for stomatitis, not pancytopenia; aggressive oral hygiene may precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic byproducts of chemotherapy, this will have no effect on pancytopenia. Unusual muscle cramps or tingling sensations in the extremities are signs of hypocalcemia and do not apply to pancytopenia. )

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history?

Childhood strep throat (Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.)

A client with dehydration suddenly becomes diaphoretic, clammy, and pale. The client's blood pressure falls to 50/30 mm Hg. In which position will the nurse place the client?

Feet elevated with head at 20* angle (Feet elevated while keeping head flat or elevated to no more than a 30-degree angle is the best position for hypovolemic shock. A prone position does not promote circulation. While the high-Fowler position facilitates breathing, it does not assist blood flow to the head. Maintaining blood flow to vital centers, not comfort, is the priority.)

Which organism is responsible for causing Lyme disease in clients?

Phthirus pubis Sarcoptes scabiei Borrelia burgdorferi Pediculushumanus var. corporis Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculushumanus var. corporis also causes pediculosis.

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?

Polyuria Tachypnea Increased restlessness Intermittent tachycardia Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. Urine output is not related to increased intracranial pressure. The respiratory rate will decrease. The pulse will be slow and bounding.

A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action?

Postural hypotension (After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described.)

The nurse is educating a client about protease inhibitors. What statement about protease inhibitors is true?

Protease inhibitors prevent viral replication. Protease inhibitors prevent the interaction between viral material and the CD4+ T-cell. Protease inhibitors prevent viral and host genetic material integration. Protease inhibitors prevent the clipping of the viral strands into small functional pieces. Protease inhibitors act by preventing viral replication and release of viral particles. NRTIs inhibits the transformation of viral single-stranded ribonucleic acid into host double-stranded deoxyribonucleic acid (DNA) by the action of the enzyme reverse transcriptase. Entry inhibitor drugs prevent the binding of the virus to the CD4 receptors. Integrase inhibitor drugs prevent the integration of viral material into the host's DNA by the action of the enzyme integrase.

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?

Put the stockings on before rising in the morning. (Support hose apply external pressure on the veins, preventing the retrograde pressure or flow that may occur in the standing or sitting positions; application before rising prevents the veins from having the opportunity to become engorged. If keeping the stockings on 2 hours and off 2 hours is followed, at some point the feet will be dependent before the stockings are put on; venous pooling and edema may occur. Application of elastic stockings at this time can cause tissue trauma. The stockings usually need not be worn while in bed with the feet elevated during sleep, because gravity prevents venous pooling. Stockings must be removed so that the legs can be washed and dried at least daily.)

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first?

Record the temperature reading and continue to monitor it. (Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2° F (37.9° C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2° F (37.9° C) is an expected response and is not an emergency requiring notification of the primary healthcare provider.)

A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure?

Reduction in the circulating blood volume (A decreased intravascular volume results in hypovolemia and hypotension, which is evidenced by a decreased blood pressure and a decreased pulse pressure. Vasomotor stimulation to the arterial walls is increased with shock. Vasodilation resulting from diminished vasoconstrictor tone is a description of neurogenic shock, which is unlikely in this situation. Although electrolyte imbalances can precipitate cardiac decompensation, cardiogenic shock is unlikely in this situation.)

Which dietary modifications can help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)?

Refraining from consuming fatty foods Refraining from consuming frequent meals Refraining from consuming high-calorie foods Refraining from consuming high-protein foods Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. Therefore the client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

What must the nurse do to determine a client's pulse pressure?

Subtract the diastolic from the systolic reading. (Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.)

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify?

Support systems that can assist the client at home (The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors. )

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion?

Synchronizer switch is in the "on" position (The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 Watts/second. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave. )

Which cells are affected in DiGeorge syndrome?

