Foundation 2 Exam #3 Prep U

A patient is suspected to have prostate cancer related to observed clinical symptoms. What definitive test can the nurse assist with to confirm a diagnosis of prostate cancer?

Prostate biopsy

What is a hallmark of the diagnosis of nephrotic syndrome?

Proteinuria

The nurse is checking placement of a nasogastric (NG) tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate?

The tube is in the stomach.

The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency?

Vitamin B12

A group of students are reviewing the female reproductive system in preparation for a test. Which of the following if identified by the students as an internal structure indicates successful learning?

Vagina

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?

Vasomotor symptoms associated with dumping syndrome

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as

angioneurotic edema.

A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?

applications of ice

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has?

peptic ulcer disease

Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:

high-fiber diet.

Which external reproductive structure is removed by circumcision?

prepuce

A client has developed urinary incontinence and is beginning bladder training to regain control over urine elimination. The catheter would be clamped and unclamped to:

promote normal bladder function.

A client has been diagnosed with acute glomerulonephritis. This condition causes:

proteinuria.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

recent foods ingested.

A nurse is caring for a client with a kidney disorder. What hormone released by the kidneys initiates the production of angiotensin and aldosterone to increase blood pressure and blood volume?

renin

Which structure is involved in keeping the testes at the necessary temperature to ensure sperm production?

scrotum

The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14-

Cardiac effects of hyperthyroidism include

palpitations.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia

A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal?

Relieve the pain.

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

Which instruction about insulin administration should a nurse give to a client?

"Always follow the same order when drawing the different insulins into the syringe."

A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate?

"All of your children will be carriers of the recessive gene but may not develop the disease."

A nurse measures a patient's urinary output every 8 hours. The nurse weighs the importance of these results by comparing the normal 24-hour urinary output with the patient's condition and medication. The normal 24-hour output should be:

1 to 2 L/day

The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL?

1,000 mL

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time?

10:00 AM

The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve?

2 in.

A patient is 62 years old and weighs 176 pounds. Post prostatectomy, the nurse assesses hourly urine outputs. Select the measurement that would require notification of the health care provider.

25 mL/hr

A client weighs 215 lbs and is 5' 8" tall. What would the nurse calculate this client's body mass index (BMI) as being?

32.7

A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?

A painless genital ulcer that appeared about 3 weeks after unprotected sex

What is the duration of regular insulin?

4 to 6 hours

The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' would the nurse expect to find?

Bulging eyes

A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea?

Burning on urination

The nurse is caring for a client experiencing an anaphylactic reaction. The nurse prepares for the maximum intensity of histamine response to occur within which time frame?

5 to 10 minutes

The nurse is educating a patient about the best time to perform breast self-examination (BSE). When does the nurse inform her is the best time after menses to perform BSE?

5 to 7 days

Which of the following is the primary function of the small intestine?

Absorption

A nurse is preparing a presentation about contraception for a young adult community group. Which of the following would the nurse expect to address as the most effective means of contraception?

Abstinence

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours

Which of the following would be most important for the nurse to include to ensure a thorough baseline history related to the reproductive system?

Age of menarche

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?

Assure the client that this is a normal reaction

The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?

Anticholinergic

Which type of medication may be used to inhibit bladder contraction in a client with incontinence?

Anticholinergic agent

The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before?

Antihistamine

The nurse is obtaining a history from a male client who states having difficulty achieving and sustaining an erection. When reviewing the medication history, which medication classification does the nurse anticipate?

Antihypertensives

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete piror to this assessment?

Ask the client to empty the bladder.

A client is undergoing treatment for prostate cancer. He has chemotherapy sessions regularly. However, of late he is showing symptoms of food allergy and loss of appetite. He has lost considerable weight as a result. Which is an appropriate nursing task in this situation?

Ask the client to keep a diet diary.

A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?

Avoid fibrous foods, lactose, fat, and caffeine.

When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?

Check for thrill or bruit over the access site.

The nurse is caring for a group of clients at a public health clinic. Which sexually transmitted disease would the nurse focus the client education on curative goals?

Chlamydia

A client with calculi in the gallbladder is said to have

Cholelithiasis

Which statement provides accurate information regarding cancer of the colon and rectum?

Colorectal cancer is the third most common site of cancer in the United States.

The actions of parathyroid hormone (PTH) are increased in the presence of which vitamin?

D

Which of the following is a age-related change associated with the immune system?

Decreased antibody production

After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?

Decreased pelvic muscle tone due to multiple pregnancies

Which tube is a nasoenteric feeding tube?

Dobbhoff

Which of the following is a cause of a calcium renal stone?

Excessive intake of vitamin D

Gastrin has which of the following effects on gastrointestinal (GI) motility?

Increased motility of the stomach

Which intervention is the most critical for a client with myxedema coma?

Maintaining a patent airway

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.

Milk Eggs Shrimp

Which glands regulate calcium and phosphorous metabolism?

Parathyroid

When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic?

Penicillin

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Place the client in the Fowler's position.

Preventive health education includes informing patients about the symptoms associated with allergic rhinitis. The nurse is aware that the most common trigger to this respiratory allergic response is:

Plant pollen.

A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, she finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram?

Pruritus

The nursing educator is talking with a group of recent nursing graduates about common diagnoses on the unit. What diffuse connective tissue disease would the instructor tell the group is caused by an autoimmune reaction that results in phagocytosis, producing enzymes within the joint that break down collagen and cause edema?

Rheumatoid arthritis (RA)

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

Right lower quadrant

In what location would the nurse palpate for the liver?

Right upper quadrant

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?

Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability?

Stimulate more hormones using the negative feedback system

A gerontological nurse is aware of the high incidence and prevalence of urinary tract infections (UTIs) among older adults. Consequently, the nurse is implementing plans of care that attempt to reduce this risk. Which of the following actions present the greatest risk of UTIs for older adults?

The use of indwelling urinary catheters

Diagnostic testing of a patient with a history of chronic renal failure has been ordered. The care provider has ordered a test of the patient's creatinine clearance in an effort to gauge the progression of his disease. The nurse understands that this test reflects what aspect of the kidney structure and function?

The volume of blood that the kidneys are able to filter in a given time

Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex?

They are localized to the area of exposure, usually the back of the hands.

A client with breast cancer is scheduled to undergo chemotherapy with aromatase inhibitors. Which of the following best reflects the rationale for using this group of drugs?

They lower the level of estrogen in the body blocking the tumor's ability to use it.

Which group of clients should not receive potassium iodide?

Those who are allergic to seafood

The nurse is caring for a patient in the hospital who is receiving a vitamin D supplement. What does the nurse understand is the importance of supplementation with this vitamin? (Select all that apply.)

Vitamin D deficiency is associated with increased risk of common cancers. Vitamin D deficiency is associated with increased risk of autoimmune disease. Vitamin D deficiency is associated with increased risk of inflammatory disorders.

The majority of patient with primary immunodeficiency are in which age group?

Younger than 20

A gynecologist told a patient that she had Chlamydia. The nurse expected the health care provider to prescribe a single dose of which of the following medications?

Zithromax

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

a blood pressure of 176/88 mm Hg.

The digestion of carbohydrates is aided by

amylase.

A client who had intracavity radiation treatment for cervical cancer 1 month earlier reports small amounts of vaginal bleeding. This finding most likely represents:

an expected effect of the radiation therapy.

Which allergic reaction is potentially life threatening?

angioedema

The best treatment for latex allergy is

avoidance of latex-based products.

A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?

back

Because of a client's reluctance to begin hormone therapy, the advance nurse practitioner prescribes venlafaxine to decrease the risk of

hot flashes.

Hormone therapy decreases the risk of

hot flashes.

For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate:

hypocalcemia.

A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of:

hypoglycemia

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for:

hypokalemia.

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction?

Gray

A nurse is presenting an educational event for a local community group. The nurse is teaching about premenstrual syndrome. What treatment guideline would the nurse teach this group?

Increase exercise.

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?

Increase the amount of fluids

A 60-year-old woman has just been diagnosed with hypothyroidism after a diagnostic workup. What sign or symptom most likely motivated the woman to originally seek care?

Lethargy and apathy

Which enzyme aids in the digestion of fats?

Lipase

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?

Liquids

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

Lithotripsy

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?

Wear a mask when performing exchanges.

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes?

increased thirst, hunger, and urination

A client admitted for treatment of a gastric ulcer is being prepared for discharge. The client will follow a regimen of antacid therapy. Discharge teaching should include which instructions? Choose all that apply.

