Final review MDC2

Which instruction should the nurse include when teaching an elderly client how to prevent constipation? Select all that apply •1. "Drink 48 oz of fluid each day" •2. "Avoid grain products and nuts" •3. "Your diet should include no more than 15 g of fiber per day" •4. "Be sure to get regular exercise"

"Drink 48 oz of fluid each day" "Be sure to get regular exercise"

How would the nurse expect a client with appendicitis to describe the pain? •1. "I have aching in my lower abdomen" •2. "The pain comes on very quickly and goes away just as quickly" •3. "The pain occurs every hour for just a few minutes" •4. "The pain is steady and is a 7 on a scale of 1 to 10"

"The pain is steady and is a 7 on a scale of 1 to 10"

A client is admitted in the early stages of peritonitis. What is the nurse's priority assessment? •1. Abdominal distention •2. Abdominal pain and rigidity •3. Hyperactive bowel sounds •4. Right upper quadrant pain

Abdominal pain and rigidity

What should the nurse include in the discharge teaching plan for a client who has diverticulitis? Select all that apply. •1. Decrease daily fluid intake •2. Adhere to a high fiber diet •3. Avoid strawberries and tomatoes •4. Decrease carbohydrates •5. Avoid nuts and corn

Adhere to a high fiber diet Avoid strawberries and tomatoes Avoid nuts and corn

A client with type 1 diabetes mellitus is exhibiting Kussmaul's respirations, abdominal discomfort, and lethargy. What intervention should the nurse perform? •1. Assess complete blood count •2. Administer Regular insulin IV as ordered •3. Start an intravenous infusion of dextrose •4. Assess neurological status

Administer Regular insulin IV as ordered

What is the most important information for the nurse to teach the client about the development of pancreatitis? •1. Alcohol abuse •2. Hypercalcemia •3. Hyperlipidemia •4. Pancreatic duct obstruction

Alcohol abuse

Care of the patient with an anorectal abscess should include which of these nursing interventions? Select all that appl. •1. Analgesics •2. Bed rest •3. Antidiarrheals •4. Sitz bath

Analgesics Sitz bath

The home health nurse is visiting a client newly diagnosed with type 1 diabetes mellitus. The client reports nausea and abdominal pain. The nurse observes dehydration and dry skin. What question should the nurse ask the client? •1. "What did you drink today?" •2 "Are you taking your insulin daily to maintain tight glycemic control?" •3. "When is the last time you had a checkup?" •4. "Did you weigh yourself today?"

Are you taking your insulin daily to maintain tight glycemic control

What is the priority nursing intervention for a client with acute appendicitis? •1. Teaching the client about surgery •2. Encouraging oral intake of clear fluids •3. Maintaining the client on bedrest •4. Assessing for symptoms of peritonitis

Assessing for symptoms of peritonitis

Which condition increases the risk for surgery in a client with ulcerative colitis •1. Bowel intussusception •2. Bowel herniation •3. Bowel outpouching •4. Bowel perforation

Bowel perforation

The nurse is admitting a client with a diagnosis of myxedema during the initial assessment which findings with the nurse be most concerned about •1. Hypertension and weight loss •2. Heat intolerance and emotional lability •3. Corneal ulcerations and increased appetite •4. Bradycardia and decreased intellectual function

Brady cardia and decreased intellectual function

A client is in the immediate postoperative stage following a bowel resection. What assessments are important for the nurse to make? Select all that apply. •1. Breath sounds •2. Temperature •3. Wound infection •4. Swallowing reflex •5. Reflux assessment

Breath sounds Temperature Wound infection *at risk for infection and respiratory compromise

What symptoms with the nurse expect to find for a client with cholecystitus? Select all that apply •1. epigastric pain •2. right shoulder pain •3. nausea •4. fever •5. hypotension

Epigastric pain, right shoulder pain, nausea, fever

The nurse is admitting a client diagnosed with primary hyperthyroidism. Which laboratory results should the nurse expect?? Select all that apply. •1. Elevated thyroid stimulating hormone •2. Decreased thyroid stimulating hormone •3. Elevated T3 levels •4. Elevated T4 levels •5. Decreased T3 levels •6. Decreased T4 levels

Decreased thyroid stimulating hormone Elevated T3 levels Elevated T4 levels

The nurse is providing education to a client diagnosed with hyperparathyroidism. The nurse determines further teaching is necessary when the client states that they will continue to: •1. Take acetaminophen •2. Take aspirin •3. Eat fresh fruit 4. Drink milk

Drink milk

A client with Crohn's disease has been experiencing 20 watery stools per day. What is the nurse's priority assessment? •1. Heart rate •2. Urinary output •3. Blood pressure •4. Electrolytes

Electrolytes

The nurses teaching a patient diagnosed with Hypothyroidism. What should the Nurse educate the patient on •1. "Your adrenal glands will need to be assessed." •2. "We will need to measure your parathyroid hormone." •3. "It will take about 2 weeks for you to feel improvement after starting your medication." •4. "A CT scan is necessary to determine the cause of your problem."