T-cells B-cells Monocytes Polymorphonuclear cells DiGeorge syndrome is a primary immune deficiency disorder in which T-cells are affected. The B-cells are affected in Bruton's X-linked agammaglobulinemia; common variable hypogammaglobulinemia; and selective IgA, IgM, and IgG deficiency. Monocytes and polymorphonuclear cells are affected in chronic granulomatous disease and Job syndrome.

What causes medications used to treat AIDS to become ineffective?

Taking the medications 90% of the time Missing doses of the prescribed medications Taking medications from different classifications Developing immune reconstitution inflammatory syndrome (IRIS) The most important reason for the development of drug resistance in the treatment of AIDS is missing doses of drugs. When doses are missed, the blood drug concentrations become lower than what is needed to inhibit viral replication. The virus replicates and produces new particles that are resistant to the drugs. Taking the medications 90% of the time prevents medications from becoming ineffective. Taking medications from different classes prevents the drugs from becoming ineffective. Immune reconstitution inflammatory syndrome (IRIS) occurs when T-cells rebound with medication therapy and become aware of opportunistic infections.

A nurse identifies 12 mm of induration at the site of a tuberculin purified protein derivative (PPD) test when a client returns to the health office to have it read. What does the nurse explain to the client about this test?

Test result is negative and no follow-up is needed Result indicates a need for further tests and a chest x-ray Test was used for screening and a Tine test now will be given Skin test is inconclusive and will have to be repeated in 6 weeks The tuberculin PPD is injected intradermally; it is the most accurate skin test for tuberculosis (TB) because of the testing material and the intradermal method used. No other skin test is appropriate as a follow-up; further tests are now warranted, including a chest x-ray film. The test result is positive, not negative; thus further testing is necessary. The Tine test is less accurate than the tuberculin PPD and is not used as a follow-up test. More than 10 mm of induration is a positive test result, not a doubtful test result.

After assessing a client who is in cardiac arrest, a primary healthcare provider prescribes a dose of medication that is much higher than is recommended for the clinical situation and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate?

That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself. (The response "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself" informs the primary healthcare provider of the nurse's dilemma and legal position without creating an adversarial professional position. A confrontational response may jeopardize the collegial relationship. "You're wrong. I do not feel comfortable administering this high of a dose," "Please tell me how you arrived at this dose. I think your calculations are incorrect," and "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug" are confrontational responses. )

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?

The monitor will record any abnormal heart rhythms while I go about my usual activities. (The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.)

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Tonic-clonic seizures Decerebrate posturing Sudden severe headache Narrowed pulse pressure Bleeding into the enclosed cavity of the skull creates pressure, causing pain. Seizures are not directly related to the hemorrhage; they result from abnormal electrical charges that may eventually develop as a consequence of tissue ischemia. Decerebrate posturing (extension posturing) indicates caudal deterioration with damage to the midbrain and pons. As the systolic pressure increases, widening of the pulse pressure occurs because of compression of vasomotor centers.

The bacteria Clostridium botulinum causes which condition in a client?

Upper respiratory tract infection Toxic shock syndrome Urinary tract infection Food poisoning with progressive muscle paralysis Clostridium botulinum bacteria causes food poisoning with progressive muscle paralysis. Toxic shock syndrome is caused by the bacteria Staphylococcus aureus. Many viruses and bacteria can cause upper respiratory tract infection but Clostridium is not one of them. Klebsiella-Enterobacter organisms most likely cause urinary tract infections.

A nurse is teaching a health class about human immunodeficiency virus (HIV). Which basic methods are used to reduce the incidence of HIV transmission? Select all that apply.

Using condoms Using separate toilets Practicing sexual abstinence Preventing direct casual contacts Sterilizing the household utensils HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.

Which is a clinical manifestation of a cluster headache?

Vertigo Neck rigidity Phonophobia Ipsilateral tearing of the eye Ipsilateral tearing of the eye, or tearing on the same side as the headache, is a clinical manifestation of cluster headaches. Neck rigidity, vertigo, and phonophobia are manifestations of migraine headaches.