"Continue to take antacids even if your symptoms subside." "You may be prescribed H2-receptor antagonists for up to 1 year."

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.

"Your immune system was most likely affected by an underlying disease process."

A client is having prostate-specific antigen (PSA) testing done. Which result would the nurse identify as abnormal?

4.6 nanograms/milliliter

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects

Why is ovarian cancer largely considered to be a lethal cancer of the female reproductive system?

All options are correct.

Which of the following is considered the gold standard for the diagnosis of liver disease?

Biopsy

A client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans?

Cottage cheese-like discharge

A client has a full bladder. Which sound would the nurse expect to hear on percussion?

Dullness

Clients with Type O blood are at higher risk for which of the following GI disorders?

Duodenal ulcers

When a patient experiences an allergic reaction, the nurse should initially assess for:

Dyspnea, bronchospasm, and/or laryngeal edema.

A patient is diagnosed with prostatitis. Which of the following is the most commonly isolated organism that will be present in this patient's laboratory results?

Escherichia coli

A nurse should perform which intervention for a client with Cushing's syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids.

The clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient?

Fatigue

The nurse is reviewing a client's history which reveals that the client has had an over secretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as which of the following?

Gigantism

A patient who is HIV positive comes to the clinic and is experiencing white patches with rough hairlike projections. The nurse observes the lesions on the lateral border of the tongue. What abnormality of the mouth does the nurse determine these lesions are?

Hairy leukoplakia

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?

Histamine

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity

The nurse knows to assess a patient with hyperthyroidism for the primary indicator of:

Intolerance to heat

Which statement is accurate regarding sildenafil?

Its side effects include headache, flushing, and dizziness.

Which of the following would the nurse most commonly assess in a client with ankylosing spondylitis?

Low back pain

A client is suspected to have a pituitary tumor due to signs of diabetes insipidus. What initial test does the nurse help to prepare the client for?

Magnetic resonance imaging (MRI)

Vomiting results in which of the following acid-base imbalances?

Metabolic alkalosis

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity

Which type of immunity becomes active as a result of infection by a specific microorganism?

Naturally acquired active immunity

Chapter 29

Nursing Assessment: Endocrine Function

Which medication classification represents a proton (gastric acid) pump inhibitor?

Omeprazole

Which of the following is the medication of choice for early syphilis?

Penicillin G benzathine

Which of the following is an enzyme secreted by the gastric mucosa?

Pepsin

Which position occurs when the uterus turns posteriorly as a whole unit?

Retroversion

A nurse who works at a college health center frequently treats female athletes for this type of menstrual disorder. What is the disorder?

Secondary amenorrhea

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?

Serum, which depletes the body's store of immunoglobulins

The nurse is reviewing the client's urinalysis results. The finding that is most suggestive of dehydration of the client is:

Specific gravity 1.035

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

Staphylococcus aureus

Which of the following nursing actions is most important in caring for the client following lithotripsy?

Strain the urine carefully for stone fragments.

Dilutional hyponatremia occurs in which disorder?

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A patient who is receiving treatment for hyperthyroidism is being monitored closely by the care team. When observing this patient for signs and symptoms of thyroid storm (thyrotoxicosis), the nurse should prioritize which of the following assessments?

Temperature and heart rate

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient?

The patient has developed peritonitis.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?

Tophi

A client is suspected of having secondary syphilis. Which test would the nurse anticipate being used to confirm the diagnosis? Select all that apply.

VDRL RPR-CT

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

Vasopressin (Pitressin)

A postmenopausal patient is experiencing dyspareunia. What methods can the nurse recommend she use to diminish the discomfort?

Water-based lubricant

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching?

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times.

The nurse practitioner who assesses a patient with hyperthyroidism would expect the patient to report which of the following conditions?

Weight loss

For a client with hyperthyroidism, treatment is most likely to include:

a thyroid hormone antagonist.

A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. What is being tested?

adrenal function

A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include

adrenal suppression.

A nurse is obtaining a male client's health history before performing a physical examination. Which information would most likely not be obtained?

age of first ejaculate

Kaposi sarcoma (KS) is diagnosed through

biopsy.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia

may feel as if their symptoms are not taken seriously.

A nurse assesses the stools of a client diagnosed with peptic ulcer disease. Inspection reveals black, tarry stools. The nurse would use which term to document this finding?

melana

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

normal.

A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in:

serum glucose level.

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?

severe abdominal pain with direct palpation or rebound tenderness

The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is

shoulder drop.

A client with seasonal allergic rhinitis comes to the clinic for a check-up. During the visit, the client tells the nurse that the symptoms primarily occur in the early fall. The nurse would suspect that the client has an allergy to which substance?

weed pollen

A client has suffered from several autoimmune disorders over the last 25 years, and lately has developed a new set of symptoms. The client's healthcare provider suspects Addison's disease. Which symptom would the nurse not expect to see?

weight gain

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client?

"This medication will relieve your pain."

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

A 65-year-old client who had chicken pox when he was 12 years old

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine I.V. as ordered

A 58-year-old patient has been diagnosed with acute prostatitis after seeking care for severe perineal pain. The patient's severe leukocytosis has prompted the care team to admit him to the medical unit of the hospital for treatment. The nurse should anticipate that this patient's treatment regimen will include which of the following?

Administration of IV antibiotics

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?

Administration of sodium polystyrene sulfonate [Kayexalate])

The nurse in the emergency department is conducting an assessment of a woman who has presented with abdominal pain. While preparing to insert a urinary catheter as ordered, the nurse notes that the patient has undergone female genital mutilation (FGM) earlier in her life. When addressing this issue with the patient, it is imperative that the nurse do which of the following?

Adopt a mindset of respect and cultural competence.

Which of the following hormones controls secretion of adrenal androgens?

Adrenocorticotropic hormone (ACTH)

A 24-hour urine collection is scheduled to begin at 8:00 am. When should the nurse initiate the procedure?

After discarding the 8:00 am specimen

A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage?

Approximately 80 to 120 mL

Which of the following describes microorganisms present without host interference or interaction?

Colonization

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?

Colonoscopy

An adolescent patient comes to the clinic with complaints of "terrible pain" during menstruation. What should the nurse document this subjective data as?

Dysmenorrhea

A client who comes to the clinic complaining of perineal pain, dysuria, and fever is diagnosed with prostatitis. The nurse understands that which of the following organisms would be the most likely cause?

Escherichia coli

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?

Hypokalemia

The nurse is planning the care of a woman who is scheduled to begin radiation therapy for the treatment of invasive breast cancer. The nurse is aware that this treatment is often well-tolerated but that it creates a risk of which of the following nursing diagnoses?

Impaired skin integrity

An 81-year-old patient of a subacute geriatric medical unit has become incontinent of stool over the past several days. This development has coincided with a decline in the patient's cognition as a result of severe Alzheimer's disease. In light of the patient's fecal incontinence, what nursing diagnosis should the nurse prioritize when planning this patient's care?

Impaired skin integrity related to fecal incontinence

The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which item should the nurse include?

Implement a 2- to 3-hour voiding schedule

The home care nurse is conducting patient teaching with a patient beginning corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when would the home care nurse instruct the patient to take her corticosteroid medication?

In the early morning between 7 AM and 8 AM

Which term refers to breast pain?

Mastalgia

The nursing educator is teaching a group of new graduates about Addison's disease. What symptom would the educator identify as being characteristic of Addison's disease?

Muscle weakness

A patient who is diagnosed with type 1 diabetes would be expected to:

Need exogenous insulin.

A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?

Oliguria

The nurse has paged a hospital patient's primary care provider because the patient's urine output over the past 12 hours is approximately 140 mL. The nurse would recognize that this patient is experiencing what health problem?

Oliguria

Which of the following medications is classified as a proton pump inhibitor (PPI)?

Omeprazole

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.

Omeprazole (Prilosec)

The nurse teaches a premenopausal female client to perform breast self-examination (BSE) at which interval?

On day 5 to day 7, counting the first day of menses as day 1

A nurse practitioner examined a patient who had been diagnosed with hepatomegaly (enlarged liver) due to accumulated fat deposits in the liver, subsequent to obesity. The nurse would palpate the liver by placing:

One hand under the right lower rib cage and press downward with the other hand.

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland?

Pancreas

The nurse has received several laboratory studies back at the clinic. Which of these results should be reported to the local health department?

Positive gonorrhea

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?