It will take about 2 weeks for you to feel improvement after starting your medication

The nurse is admitting a client with newly diagnosed Cushing's syndrome. Which laboratory values should the nurse expect to find? •1. Decreased sodium and decreased glucose •2. Decreased cortisol and decreased glucose •3. Increased cortisol and decreased sodium •4. Increased cortisol and increased sodium

Increased cortisol and, increased sodium

A client has developed diabetic ketoacidosis (DKA), secondary to infection. The nurse should assess for which potential problems? •1. Shallow respirations and severe abdominal pain •2. Kussmaul's respirations and a fruity odor to the breath •3. Decreased respirations and increased urine output •4. Cheyne-Stokes respirations and foul-smelling urine

Kussmaul's respirations and a fruity odor to the breath

A client is admitted to the medical floor with a diagnosis of pancreatitis. What is the priority nursing intervention? •1. Solid regular diet and avoid analgesics •2. Pain management and maintain NPO status •3. Allow the client to dictate food and caffeine servings •4. Support surgical management interventions

Pain management and maintain NPO status

Which condition may lead to hemorrhoids? •1. Diarrhea •2. Diverticulosis •3. Portal hypertension •4. Rectal bleeding

Portal hypertension **high intra abd pressure

An enema is prescribed for a client with suspected appendicitis. What is the most appropriate action by the nurse? •1. Prepare 750 ml of irrigating solution warmed to 100 F •2. Question the health care provider about the order •3. Provide privacy and explain the procedure to the client •4. Assist the client to left lateral Sim's position

Question the health care provider about the order

What symptoms would the nurse expect to find for a client with appendicitis? Select all that apply •1. right lower quadrant pain •2. anorexia •3. nausea •4. hypothermia •5. projectile vomiting

Right lower quadrant pain anorexia nausea

The nurse is caring for a client who has experienced a cerebral vascular accident (CVA). The client's urinary output has decreased to 10 mL/hr. What is the nurse's priority assessment? •1. Thyroid hormone •2. Cardiac status •3. Serum cortisol level •4. Serum sodium level

Serum sodium level

Which test should the nurse anticipate for a client experiencing weight gain, intolerance to cold, constipation, and lethargy? •1. Liver function tests •2. Hemoglobin A1C •3. T3, T4, and TSH •4. 24-hour urine free cortisol measurement

T3, T4, and TSH

The nurse is caring for a client two days post abdominal surgery. The surgery resulted in the creation of a stoma. What is the nurse's priority while caring for this client? •1. Assessing the client's body image •2. Teaching the client how to care for the stoma and that a collection bag will need to be worn at all times •3. Addressing the client's sexual concerns •4. Explaining dietary changes

Teaching the client how to care for the stoma and that a collection bag will need to be worn at all times

Crohn's disease can be described as a chronic inflammatory disease. Which areas of the gastrointestinal system may be involved with this disease? •1. The entire length of the large colon •2. Only the sigmoid area •3. The layers of mucosa and submucosa •4. The small intestine and colon, affecting the entire thickness of the bowel

The small intestine and colon, affecting the entire thickness of the bowel

A nurse is admitting a client with hypothyroidism. What is the priority assessment? •1. Polyuria, polydipsia, and weight loss •2. Heat intolerance, nervousness, weight loss, and hair loss •3. Coarsening of facial features and extremity enlargement •4. Tiredness, cold intolerance, weight gain, and constipation

Tiredness, cold intolerance, weight gain, and constipation

Which condition might the nurse find in the medical history of a client with colon cancer? •1. Appendicitis •2. Hemorrhoids •3. Hiatal hernia •4. Ulcerative colitis

Ulcerative colitis

Which risk factors would place a client at risk for the development of cholelithiasis? Select all that apply. •1. Use of oral contraceptives •2. History of diabetes mellitus •3. Increased daily exercise •4. Obesity •5. Age less than 25 years

Use of oral contraceptives History of diabetes mellitus Obesity

Which of the following a nurse assess in a patient with malabsorption syndrome? Please select all that apply •1. Weight loss •2. Abdominal bloating •3. Increased bruising •4. Positive Hydrogen breath test •5. Negative stool test for fat

Weight loss Abdominal bloating Increased bruising Positive Hydrogen breath test

Which of the following are signs or symptoms of irritable bowel syndrome? Please select all that apply. •1. abdominal pain •2. bloating •3. constipation •4. fever •5. diarrhea

abdominal pain bloating constipation diarrhea

Patient that is postop day four from a hysterectomy is at risk for developing a mechanical bow obstruction •1. True •2. False

false

The nurse is providing nutritional teaching for a client with a family history of colon cancer. Which choice demonstrates an understanding of the appropriate diet for the client? •1. 1 high fiber low fat •2.Vegetarian chili •3. Hot dogs and sauerkraut •4. Egg salad on rye bread •5. Spaghetti and meat sauce

high fiber low fat

The nurse admits a client diagnosed with a new onset of type 1 diabetes mellitus. Which symptoms should the nurse expect to find during his initial physical assessment? •1. polydipsia, polyuria, and weight loss •2. weight gain, tiredness, and bradycardia •3. irritability, diaphoresis, and tachycardia •4. diarrhea, abdominal pain, and weight loss