Which organism causes malaria?

Vibrio Sporozoa Ringworm Spirochetes Sporozoa such as Plasmodium malariae cause malaria. Vibrio are curved-rod-shaped bacteria; these microorganisms causes cholera. Ringworm such as tinea corporis may cause mycotic infections. Spirochetes are spiral-shaped bacteria; these microorganisms may cause leprosy and syphilis.

When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs?

Worsening ankle edema as the day progresses (When the legs are dependent, gravity and incompetent valves promote increased hydrostatic pressure in leg veins; as a result, fluid moves into the interstitial spaces. Clients report feeling an ache or heaviness in the legs, not burning sensations. Calf pain when the feet are dorsiflexed, which is referred to as Homans sign, most often is associated with thrombophlebitis. Increasing sensitivity of the legs to cold reflects inadequate arterial blood supply; arterial circulation is not affected by varicose veins.)

What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)?

Removing the catheter Keeping the drainage bag off of the floor Washing hands before and after assessing the catheter Cleansing the urinary meatus with soap and water daily Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.

A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, what does the nurse expect the client's postoperative plan of care to include?

Sequential compression stockings (Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates; this promotes venous return and prevents venous stasis and thromboembolism. Turning on the operative side is contraindicated because it places tension on the hip joint and may traumatize the incision. Isometric exercises may be prescribed to promote muscle strength; however, preventing the major complication thromboembolism is the priority. Passive ROM is contraindicated immediately after surgery.)

A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up?

"I am not good at remembering to take medications." (Not adhering to the treatment regimen may interfere with effective resolution of the MI, and further intervention is necessary. The other statements, such as "I want to stay as pain-free as possible," "I should not have any problems in reducing my salt intake," and "I wrote down my dietary information for future reference," are appropriate responses related to teaching concerning self-care after an MI)

A client has mitral valve insufficiency (regurgitation). The nurse is auscultating the heart to determine the presence of regurgitation. Where should the stethoscope be placed?

Between the 5th and 6th intercostal space (Point d is the mitral area at the fifth intercostal space at the left midclavicular line (also called the apex of the heart); the S1 heart sound (closure of the mitral and tricuspid valves, the "lub" in the "lub-dub" associated with heart sounds) is heard here. Mitral insufficiency produces a high-pitched blowing sound throughout systole. Point a is the aortic area at the second intercostal space to the right of the sternum. This area best reflects closure of the semilunar valves (pulmonic valve between the right ventricle and pulmonary artery; aortic valve between the left ventricle and the aorta). Ejection clicks associated with aortic stenosis also are heard at this site. Point b is the pulmonic area at the second intercostal space to the left of the sternum; this area best reflects problems of the pulmonic valve, such as pulmonic stenosis. Point c is not part of the assessment of the heart; this is the area over the right main bronchus, which is used to assess bronchovesicular breath sounds.)

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. What does the nurse explain to the client regarding the diagnostic criterion for acquired immunodeficiency syndrome (AIDS)?

Contracts HIV-specific antibodies Develops an acute retroviral syndrome Is capable of transmitting the virus to others Has a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%) AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

What is the function of limbic system?

Influence emotional behavior Regulate autonomic functions Facilitate automatic movements Relay sensory and motor inputs for cerebrum Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment. Which goal is the nurse trying to achieve?

Prevent cataracts Prevent blindness Prevent retinal detachment Prevent blurred distance vision POAG progresses gradually without symptoms; if untreated, blindness occurs. Peripheral vision slowly disappears until tunnel vision occurs in which there is only a small center field. Without treatment, eventually all vision is lost. POAG is not related to the development of cataracts, retinal detachment, or blurred distance vision.

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do?