Positron emission tomography (PET)

Which intervention is the single most important aspect for the client at risk for anaphylaxis?

Prevention

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?

Prothrombin time (PT)

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

Protrusion of the upper stomach into the lower portion of the thorax.

A nurse is caring for a client with Cushing's syndrome. Which would the nurse not include in this client's plan of care?

Provide a high-sodium diet.

Which of the following would a nurse encourage a client with gout to limit?

Purine-rich foods

Which term refers to inflammation of the renal pelvis?

Pyelonephritis

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular

The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

Reports increased fatigue

A nurse is obtaining health history from a young adult woman. Which of the following would alert the nurse to a possible problem?

Reports of dyspareunia

The nurse is reviewing the history and physical examination of a client diagnosed with hyperthyroidism. Which of the following would the nurse expect to find?

Reports of increased appetite

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition the client every 2 hours.

Following percutaneous nephrolithotomy, the client is at greatest risk for which nursing diagnosis?

Risk for infection

An elderly patient is diagnosed with parotitis. The nurse is aware that this bacterial infection is most likely caused by:

Staphylococcus aureus.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered?

Tacrolimus

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Tetany

After teaching a group of students about systemic lupus erythematosus, the instructor determines that the teaching was successful when the students state which of the following?

The belief is that it is an autoimmune disorder with an unknown trigger.

When assisting the client to interpret a negative HIV test result, what does the nurse tell the client that this result means?

The body has not produced antibodies to the AIDS virus.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

Which of the following would be most important to include in a teaching plan for a client who has had a vasectomy?

Using a reliable method of contraception for several weeks.

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

diarrhea and abdominal pain

Within the female internal reproductive structures, where is the egg most commonly fertilized?

fallopian tubes

One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:

restricting sources of potassium usually found in fresh fruits and vegetables.

A client with a history of HSV-2 infection asks the nurse about future sexual activity. Which of the following responses would be most appropriate?

"Inform all potential sexual partners about the infection, even if it is inactive."

Which client would the nurse identify as being at highest risk for the development of testicular cancer?

A 25-year-old male with a history of cryptorchidism

A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?

A GFR of 30-59 mL/min/1.73 m2

Which term refers to fixation or immobility of a joint?

Ankylosis

A client with anorexia reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color?

Black

Which diagnostic test is indicated for postmenopausal bleeding?

Endometrial biopsy

Nursing assessment findings reveal joint swelling and tenderness of the great toe. The nurse suspects which of the following?

Gout

A nurse has been asked to be a guest speaker at a local high school. The topic is STIs. When preparing the presentation, which STI would the nurse identify as most common in young, sexually active people?

HPV

Which term refers to an incomplete antigen?

Hapten

A nurse practitioner assessed a patient's complaints about a vaginal discharge and prescribed Flagyl. The nurse was able to diagnose bacterial vaginosis because of this defining characteristic, a discharge that:

Has a fish-like odor.

The nurse is providing an educational event at the local community center on prostate cancer. A 53-year-old male attendee asks about the prevention and detection of prostate cancer. What information should the nurse provide to this man that would assist in the early identification of prostate cancer?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?

Have regular follow-up care.

Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

Hemoglobin and hematocrit

Which findings best correlate with a diagnosis of osteoarthritis?

Joint stiffness that decreases with activity

A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which action?

Maintain skin and stomal integrity.

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain the client in a semi-Fowler's position.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway

A patient with a diagnosis of type 2 diabetes has been vigilant about glycemic control since being diagnosed and has committed to increasing her knowledge about the disease. To reduce her risk of developing diabetic nephropathy in the future, this patient should combine glycemic control with what other preventative measure?

Maintenance of healthy blood pressure and prompt treatment of hypertension

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is

Malnutrition

The nurse is completing a community education via a pamphlet on sexually transmitted diseases. Which key point would the nurse place in bold letters?

Many people are asymptomatic and show no symptoms contributing to the spread of the disease.

Chapter 36

Nursing Assessment- Immune Function

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis

Retention of which electrolyte is the most life-threatening effect of renal failure?

Potassium

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

Parathyroid hormone (PTH) has which effects on the kidney?

Stimulation of calcium reabsorption and phosphate excretion

A nurse explains to a client with thyroid disease that the thyroid gland normally produces:

T3, thyroxine (T4), and calcitonin.

The nurse is caring for a patient receiving hemodialysis treatments and who has an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?

Taking a blood pressure reading on the affected arm can cause clotting of the fistula.

Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.

Tall, peaked T waves

Which is the most common type of prostate surgery?

Transurethral resection of the prostate

Which diagnostic test is done to determine suspected pituitary tumor?

computed tomography scan

The nurse is preparing a client for a nuclear scan of the kidneys. Following the procedure, the nurse instructs the client to

drink liberal amounts of fluids.

The most common symptom of esophageal disease is

dysphagia.

An enzyme that begins the digestion of starches is

ptyalin.

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience:

weight loss.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest."

Which statement by the nurse demonstrates effective communication techniques when initiating a discussion about sex with a 25-year-old female client?

"What questions do you have related to your sexual health?"

The nurse is reviewing the medical record of a client who has been diagnosed with prostate cancer. The nurse notes that the Gleason score was used to grade the cancer. Which total score would the nurse interpret as indicating a highly aggressive cancer?

9

A routine serum glucose analysis indicated the presence of renal glycosuria. The nurse knew that the serum glucose level was:

>180 mg/dL.

A nurse is caring for a patient with impaired renal function. A creatinine clearance measurement has been ordered. The nurse is aware that the specimens needed for the calculation of the patient's creatinine clearance will include what?

A 24-hour urine specimen collection and a serum creatinine level midway through the urine collection process

Which client would the nurse identify as having the greatest risk for testicular cancer?

A 36-year-old Caucasian American who is HIV positive

A nurse practitioner is aware of the high incidence and prevalence of hypothyroidism and regularly encourages many patients to undergo screening of their thyroid secreting hormone (TSH) levels. Which of the following individuals likely faces the greatest risk of developing hypothyroidism?

A 55-year-old woman who complains of fatigue

A nurse who works on a busy urology unit provides care for many patients who have had surgical interventions for the treatment of prostate disease. Currently, the nurse is planning necessary tasks for the morning, including surgical dressing changes as ordered. Which of the following patients will not have a visible surgical incision or dressing?

A 66-year-old man who has had a transurethral resection of the prostate (TURP)

The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing?

A UTI

After relocating to new community, a 60-year-old man has presented for care to a nurse practitioner. During the nurse's initial health assessment, the man states that he has had a diagnosis of gastroesophageal reflux disease (GERD) for several years. The nurse should anticipate that a medication reconciliation is likely to reveal that the man has been prescribed:

A proton pump inhibitor (PPI)

A nurse is conducting a comprehensive assessment of a 73-year-old male patient. When performing an assessment of this patient's genitourinary system, the nurse should anticipate which of the following age-related changes?

A scrotum that hangs lower than that of younger men

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

A nurse is developing a plan of care for a female client experiencing her first outbreak of genital herpes. Which nursing diagnosis would the nurse most likely identify as the priority?

Acute pain related to the development of the genital lesions

A nurse is aware that even though tube feedings are generally well-tolerated by most patients, there is a still a risk of dumping syndrome. Which of the following actions has the greatest potential to reduce a patient's risk of experiencing dumping syndrome?

Administering feedings at a low, continuous rate rather than by bolus

The nurse is caring for a patient with hyperparathyroidism. What level of activity would the nurse expect the health care provider to order?

Ambulation and activity, as tolerated

A male patient in his 20s has been diagnosed with a chlamydial infection and states that he is "terrified" at the prospect of having to inform his fiancée. In light of this patient's statement, what action should the nurse first perform?

Assess the specific reasons why the patient fears this discussion with his fiancée.

A 61-year-old woman presented to a scheduled appointment with her nurse practitioner, stating, "I'm having a lot of trouble with constipation over the past few months." What action should the nurse first take in response to this patient's health complaint?

Assess the woman's typical bowel patterns and her expectations for bowel function.

An older adult patient with a number of comorbidities has opted to begin peritoneal dialysis rather than hemodialysis. A nephrology nurse has been coordinating his care from the insertion of the dialysis catheter to the application of his first few dialysis treatments. To closely monitor the patient for complications of this procedure, the nurse should prioritize which of the following assessments?

Assessing the patient for signs and symptoms of infection

A female client is diagnosed with breast abscess. She would like to continue to breast-feed her newborn. Which of the following would be most appropriate in this situation?

