Evolve Week 10 Questions (Ch 58,
A client is hospitalized with a possible disorder of the adrenal cortex. Which nursing activity is best for the charge nurse to delegate to an experienced nursing assistant? Ask about risk factors for adrenocortical problems. Assess the client's response to physiologic stressors. Check the client's blood glucose levels every 4 hours. Teach the client how to do a 24-hour urine collection.
c
When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? Having a larger meal early in the morning Consuming increased carbohydrates and moderate protein Restricting fluids to 1500 mL/day Limiting alcoholic beverages to once weekly
b To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.
A client has suspected alterations in antidiuretic hormone (ADH) function. Which diagnostic test does the nurse anticipate will be requested for this client? Adrenocorticotropic hormone (ACTH) suppression test Chest x-ray Cranial computed tomography (CT) Renal sonography
c
A client with an endocrine disorder says, "I can't, you know, satisfy my wife anymore." What is the nurse's best response? "Can you please tell me more?" "Don't worry. That is normal." "How does she feel?" "Should I make an appointment with a counselor?"
a
The charge nurse on the medical-surgical unit is making client assignments for the shift. Which client is the most appropriate to assign to an LPN/LVN? Client with Cushing's syndrome who requires orthostatic vital signs assessments Client with diabetes mellitus who was admitted with a blood glucose of 45 mg/dL Client with exophthalmos who has many questions about endocrine function Client with possible pituitary adenoma who has just arrived on the nursing unit
a
The nurse is instructing a client who will undergo a suppression test. Which statement by the client indicates that teaching was effective? "I am being tested to see whether my hormone glands are hyperactive." "I am being tested to see whether my hormone glands are hypoactive." "I am being tested to see whether my kidneys work at all." "I will be given more hormones as a trigger."
a
The nurse is teaching a client about maintaining a proper diet to prevent an endocrine disorder. Which food does the nurse suggest after the client indicates a dislike of fish? Iodized salt for cooking More red meat More green vegetables Salt substitute for cooking
a
The nurse should encourage fluids every 2 hours for older adult clients because of a decrease in which factor? Antidiuretic hormone (ADH) production General metabolism Glucose tolerance Ovarian production of estrogen
a
Which gland releases catecholamines? Adrenal Pancreas Parathyroid Thyroid
a
When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? Kidney failure Refractory ascites Fetor hepaticus Paracentesis scheduled for today
a The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.
A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? Colon cancer with metastasis to the liver Hypertension Hepatic encephalopathy Ascites and shortness of breath
a Transplantation is performed for hepatitis and primary (not secondary) liver cancers.
When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? (Select all that apply.) Prolonged partial thromboplastin time Icterus of skin Swollen abdomen Elevated magnesium Currant jelly stool Elevated amylase level
a, b, c The liver produces clotting factors. Icterus, jaundice, results from cirrhosis. The client with cirrhosis may develop ascites. Elevated magnesium is not related to cirrhosis. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of AST and ALT; amylase is typically elevated in pancreatitis
When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) Esophageal varices Hematuria Fever Ascites Hemorrhoids
a, d, e Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.
A client is hospitalized for pituitary function testing. Which nursing action included in the client's plan of care will be most appropriate for the RN to delegate to the LPN/LVN? Assess the client for clinical manifestations of hypopituitarism. Inject regular insulin for the growth hormone stimulation test. Palpate the thyroid gland for size and firmness. Teach the client about the adrenocorticotropic hormone stimulation test.
b
In type 1 diabetes, insulin injections are necessary to maintain which action between insulin and glucose? Glucose intolerance Homeostasis Insulin intolerance Negative feedback
b
The nurse is assessing a client for endocrine dysfunction. Which comment by the client indicates a need for further assessment? "I am worried about losing my job because of cutbacks." "I don't have any patience with my kids. I lose my temper faster." "I don't seem to have any stressors now." "My weight has been stable these past few years."
b
The nurse is teaching a client about the correct procedure for a 24-hour urine test for creatinine clearance. Which statement by the client indicates a need for further teaching? "I should keep the urine container cool in a separate refrigerator or cooler." "I should not eat any protein when I am collecting urine for this test." "I won't save the first urine sample." "To end the collection, I must empty my bladder, adding it to the collection."
b
To best determine how well a client with diabetes mellitus is controlling blood glucose, which test does the nurse monitor? Fasting blood glucose Glycosylated hemoglobin (HbA1c) Oral glucose tolerance test Urine glucose level
b
Which statement is true about hormones and their receptor sites? Hormone activity is dependent only on the function of the receptor site. Hormones need a specific receptor site to work. Hormones need to be plasma-bound to activate the receptor site. Hormone stores are available for activation until needed.
b
The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? Client with ascites who had a paracentesis 2 hours ago and is reporting a headache Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
b A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented.