polydipsia, polyuria, and weight loss

The nurses caring for a post operative client who has undergone surgical removal of the pituitary gland and has now developed diabetes insipidus the nurse should assess for •1. hypertension and bradycardia •2. polyuria and severe dehydration •3. fluid overload and hyponatremia •4. glucosuria and weight gain

polyuria and severe dehydration

What is the nurse's priority while caring for a client with severe diarrhea? •1. administering pain medications •2. replacing electrolytes and fluids •3. assessing for excessive flatus •4. assessing for irritation of the perineal and rectal area

replacing electrolytes and fluids

The nurse is preparing a teaching plan for a client diagnosed with diverticulosis. What is the most important information for the nurse to provide to this client? •1. "You should not experience any pain" •2. "Peritonitis may be a complication of this condition" •3. "Antibiotics may be prescribed" •4. "Constipation may lead to the development of the disease" •5. "Laxative use is a common cause of the disease"

•"Peritonitis may be a complication of this condition", •Antibiotics may be prescribed", •Laxative use is a common cause of the disease"

The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority? •1. Preventing infection •2. Client is alert and oriented •3. Relieving anxiety •4. Lowering blood pressure

•Client is alert and oriented

Which assessment findings should the nurse expect in a patient with Addison's disease? •1. Weight gain and loss of skin pigment •2. Fatigue and muscle weakness •3. Hypertension and hypernatremia •4. Increased appetite and hypokalemia

•Fatigue and muscle weakness

What is the nurse's priority while caring for a client with peritonitis? •1. Fluid and electrolyte balance •2. Gastric irrigation •3. Pain management •4. Psychosocial issues

•Fluid and electrolyte balance

The nurse is providing education to a group of clients newly diagnosed with type 1 diabetes mellitus. One client asks why the glycosylated hemoglobin blood test is done. What is the nurse's best response? •1. HbA1c measures hemoglobin level in addition to blood glucose levels •2. HbA1c is used to assess long-term glycemic control •3. HbA1c provides information about conditions that effect a red blood cell's life span •4. HbA1c provides information about serum protein and albumin

•HbA1c is used to assess long-term glycemic control

The nurse is caring for a client recently diagnosed with Cushing's syndrome. Which assessment finding should the nurse expect to find? •1. Hypotension •2. Hypertension •3. Emaciation •4. Weight loss

•Hypertension

A client who has been treated for type 1 diabetes mellitus for five years reports numbness and tingling in the lower extremities. What should the nurse do as a priority? •1. Inspect the patient's feet for sores •2. Soak the patient's fee •3. Elevate the patient's feet •4. Massage the patient's lower extremities

•Inspect the patient's feet for sores

The nurse is teaching health promotion to a group of adults in the community. Which action would the nurse advise to decrease the risk factors for type 2 diabetes mellitus? •1. Following a fat-free diet and non-impact exercise three times a week •2. Maintaining an ideal weight and participating in daily exercise •3. Following a very low carbohydrate diet that includes moderate amounts of fat •4. Smoking cessation and a diet high in protein and fat

•Maintaining an ideal weight and participating in daily exercise

The nurse is admitting a client to the unit with Cushing's syndrome. The nurse is likely to find which signs or symptoms related to prolonged cortisol therapy? •1. Weight loss and heat intolerance •2. Changes in skin texture and low body temperature •3. "Moon face" and weight gain •4. Polyuria and dehydration

•Moon face" and weight gain

A client is started on steroid therapy after an adrenalectomy. Which information is most important to share with this client?? Select all that apply. •1. Take the prescribed dose daily, and do not stop abruptly. •2. Notify your healthcare provider if you experience increased urination. •3. Discontinue steroid therapy after two weeks. •4. Take this medication until your doctor tells you to stop. •5. Take two doses if you miss a dose.

•Take the prescribed dose daily, and do not stop abruptly. • Notify your healthcare provider if you experience increased urination. •. Take this medication until your doctor tells you to stop.

Which assessment would be a priority for a nurse caring for a client with hypoparathyroidism? •1. Tetany •2. Increased thyroid hormone •3. Decreased phosphate •4. Increased potassium

•Tetany

A client is being screened for diabetes mellitus and has two recent fasting blood glucose results of 132 mg/dl and 146 mg/dl. How should these results be interpreted? •1. These are normal results. No further action is needed •2. These results indicate diabetes mellitus. Follow-up is required. •3. The fasting blood glucose tests should be repeated two more times. •4. The client should be scheduled for a hemoglobin A1C test.

•These results indicate diabetes mellitus. Follow-up is required.

A nurse is teaching a group of nursing students about the thyroid gland and aging. Which information should the nurse plan to teach? •1. The thyroid gland increases in size with increasing age. •2. Older adults require higher doses of replacement therapy. •3. Thyroid hormone secretion decreases with age. •4. The basal metabolic rate increases with age.

•Thyroid hormone secretion decreases with age.