Assist the client to pump the breasts to remove breast milk.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis

What is the term for a concentration of urea and other nitrogenous wastes in the blood?

Azotemia

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?

Azotemia

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Bile-stained vomiting

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?

Black and tarry

Behavioral interventions for urinary incontinence can be coordinated by a nurse. A comprehensive program that incorporates timed voiding and urinary urge inhibition is referred to as what?

Bladder retraining

A woman in her late 30s has been having unusually heavy menstrual periods combined with occasional urine and stool leakage over the past few weeks. Upon further enquiry, she reveals that she also has postcoital pain and bleeding. To which diagnosis will the investigation most likely lead?

Cervical cancer

Which is an accurate statement regarding cancer of the esophagus?

Chronic irritation of the esophagus is a known risk factor.

What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss?

Consume adequate amounts of fluid.

Students are reviewing information about hypersensitivity disorders in preparation for class discussion the next day. The students demonstrate understanding of the material when they identify which of the following as a type IV hypersensitivity disorder?

Contact dermatitis

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply.

Disturbed body image related to changes in appearance, sexual dysfunction, and role function Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Risk for injury related to altered clotting mechanisms

The diabetic nurse educator is teaching a class for newly diagnosed diabetics and their families. In this class, the educator is teaching about "sick day rules." What guideline applies to periods of illness in a diabetic patient?

Do not eliminate insulin when nauseated and vomiting.

A patient is planning to use a negative-pressure (vacuum) device to maintain and sustain an erection. What should the nurse caution the patient about with the use of this device?

Do not leave the constricting band in place for longer than 1 hour to avoid penile injury.

An appropriate nursing intervention for the client following a nuclear scan of the kidney is to:

Encourage high fluid intake.

Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?

Fever

A 22-year-old woman is scheduled to begin radiotherapy for the treatment of invasive cervical cancer. The nurse should be aware that there is a high likelihood that the woman has a history of what sexually transmitted infection?

Human papillomavirus (HPV)

Review the following four examples of ideal body weight (IBW), actual weight, and body mass index (BMI). Using three criteria for each example, select the body weight that indicates morbid obesity.

IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2

The nurse is obtaining a medication history from a client who is reporting erectile dysfunction. Which medication would the nurse identify as being least likely to contribute to the client's condition?

Ibuprofen

When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.

Ig E

When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first?

Inspection

The nurse understands that a single dose of azithromycin as treatment for a chlamydia infection is prescribed by the health care provider for what reason?

It can be administered to the client at the health care provider's office.

Which of the following is considered the most serious manifestation of angioneurotic edema?

Laryngeal swelling

What part of the GI tract begins the digestion of food?

Mouth

Peptic ulcer disease occurs more frequently in people with which blood type?

O

Which is the leading cause of disability and pain in the elderly?

Osteoarthritis (OA)

Which of the following is the most common cause for a patient to seek medical attention for arthritis?

Pain

A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer?

Painless, gross hematuria

A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?

Pneumocystis jiroveci

The parents of a 3-year-old boy have just been informed that allergy testing suggests their son has multiple food allergies. When providing health education for this family, what subject should the nurse prioritize?

Possible sources of food allergens and strategies for avoiding offending foods

Clostridium difficile infection has been moving through an extended-care facility, and several of the elderly residents have been experiencing severe diarrhea. One particularly sick resident has told the nurse that he is now experiencing extreme fatigue and muscle cramps and that his heart feels like it occasionally "skips a beat." The nurse should facilitate a stat assessment of this resident's:

Potassium levels

Which of the following is considered first-line treatment for prostate cancer?

Radical prostatectomy

The nurse is reviewing the plan of care for a client with a disorder of the thyroid gland. Which diagnostic test would the nurse expect the physician to order to evaluate thyroid hormones?

Radioimmunoassay

A 16-year-old girl presents at the emergency department complaining of right lower quadrant pain and is diagnosed with appendicitis. When assessing this patient, what signs or symptoms should the nurse expect to find?

Rebound tenderness, McBurney's sign, low-grade fever

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?

Recent history of streptococcal infection

When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?

Rectal bleeding

Which of the following is the most common symptom of a polyp?

Rectal bleeding

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

The nurse is planning the care of an 8-year-old boy who has been diagnosed with atopic dermatitis. In the boy's plan of nursing care, what nursing diagnosis should the nurse prioritize?

Risk for impaired skin integrity related to atopic dermatitis

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Risk for infection

A young male patient of a free clinic has been diagnosed with gonorrhea and has begun treatment. The nurse at the clinic is providing the man with relevant health education and has emphasized the importance of using condoms. The man replies, "I can't stand using condoms because I can't feel anything if I use one. I'll have to think about that." The nurse should consequently identify which of the following nursing diagnoses?

Risk for infection transmission related to lack of STI prevention measures

Patients with hyperthyroidism are characteristically:

Sensitive to heat

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Serum glucose level of 52 mg/dl

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

Stridor

A client expresses concerns about future reproduction after a surgery to correct the cancer of the testes. For this client, treatment proceeded without first collecting and storing sperm. Which alternative should the nurse suggest to the client?

Suggest donor insemination or adoption

A nurse practitioner is preparing to perform a pelvic examination of an adult patient. When performing this assessment, the ideal position is:

Supine lithotomy

The nurse knows to follow the CDC's guidelines for Standard Precautions while caring for patients regardless of known or unknown infectious status. The nurse is aware that barrier protection is not necessary for which body fluid?

Sweat

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?

The consistency of stool and comfort when passing stool

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

The digestion of dietary and blood proteins.

Which is a major manifestation of Wiskott-Aldrich syndrome?

Thrombocytopenia

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

Following a vasectomy, which is the most important instruction to provide to the client?

Use another form of birth control until further notice.

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis

Although not designated as endocrine glands, several organs within the body secrete hormones as part of their normal function. Which organ secretes hormones involved in increasing blood pressure and volume and maturation of red blood cells?

kidneys

A client is undergoing diagnostics for an alteration in thyroid function. What physiologic function is affected by altered thyroid function?

metabolic rate

A nurse is preparing a review class for a group of nurses returning to the workforce. The topic is the endocrine system. When describing the functions of this system, the nurse would discuss the system's role in regulating which body function? Select all that apply.

metabolism tissue function reproduction growth

A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client?

"Be sure to wear sunscreen while taking this medicine."

A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response by the nurse is most appropriate?

"Diet, exercise, and weight loss can eliminate the need for medication."

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement?

"I have learned some relaxation strategies that decrease my stress."

A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation."

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?

"I really don't like to be in small, enclosed spaces."

A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?

"I've had trouble getting started when I urinate, often straining to do so."

A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms."

A clinic nurse has been charged with the responsibility of teaching avoidance strategies to an adult patient who has allergic rhinitis. What measure should the nurse recommend to this patient?

"If possible, make sure that no one smokes tobacco in your home."

A nurse is presenting at a community health promotion fair that is focused on disease prevention and screening. A middle-aged participant has brought up an article that she recently read about bladder cancer and has asked the nurse about prevention measures. How should the nurse respond to this woman's inquiry?

"If you smoke cigarettes, quitting will greatly reduce your risk of bladder cancer."

A community health nurse is participating in a health forum that has been organized by a local community group. When addressing the topic of breast cancer, what should the nurse teach participants about the risk factors for the disease?

"If your mother, grandmother, or sister had breast cancer, you likely have a higher-than-average risk."

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?

"It is a vent that prevents backflow of the secretions."

After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?

"It is appropriate to warm the dialysate in a microwave."

A nursing student asks the instructor why the pituitary gland is called the "master gland." What is the best response by the instructor?

"It regulates the function of other endocrine glands."

The nurse is demonstrating the technique for performing a testicular self examination (TSE) to a group of men for a company health fair. One of the men asks the nurse at what age a man should begin performing TSE. What is the best answer by the nurse?

"It should begin in adolescence."

The nurse is seeing a client who came into the sexual health clinic after discovering condylomata along her labia. The client states, "This makes no sense, I don't even know who I got this from and I have been so careful!" What is the nurse's best response?

"It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated."

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

"It tells us about your sugar control for the last 3 months."

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again."

The nurse is talking to a client who has come to the doctor's office to ensure that the client's sexually transmitted infection (STI) has been successfully treated. Which statement by the client requires further instruction?

"It's great that I don't have to worry about having this infection again because I'm now immune to it."