Request that the client's food be pureed. Feed the client to conserve the client's energy. Have a family member assist the client with each meal. Encourage the client to participate in the feeding process. As part of the rehabilitative process after a brain attack, clients should be encouraged to participate in their own care to the extent that they are able and to extend their abilities by establishing short-term goals. A client with a brain attack may or may not have dysphagia; altering the consistency of food without the need to do so may make it less palatable. Making the client feel helpless discourages independence. Having a family member assist the client with each meal is unrealistic; family members may not be available because of other responsibilities.

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding?

Sinus rhythm with PACs (A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.12 seconds. P and QRS waves are consistent in shape. Bradycardia is defined as a heart rate less than 60 beats per minute.)

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond?

This surgery significantly decreases symptoms in most clients (The majority of those who have this surgery have marked relief from their symptoms because the flow of blood to myocardial cells is increased. Whether the procedure will enable the client to return to work depends on the client's presurgical condition and occupation, not the surgery itself. So far, studies have failed to show that coronary artery bypass surgery affects life span. The surgery itself does not affect the disease process; clients must reduce risk factors (obesity, smoking, and high-fat/high-cholesterol diet) as well.)

A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case findings?

Tuberculosis has been rising dramatically in the general population. Older adults with chronic illness are more susceptible to tuberculosis. There is a high incidence of tuberculosis in children less than 12 years of age. Death from tuberculosis has been generally on the decrease in the United States (Canada). The client's chronic illness and older age increase vulnerability; the daughter's condition should be explored in greater detail. Tuberculosis is only one of many potential causes of the daughter's clinical condition. Children who have not yet reached puberty and adolescence have the lowest incidence of tuberculosis. Morbidity and mortality resulting from tuberculosis are increasing, not decreasing.

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?

Sit on the edge of the bed so they can hold the client upright. Slide to the floor so the client will not be injured as a result of a fall. Bend forward so that blood flow to the brain is increased. Lie down immediately so they can take the client's blood pressure. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor and bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which will traumatize the spinal cord; taking the blood pressure at this time is not necessary.

When planning a citywide national homeland security (Canada: Public Health Agency of Canada's Centre for Emergency Preparedness) disaster preparedness drill, a nurse is assigned to the triage committee. Place the following criteria in an order that reflects the most efficient triage plan for an actual mass casualty incident (MCI).

1. Tension pneumothorax 2. Compound femur fracture 3. Laceration of the thigh muscle 4. Severe wrist pain 5. Crushing head injury (Critically ill clients who can survive with care are categorized as "immediate" and are treated first; they receive a code of "Red." In a major disaster, the exact opposite of what is done in a nondisaster situation occurs. The object is to get the greatest number of survivors treated fast. A tension pneumothorax involves increasing positive pressure in the pleural space, which leads to lung collapse. An inability to breathe can quickly lead to death if not treated immediately. Open fractures of the long bones are also categorized as "Red" because, if untreated, infection and bleeding are life-threatening complications. This, however, does not pose the immediate threat that a tension pneumothorax does. Those who are injured but for whom care can be postponed for a few hours are categorized as "delayed" and treated second; they receive a code of "Yellow." Treatment of vascular injuries without evidence of shock can be delayed. Those who have minor injuries are categorized as "minimal" and are treated third; they receive a code of "Green." A sprain is not life threatening; care can be delayed for an extended period. Those who are critically ill and have little or no chance of survival are categorized as "expectant" and are treated last; they receive a code of "Black." A crushing head injury causes severe brain injury; chances of survival are unlikely.)

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply.

1. Wash hands before entering the client's room 2. Advise use of a soft toothbrush for oral hygiene 3. Report an elevation in temperature immediately (It is essential to prevent infection in a client with severe bone marrow depression; thorough handwashing before touching the client or client's belongings is important. Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary healthcare provider immediately because it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. This is not related to bone marrow suppression. Clients who have severe bone marrow depression must avoid eating raw fruits and vegetables and undercooked meat, eggs, and fish to prevent possible exposure to microbes.)