When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? Clients who work with shellfish Men who prefer sex with men Clients traveling to a third-world country Clients with elevations of aspartate aminotransferase and alanine aminotransferase
b Consuming raw or undercooked shellfish may cause hepatitis A. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is going to be exposed to blood and body fluids. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk
In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? Increased blood pressure, increased respiratory rate Decreased blood pressure, increased heart rate Increased respiratory rate, increased apical pulse, pallor Tachypnea, diaphoresis, increased blood pressure
b Decreased blood pressure and increased heart rate are indicative of shock
A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? Preventing hypotension Keeping the T-tube in a dependent position Administering antibiotic vaccinations Administering immune-suppressant drugs
b Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will prevent the complication of acute kidney injury. Administering antibiotic vaccinations will prevent infection. Administering immune-suppressant drugs will prevent graft rejection.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? Client with hepatitis A reporting severe and ongoing itching Client with severe ascites who has a temperature of 101.4° F (38° C) Client with cirrhosis who has had a 3-pound weight gain over 2 days Client with esophageal varices and mild right upper quadrant pain
b The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.
Which activity by the nurse will best relieve symptoms associated with ascites? Administering oxygen Elevating the head of the bed Monitoring serum albumin levels Administering intravenous fluids
b The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath.
The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? Client who is taking lactulose and has diarrhea Client with hepatitis C who requires a dressing change Client with end-stage cirrhosis who needs teaching about a low-sodium diet Obtunded client with alcoholic encephalopathy who needs a blood draw
c
Which negative feedback response is responsible for preventing hypoglycemia during sleep in nondiabetic clients? Alpha cells of the pancreas Beta cells of the pancreas Glucagon release Insulin release
c
Which problem for a client with cirrhosis takes priority? Insufficient knowledge related to the prognosis of the disease process Discomfort related to the progression of the disease process Potential for injury related to hemorrhage Inadequate nutrition related to an inability to tolerate usual dietary intake
c
When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? Hemoglobin and hematocrit Leukocytes Alpha-fetoprotein Serum albumin
c Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Serum albumin levels may be low in liver cancer and in malnutrition.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? Provides enzymes necessary to digest dairy products Reduces portal pressure Promotes gastrointestinal (GI) excretion of ammonia Decreases GI bleeding
c Reduces serum ammonia by excreting ammonia through the GI tract
A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? Obtain the charts from the previous admission. Listen for bowel sounds in all quadrants. Obtain pulse and blood pressure. Ask about abdominal pain.
c The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage
What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? The client must not consume alcohol. Avoid sharing the bathroom with the client. Members of the household must not share toothbrushes. Drink only bottled water and avoid ice.
c Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared.
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) Recent influenza infection Brown stool Tea-colored urine Right upper quadrant tenderness Itching
c, d, e Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. The stool in hepatitis may be tan or clay-colored.
A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? Requesting vaccination for hepatitis A Using a needleless system in daily work Getting the three-part hepatitis B vaccine Requesting an injection of immunoglobulin
d
The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? Assessing skin integrity and abdominal distention Drawing blood from a central venous line for electrolyte studies Evaluating laboratory study results for the presence of hypokalemia Placing the client in a semi-Fowler's position
d
The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? Positive Babinski's sign Hyperreflexia Kehr's sign Asterixis
d
The nurse is reviewing the laboratory test results for a client admitted with a possible pituitary disorder. Which information has the most immediate implication for the client's care? Blood glucose 125 mg/dL Blood urea nitrogen (BUN) 40 mg/dL Serum potassium 5.2 mEq/L Serum sodium 110 mEq/L
d
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? "Cirrhosis is a chronic disease that has scarred my liver." "The scars on my liver create problems with blood circulation." "Because of the scars on my liver, blood clotting and blood pressure are affected." "My liver is scarred, but the cells can regenerate themselves and repair the damage."
d Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? Vitamin K-containing products Potassium-sparing diuretics Nonabsorbable antibiotics Nonsteroidal anti-inflammatory drugs (NSAIDs)
d Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.
How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? Provides small frequent meals for the client Suggests taking daily potassium supplements Elevates the head of the bed in high-Fowler's position Requests a bedside commode for the client
d Lactulose therapy increases the frequency of stools.
Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider? The dressing has a 2-cm area of serous drainage. The client's platelet count is 135,000/mm3. The client's albumin level is 2.8 mg/dL. The client's heart rate is 122 beats/min.
d Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider.
Which intervention is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? Measure and record drainage. Monitor aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Obtain informed consent for the procedure. Have the client void before the procedure is performed.
d Voiding before the procedure prevents bladder injury.
It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? Right shoulder pain Polyuria Bone marrow suppression Bleeding
d When monitoring a client post hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority.