Following an extensive diagnostic workup, a 40-year-old woman's complaints of fatigue and muscle pain have been attributed to systemic lupus erythematosus (SLE).When performing health education with this patient, what should the nurse emphasize?

"It's important to limit your exposure to sunlight and to use a good sunscreen."

A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate?

"Keep your showers brief, patting your skin dry after showering."

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

"Ketones will tell us if your body is using other tissues for energy."

A patient with end-stage renal disease (ESRD) is scheduled for his first hemodialysis treatment. The patient asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply?

"Low blood pressure and cramping sometimes occur."

A male patient's present signs and symptoms are suggestive of an incompetent cardiac sphincter, and he has been scheduled for an upper GI series (barium swallow). What preprocedure teaching should the nurse provide to this patient?

"Make sure that you don't eat anything after midnight the day before your test."

The nurse is completing community education when asked by a client without health insurance why a mammogram is needed if the women are completing breast self-examinations at home. The nurse is most correct to respond stating which of the following?

"Mammograms can detect cysts or tumors too small to palpate."

The nurse is caring for a client who has just been diagnosed with chlamydia and is very upset. The client says, "I don't understand this. The person I had sex with did not have any symptoms at all. How could I have known?" What is the best response by the nurse to this client?

"Many people with chlamydia won't have symptoms for up to 3 weeks after being infected."

A nurse is preparing to obtain a sexual history from a client using the PLISSIT model. Which question would be most appropriate for the nurse to ask first?

"May I ask you some questions about your sexual health?"

An obese male patient has sought advice from the nurse about the possible efficacy of medications in his efforts to lose weight. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity?

"Medications may be of some use, but they don't tend to resolve obesity on their own."

The nurse is providing client education to a 45-year-old female who asks how she can be certain that she has reached menopause. How should the nurse respond?

"Menopause is likely if you have not menstruated for 12 months."

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

"Monitor your body temperature."

A 32-year-old client has been diagnosed with an ovarian cyst and asks the nurse, "Should I be worried about cancer?" Which response by the nurse would be most appropriate?

"Most cysts are benign in younger women, but it's good to have it checked out."

A client is being treated for trichomoniasis. The client has received instructions about the prescribed drug therapy. The nurse determines that the client needs additional teaching when she states which of the following?

"My partner will not need any treatment."

A client undergoing treatment for vaginitis is also counseled about measures to prevent its recurrence. Which statement by the client best indicates effective counseling?

"My sexual partner will also need to be treated."

The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?

"My urine will be eliminated through a stoma."

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours."

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?

"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider."

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?

"The full benefit of the medication may take up to 2 weeks to be achieved."

A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching?

"The majority of primary immunodeficiencies are diagnosed in infancy."

A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met?

"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."

An adolescent informs the school nurse that she is afraid of contracting an STI but her boyfriend does not want to use condoms. What is the best response by the nurse?

"The use of condoms is one of the best ways to reduce the risk of acquiring an STI."

The nurse is meeting with the mother of an 11-year-old girl to provide decision making support and education regarding human papillomavirus (HPV) vaccination. The mother states, "I am confused about why my 11 year old needs to be protected from a sexually transmitted infection. She is so young and not sexually active. Why does she need the vaccination now?" What is the nurse's best response?

"The vaccination helps to prevent cervical cancer in adult women. It works better if she has it before she becomes sexually active. Let's talk about some of the concerns you have about the vaccination"

A patient who is recovering from a coronary artery bypass graft (CABG) is anxious about resuming normal levels of activity and mobility, citing a fear of putting undue strain on his heart, as well as being unable to safely mobilize. Consequently, the patient has expressed his intention to remain on bed rest for several days. How should the nurse respond to this patient's concerns about activity and mobility?

"There are actually a lot of benefits of moving early and often. While you're mobilizing, we'll keep you safe."

The nurse is caring for a client who asks,"I heard the nurse tell my doctor I have adenexal tenderness. What does that mean?" The client has also been experiencing fever and loss of appetite. How should the nurse respond?

"This means the internal body parts surrounding your uterus are also sore. Knowing this helps confirm that you have pelvic inflammatory disease and now you can be given the correct treatment."

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?

"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort."

Serologic testing of a middle-aged woman with a recent history of severe flu-like symptoms has just resulted in a diagnosis of hepatitis A. Which of the following assessment questions should the nurse prioritize when discussing this diagnosis with the patient?

"Which restaurants have you eaten in over the past few weeks?"

A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?

"White blood cells are produced in the bone marrow."

A 44-year-old man admits to his nurse that he has been having difficulty attaining and maintaining an erection for the past few years. The patient states that he is deeply embarrassed about this problem and has not previously discussed it with anyone. How can the nurse most accurately respond to this patient's statement?

"You're not alone in this. About half of all men over 40 experience this problem at some point."

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

"Your body is using protein and fat for energy instead of glucose."

The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? __________________

4000

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42

A client returns from the operating room after receiving extensive abdominal surgery. He has 1,000 mL of lactated Ringer's solution infusing via a central line. The physician orders the IV fluid to be infused at 125 mL/hr plus the total output of the previous hour. The drip factor of the tubing is 15 gtt/min, and the output for the previous hour was 75 mL via Foley catheter, 50 mL via nasogastric tube, and 10 mL via Jackson Pratt tube. For how many drops per mintue should the nurse set the IV flow rate to deliver the correct amount of fluid? Enter the correct number ONLY.

65

The nurse is aware that the best time of day for the total large corticosteroid dose is between:

7:00 AM and 8:00 AM

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80 to 120 mL

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

8:30 AM.

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What would the nurse include in this client's care plan? Select all that apply.

Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Assess respiratory status every 4 hours and prn.

The nurse explained the difference between the herpes simplex viruses (HSV-1 and HSV-2). One characteristic of HSV-1 is that it:

Affects the mouth and lips.

The nurse is giving an educational event to a local men's group about prostate cancer. What nationality should you be sure to tell the attendees of this event should receive information regarding the predisposition of prostate cancer?

African Americans

The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises?

After the client has had a warm paraffin hand bath

A nurse is reviewing a female client's history, which includes the following information: Age at menarche: 14 years Cesarean delivery: 2 pregnancies Age at first pregnancy: 35 years Alcohol use: approximately 1 to 2 glasses of wine/month The nurse identifies which as a possible risk factor for the client to develop breast cancer?

Age at first pregnancy

A client is being seen by an urologist for perineal pain, low back pain, fever lasting 5 days, and painful urination. The physician confirms a diagnosis of prostatitis and orders treatment. During client education, which recommendation does the nurse make?

All options are correct.

A client is undergoing diagnostics due to a significant drop in renal output. The physician has scheduled an angiography. What postprocedural assessment will the nurse perform on the client?

All options are correct.

A client was admitted for critical care due to esophageal varices and precarious physical condition. What could cause the client's varices to hemorrhage?

All options are correct.

A client has just had a left radical mastectomy, and the nurse is providing information on complications that may arise due to removing the axillary lymph nodes. Which would not be included?

All would be included in the discussion.

A nurse is managing the care of a client who has gout. Which medication would be prescribed as the drug of choice to prevent tophi formation and promote tophi regression?

Allopurinol

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

Alterations in mood Agitation Insomnia

Which of the following digestive enzymes aids in the digesting of starch?

Amylase

Which of the following is accurate regarding acquired immunity? Select all that apply.

An immunologic response acquired during life but not present at birth Usually develops as a result of exposure to an antigen through immunization Can develop by contracting a disease

An elderly patient has developed Clostridium difficile-related diarrhea, a problem that has led to dehydration and hypokalemia. The increased peristalsis that characterizes diarrhea has the potential to cause fluid volume deficit and electrolyte deficits because:

An increase in peristalsis means that the colon cannot absorb the substances that it normally absorbs.

The nurse is caring for a patient who has been NPO for 2 days pending a diagnostic procedure that has been repeated cancelled. When evaluating this patient's urinalysis, what would the nurse anticipate?

An increased urine specific gravity

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

An irregular apical pulse

A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. What outcome will the decrease in erythropoietin have?

Anemia from the decrease in maturation of red blood cells

Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?

Angiography

The nurse is providing information at the local YMCA about screenings for breast and cervical cancer. The nurse should inform young women that they should begin their screenings at what time?

Annual breast and pelvic examinations are important for all women 21 years of age or older and for those who are sexually active, regardless of age.

A client developed an infection while on vacation in Central America and is now taking the antibiotic chloramphenicol. What should the client be monitored for when taking this drug?

Aplastic anemia

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch

A patient with a new ileostomy is preparing to go home. What should the patient be taught about changing his ileostomy?

Apply a skin barrier to the peristomal skin prior to applying the pouch.

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?

Approximately 80 to 120 mL

The nurse instructs a female client about contraceptive options. The nurse explains that the intrauterine device (IUD) is a good contraceptive option for women who:

Are in a monogamous relationship.

A male patient's symptomatic HIV has progressed to AIDS, and the patient is now unable to independently perform most of his activities of daily living. To prevent skin breakdown, what action should the nurse take?

Arrange for a pressure-reducing mattress.

After recently being admitted to the emergency department with signs and symptoms of hyperglycemia, a 33-year-old man was subsequently diagnosed with diabetes. The patient's blood sugars have been stabilized, and the man has begun diabetes education with a nurse educator. When working with this patient, the nurse educator should first:

Ascertain the patient's readiness and willingness to learn

A patient with portal hypertension has been admitted to the medical floor. What will the nurse assess for related to portal hypertension?

Ascites

The nurse is about to begin conducting a pelvic examination of a client. The client reports having lower back and hip pain anytime she has to lie on her back. What is the best way for the nurse to proceed with the examination?

Ask the client to lie on her left side with the right leg bent

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation?

Ask the physician to delay the discharge because the client requires further teaching.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the intial appropriate action by the nurse?

Assess the client's abdomen and vital signs.

The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following?

Bleeding

A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has?

Bleeding esophageal varices

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit?

Blistering

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl

A patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder?

Blood pressure varying between 120/86 and 240/130 mm Hg

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis.

Blurred or deteriorating vision Fatigue and irritability Polyuria and polydipsia Wounds that heal slowly or respond poorly to treatment

Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?

Blurred vision

Which of the following would a nurse expect to assess in a client with peritonitis?

Board-like abdomen

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

A nurse is describing the advantages and disadvantages associated with tamoxifen therapy as a means of breast cancer prevention. The nurse would identify that the drug has a beneficial effect on which of the following?

Bone mineral density

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?

Borborygmus

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?

Bowel perforation

A female patient experienced a severe reduction in body fat by extreme caloric restriction and exercise. Which of the following female reproductive abnormalities could she acquire as a result of the reduction in body fat?

Cessation of menstruation

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?

Change the wafer and pouch.

A group of students are reviewing information about the classifications of testicular cancer. The students demonstrate understanding of the information when they describe which of the following?

Choriocarcinoma is an example of a nonseminoma.

A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?

Chronic constipation with sporadic bouts of diarrhea

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of?

Chronic diarrhea

A 39-year-old woman with a diagnosis of endometriosis has met with her care provider to discuss treatment options. The nurse who is planning this woman's care should prioritize which of the following nursing diagnoses?

Chronic pain related to endometriosis

The nurse is caring for a patient who is postoperative day 3 following bowel resection and the creation of a colostomy. While changing the dressing, the nurse notes the stoma is dusky in color. How should the nurse interpret this assessment finding?

Circulation to the stoma is compromised.

The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?

Clamp the tubing and give the patient a rest period.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

Clay-colored or whitish

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools

Which nursing assessment finding indicates the client with renal dysfunction has not met expected outcomes?

Client reports increasing fatigue.

Which of the following clients is at highest risk for peptic ulcer disease?

Client with blood type O

The nurse at the diabetes clinic is instructing a client who is struggling with compliance to the diabetic diet. When discussing disease progression, which manifestation of the disease process on the urinary system is most notable?

Clients have chronic renal failure.

In which group is it most important for the client to understand the importance of an annual Papanicolaou test?

Clients infected with the human papillomavirus (HPV)

A female client recently diagnosed with chlamydia comes to the clinic for a check-up. During the visit, the client says, "I had no idea I had chlamydia. I didn't have any symptoms." The nurse would incorporate knowledge of which information when responding to the client?

Clients with chlamydia frequently are asymptomatic.

A patient has a concentration of Staphylococcus aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages?

Colonization

When describing the functions of the kidney to a client, which of the following would the nurse include?

Control of water balance

When describing the functions of the kidney to a client, which of the following would the nurse include? Select all that apply.

Control of water balance Secretion of the enzyme renin

The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?

Coolness and mottling of a newly constructed breast site

The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change?

Creatinine clearance

The health care provider ordered four tests of renal function for a patient suspected of having renal disease. Which of the four is the most sensitive indicator?

Creatinine clearance level

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing syndrome

A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate?

Donors are selected from compatible living donors.

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?

Dorsal aspect of the hand

What information should the nurse include in the teaching plan for a client being treated for diverticulosis?

Drink at least 8 to 10 large glasses of fluid every day

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?

Dry skin thoroughly after washing

A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event?

Dumping syndrome

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?

Dyspnea, bronchospasm, and/or laryngeal edema.

Which of the following would be least appropriate to suggest to a client with a urinary diversion to control odor?

Eat plenty of cheese and eggs.

A nurse is caring for a patient who has had bariatric surgery and is developing a teaching plan for the patient. Which information is essential for the nurse to include in this teaching?

Eat six small meals daily spaced at equal intervals.

A patient comes to the clinic complaining of pain in the epigastric region. The nurse suspects that the patient's pain is related to a peptic ulcer when the patient states the pain is relieved by what?

Eating

Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications?

Ectopic pregnancy

A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that, in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what?

Emotional stability and understanding of required lifestyle changes.

A patient who has experienced a rapid progression of osteoarthritis has lost a significant amount of function in his hands. This pathophysiological process has been accompanied by obvious physical changes, to which the patient has stated, "I try to keep these gnarled old hands out of sight so no one has to look at them." How can the nurse best respond to this patient's statement about body image?

Encourage him to verbalize his feelings about his appearance in more detail.

Which is an appropriate nursing intervention in the care of the client with osteoarthritis?

Encourage weight loss and an increase in aerobic activity

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP)

A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist?

Endoscopy

A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?

Engulfment and digestion of bacteria and foreign material

The nurse is providing preoperative care to a client who is to undergo a radical prostatectomy for prostate cancer. The client's plan of care includes the nursing diagnosis of "anxiety related to surgery and its outcome." Which of the following would be most appropriate for the nurse to do?

Ensure privacy when discussing sensitive or embarrassing sexual issues.

The nurse is preparing to administer a patient's scheduled dose of Novolin 70/30. When administering this dose of insulin, the nurse should:

Ensure that the insulin is not given near a previous injection site

A client is scheduled for an abdominal ultrasound as a follow up to her pelvic examination. Which action by the nurse would be most appropriate?

Ensuring that the client has a full bladder

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

Enzyme-linked immunosorbent assay (ELISA)

A teenage boy is undergoing allergy testing and has had blood work drawn as part of the diagnostic workup. When reviewing the patient's laboratory results, the nurse should pay particular attention to the levels of what white blood cell (WBC) component?

Eosinophils

A group of students is reviewing material about endocrine system function. The students demonstrate understanding of the information when they identify which of the following as secreted by the adrenal medulla?

Epinephrine

A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?

Epoetin alfa (Epogen)

A 61-year-old man's elevated prostate screening antigen (PSA) levels and abnormal digital rectal examination (DRE) results prompted his care provider to refer him for treatment. The patient has subsequently been diagnosed with prostate cancer and is scheduled for surgery. The nurse should recognize that this patient's plan of nursing care should include interventions to address what potential long-term complication of prostate surgery?

Erectile dysfunction

After teaching a group of students about erectile dysfunction, the instructor determines that the teaching was successful when the students identify which of the following as true?

Erectile dysfunction may be due to testosterone insufficiency.

A 60-year-old man with several health problems and a history of increasing joint stiffness over the past several months is being assessed for the presence of rheumatic diseases. Which of the following laboratory findings is most clearly suggestive of an inflammatory process?

Erythrocyte sedimentation rate (ESR) of 22 mm/hr (normal 0 to 20 mm/hr)

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?

Esophageal tumor

A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development, which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs?

Estrogen

A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged IV pole. She then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?

Evaluating patency of the drainage lumen

A patient admitted with nephrotic syndrome is being cared for on a medical unit. When writing this patient's care plan, what nursing diagnoses should the nurse prioritize?

Excess fluid volume related to excessive protein losses in the urine

A patient is having a biopsy that will remove the entire mass, plus a margin of surrounding tissue. What type of biopsy will be documented on the operative permit?

Excisional biopsy

A client is being seen in the clinic to receive the results of the lab work to determine thyroid levels. The nurse observes the client's eyes appear to be bulging, and there is swelling around the eyes. What does the nurse know that the correct documentation of this finding is?

Exophthalmos

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?

Exposure to foreign antigens may cause altered immune function.

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

Facial erythema, pericarditis, pleuritis, fever, and weight loss

The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?

Familial polyposis

The client is asking if there is a pill that can be ordered to control the symptoms of menopause. Which assessment finding is most important in determining nursing care in association with hormone replacement therapy?

Family history of breast cancer

Which medication is classified as a histamine-2 receptor antagonist?

Famotidine

The client with rheumatoid arthritis has a red blood cell count of 3.2 cells/cu mm. Which nursing diagnosis has the highest priority for the client?

Fatigue

A health care provider prescribed fluticasone for a client with a severe case of allergic rhinitis. The client took a first dose on February 2. What is the latest date by which the drug will be fully effective?

February 15

A 13-year-old who started her menstrual cycle at age 12 asks the nurse practitioner how frequently her "period" should come. The nurse takes a calendar and has the girl circle the date of her last period, which started on January 7. The nurse then circles when her next period should start based on the average number of days in a normal cycle. What date did the nurse circle?

February 5

A 60-year-old woman has begun a course of oral antibiotics for the treatment of a urinary tract infection (UTI). The patient's nurse should recognize that the causative microorganisms most likely originated from:

Fecal contamination from the patient's perineum

Which of the following is the first barrier method that can be controlled by the woman?

Female condom

A health care provider suspects that a thyroid nodule may be malignant. The nurse knows to prepare information for the patient based on the usual test that will be ordered to establish a diagnosis. What is that test?

Fine-needle biopsy of the thyroid gland

A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings?

Finger

The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. Which study will the nurse prepare the client for?

Flexible sigmoidoscopy

Nursing students are reviewing various medications that can be used to treat allergic disorders. The students demonstrate understanding of the information when they identify which of the following as an intranasal corticosteroid?

Fluticasone

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?

Genital herpes

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

Glucagon

The nurse is caring for a client with diabetes who developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar level?

Glucagon

Which hormone would be responsible for increasing blood glucose levels by stimulating glycogenolysis?

Glucagon

A client is having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress?

Glucocorticoids

The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse recalls that several substances are filtered from the blood by the glomerulus and these substances are then excreted in the urine. The nurse identifies the presence of which substances in the urine as abnormal findings?

Glucose and protein

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply.

Glucose metabolism Ammonia conversion Protein metabolism

A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?

Goiter

The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection?

Gonorrhea

The nurse teaches the client that the presence of crystals in the synovial fluid obtained from arthrocentesis confirms which disease process?

Gout

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

Graves' disease.

Hematoma and seroma formation are complications of breast surgery. Which of the following is the indicator that should be reported to the surgeon?

Gross swelling

A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

HIV encephalopathy

A resident of an assisted-living facility was forced to call for help after she was unable to stand up from the toilet in her bathroom. The woman is embarrassed that she needed this assistance, and the nurse who oversees the facility knows that this situation was primarily due to the resident's rheumatoid arthritis. How should the nurse best respond to this resident's decreased mobility?

Have grab bar installed in the woman's bathroom.

An occupational health nurse is assessing a woman who experienced an anaphylactic reaction to a dip that contained crab during an office celebration. Because the woman promptly self-administered epinephrine, her status has normalized and she is now resting in a colleague's office. What action should the nurse perform?

Have the woman transported to a nearby emergency department.

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage?

Hematemesis

A nursing educator is speaking with a group of new graduates about a patient who has acute glomerulonephritis. The educator should tell the nurses that the patient may exhibit which of the following clinical manifestations?

Hematuria

The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of a malignant tumor of the bladder?

Hematuria

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

Hemolytic

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?

Hemorrhage

Which of the following is an immediate danger after a prostate surgery?

Hemorrhagic shock

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy

A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses?

Hepatitis C

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus?

High sugar pulls fluid into the bloodstream, which results in more urine production.

A nurse practitioner working in a dermatology clinic explained to a group of nursing students that the pathophysiology of an allergic response involves a chain of events that includes responses from lymphocytes, IgE, mast cells, and basophils. The nurse mentioned that the most important chemical mediator involved in the response is:

Histamine.

The diagnosis of prostate cancer is confirmed by which of the following?

Histologic exam of tissue

A 68-year-old man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patient's history, what might the nurse note that contributes to erectile dysfunction?

History of heavy alcohol use

Which of the following should nurses teach all men, especially those who have had cryptorchidism?

How to perform a testicular self-examination.

Which of the following is the most common sexually transmitted infection (STI) among young, sexually active people?

Human papillomavirus (HPV)

A nurse practitioner who works for Planned Parenthood is responsible for health education seminars. During these presentations, the nurse always discusses the symptoms of the most common STI among young, sexually active people. This is:

Human papillomavirus.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive

A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?

Hyperkalemia

Regulation of electrolyte balance is a management goal for patients suffering from renal disease. Which of the following lab results is considered the most life-threatening effect of renal failure?

Hyperkalemia

The nurse is caring for a patient in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

Hyperkalemia.

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement?

Hypertension

The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with?

Hyperthyroidism

A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal?

Hyperuricemia

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

Hypocalcemia

The nurse is aware that the clinical symptoms of a patient with hypoparathyroidism are the result of the initial physiologic response of:

Hypocalcemia.

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which symptom when caring for this client?

Hypoglycemia

A client with acromegaly has been given the option of a surgical approach or a medical approach. The client decides to have a surgical procedure to remove the pituitary gland. What does the nurse understand this surgical procedure is called?

Hypophysectomy

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension

A critical care nurse is closely monitoring a patient who has recently undergone surgical repair of a bleeding peptic ulcer. The nurse should prioritize assessments of which of the following signs and symptoms of a recurrence of hemorrhage?

Hypotension and tachycardia

The nurse is obtaining a health history from a 58-year-old client stating that he is having difficulty obtaining an erection during sexual activity. The client asks how an "erectile medication" works and if there are any side effects to the medication. The nurse explains the action of the medication and directions for use and warns of which side effect related to the client's history?

Hypotension with nitrate use

A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply.

Hypothermia Hypotension Hypoventilation

The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?

Hypovolemic shock caused by hemorrhage

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not include when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

IgE

What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as histamine when a client is having an allergic reaction?

IgE

There are several types of reactions to latex. The nurse knows to be most concerned about laryngeal edema with the following reaction:

IgE-mediated hypersensitivity.

Which nursing diagnosis is least appropriate for the client with rheumatoid arthritis?

Imbalanced nutrition: greater than body requirements

A 44-year-old man has come to the clinic with an asthma exacerbation. He tells the nurse that his father and brother also suffer from asthma, as does his 15-year-old son. The nurse explains that this is an allergic response based on a genetic predisposition. The specific allergen initiated by this immunological mechanism is usually mediated by:

Immunoglobulin E

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?

Immunosuppressive agents

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?

Impaired Skin Integrity

A woman who has experienced severe seasonal allergies in recent years has been referred for allergy skin testing. The nurse at the allergy clinic should be aware of the need to take precautions against the patient's risk of which of the following nursing diagnoses?

Impaired gas exchange

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

Impaired nutrition: less than body requirements

A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?

Increase carbohydrates and limit protein intake.

What is a characteristic of the intrarenal category of acute kidney injury (AKI)?

Increased BUN

The nurse is assessing the breast of a female patient and observes a prominent venous pattern on the left breast. What does the nurse understand that this can be indicative of?

Increased blood supply required by a tumor

When assessing a client with benign prostatic hyperplasia, which of the following would the nurse expect the client to report as the initial complaint?

Increased effort to void

The nurse is providing preprocedure teaching about an ultrasound. The nurse informs the patient that, in preparation for an ultrasound of the lower urinary tract, the patient will require what?

Increased fluid intake to produce a full bladder

An adult patient is experiencing a temporary decrease in serum levels of T3 and T4. What physiological response is this state likely to result in?

Increased release of TSH

What does the nurse understand will result if the patient has a deficiency in the normal level of complement?

Increased susceptibility to infection

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

Ineffective airway clearance related to obstruction by mucus

A patient has had rheumatoid arthritis for over 10 years, and the health care provider has now ordered cyclophosphamide (Cytoxan) for treatment of the disease. The nurse must be alert to what side effects of this medication when administering an immunosuppressant?

Infection

A public health nurse is facilitating a health forum at a high school and has presented the deleterious effects of Chlamydia trachomatis and Neisseriae gonorrhoeae infection. Why are these sexually transmitted infections (STIs) associated with a high risk of pelvic inflammatory disease and infertility among infected females?

Infection is often not accompanied by recognizable signs and symptoms.

A patient presents to the walk-in clinic complaining of vomiting and burning in his mid-epigastria. The nurse knows that to confirm peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

Infection with Helicobacter pylori

A nurse who works in a busy, urban clinic is aware of the importance of a thorough assessment of sexual history for the women who are patients of the clinic. When initiating such assessments, the nurse should begin by:

Informing the patient that she will be asked some questions about her sexual health

A nurse practitioner is assessing the size and position of a patient's uterus and ovarian structures. To perform this assessment, the nurse has informed the patient that bimanual palpation will be performed. How will the nurse perform this assessment?

Insert fingers of one hand into the vagina and palpate outside with the other hand.

Computed tomography of a patient with a sudden onset of severe nausea and vomiting has revealed the presence of a pyloric obstruction. Which of the following interventions is the nurse's priority in the immediate care of this patient?

Insertion of a nasogastric (NG) tube to suction to decompress the stomach

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. What instruction should the nurse give to the client to minimize injury?

Install safety devices in the home.

A patient presents with vulvar itching and diffuse green vaginal discharge. Upon evaluation, she is prescribed metronidazole (Flagyl). What is the paramount nursing intervention in discharge planning?

Instruct the patient not to drink alcohol with this treatment.

A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:

Intestinal malabsorption.

A nurse who oversees the care that is provided in a long-term care facility is aware that there are numerous age-related changes to every body system. Which of the following phenomena may be a result of age-related changes to the endocrine system?

Intolerance to cold

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?

Intradermal

A nurse is teaching a client about the need to use mineral supplements along with a multivitamin daily after bariatric surgery. Which minerals would the nurse include in the teaching? Select all that apply.

Iron Folic acid Copper

An older adult patient had a gastrectomy performed several weeks ago and is being followed closely by the care team. Due to potential complications of this surgery, the nurse should closely monitor the patient's levels of:

Iron and vitamin B12

A nurse working in a gynecologist's office reviews breast self-examination (BSE) with a patient and explains the difference between a breast fibroadenoma and a malignancy. Which of the following characteristics associated with a malignancy are most descriptive of this type of mass? Select all that apply.

Irregular in shape Fixed to the skin Associated with signs of retraction

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?

It enhances transport of glucose across the cell wall.

A patient is diagnosed with the most common type of uterine fibroid, an intramural fibroid. The nurse includes which information in teaching the patient about this type of fibroid?

It grows within the wall of the uterine muscle.

Which statement is true regarding hormonal contraception?

It increases risk for venous thromboembolism.

Which points should be included in the medication teaching plan for a client taking adalimumab?

It is important to monitor for injection site reactions.

The nurse is assessing an older adult female who has not seen her physician in 2 years. The nurse is assisting the patient into a gown and notices that the patient has edema and pitting of the skin on the right breast. What does the nurse understand is the significance of this finding?

It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer.

A client is scheduled for a cholecystogram for later in the day. What is the nurse's understanding on the diagnostic use of this exam?

It visualizes the gallbladder and bile duct.

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output?

It's an abnormal finding that requires further assessment.

A patient has been admitted to the hospital with signs and symptoms of acute renal failure. Knowing the vital role that the kidneys play in maintaining fluid and electrolyte balance, the care team is monitoring the patient's laboratory values closely. Which of the following laboratory values is suggestive of renal failure?

K+ 7.1 mmol/L

A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the patient be instructed to do?

Keep her hands well moisturized.

The nurse knows to advise the patient with hyperparathyroidism that he or she should be aware of signs of the common complication of:

Kidney Stones

The nurse reviews a client's history and notes that the client has a history of hyperparathyroidism. The nurse would identify that this client most likely would be at risk for which of the following?

Kidney stones

A 52-year-old patient is scheduled to undergo ileal conduit surgery and has several appropriate questions for the nurse. What would be the most relevant nursing diagnosis for this patient?

Knowledge deficit about the surgical procedure and postoperative care

A 32-year-old man who has a body mass index of 32 (morbidly obese) is considering bariatric surgery. In the time leading up to this surgery, which of the following nursing diagnoses will be the primary focus of interventions?

Knowledge deficit related to the implications of bariatric surgery

The nurse recognizes the client is in which stage of syphilis when the client has no signs or symptoms of syphilis?

Latency

A patient with osteoarthritis is taking up to 4 grams of acetaminophen daily. The nurse knows to obtain periodic:

Liver enzyme results.

A 59-year-old male patient was diagnosed with cirrhosis several years ago. After years of successful management of his chronic disease, he experienced a constellation of symptoms that eventually resulted in a diagnosis of hepatocellular carcinoma (HCC). What treatment holds the greatest potential for curing this patient's health problem?

Liver transplantation

A nursing student asks the instructor how to identify rheumatoid nodules in a client with rheumatoid arthritis. Which of the following characteristics would the instructor include?

Located over bony prominence

The nurse teaches the client that reducing the viral load will have what effect?

Longer survival

A nurse who is taking care of a patient with a spinal cord injury documents the frequency of reflex incontinence. The nurse understands that this is most likely due to:

Loss of motor control of the detrusor muscle.

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?

Low purine

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?

Low residue

A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?

Low-purine diet

A 49-year-old man with a history of heavy alcohol use and liver cirrhosis has been admitted to the hospital's medical unit due to an exacerbation of his health problems that has resulted in massive ascites. The nurse should be prepared to implement which of the following interventions in an effort to resolve the patient's ascites?

Low-sodium diet and administration of diuretics

During which phase of the menstrual cycle is progesterone secreted by the corpus luteum?

Luteal

The menstrual cycle is dependent on the interplay among a number of hormones. The hormone(s) responsible for stimulation of progesterone is (are):

Luteinizing hormone.

The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which of the following?

Lymphedema

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?

Lymphocytes

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?

Macrophages

A nurse who works in a clinic is aware of the importance of thorough and thoughtful urologic assessments, despite the fact that these assessments have the potential to make patients uncomfortable. When interviewing patients about their urologic health, the nurse should:

Maintain a composed but empathic demeanor.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4 to 6 hours

Which assessments are important in a client diagnosed with ascites?

Measurement of abdominal girth

The nurse is conducting a history and assessment related to a client's incontinence. Which element should the nurse include in the assessment before beginning a bladder training program?

Medication usage

Which nursing assessment finding is most significant in determining the plan of care in a client with erectile dysfunction?

Medication use

The nurse is preparing a presentation for an older adult group of males at a senior center. Which of the following would the nurse expect to include when describing the effects of aging on the male reproductive system?

Men retain the ability to fertilize ova irrespective of age.

Which of the following is a term used to describe excessive menstrual bleeding?

Menorrhagia

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?

Methotrexate (Rheumatrex)

Which drug is the most effective treatment for trichomoniasis?

Metronidazole

Which of the following is the most effective treatment for trichomoniasis?

Metronidazole (Flagyl)

A patient asks the nurse if there are any available nonsurgical options to terminate a pregnancy if she is only 2 weeks pregnant. What information should the nurse provide to the patient about a medication that blocks progesterone?

Mifepristone (RU-486, Mifeprex) is used only in early pregnancy to terminate a pregnancy nonsurgically.

An arthrocentesis is done to remove synovial fluid from a joint. Synovial fluid from an inflamed joint is characteristically:

Milky, cloudy, and dark yellow.

The nurse is caring for a client who has an excess amount of potassium being excreted and has a serum level of 6.2 mEq/L. What group of adrenal hormones is likely to be impacting the laboratory result?

Mineralocorticoids

A patient has been admitted to a medical unit with respiratory symptoms that are characteristic of tuberculosis. When transporting the patient to radiology for a chest x-ray, the nurse has applied a mask that covers the patient's nose and mouth. This action addresses which component of the chain of infection?

Mode of exit

A client is scheduled for a renal angiography. Which of the following would be appropriate before the test?

Monitor the client for an allergy to iodine contrast material.

A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?

Monitor urine output hourly and report output less than 30 mL/hr.

The nurse is preparing a presentation for a men's community group about health promotion. Which of the following would the nurse include as a current recommendation for screening?

Monthly testicular self-examination (TSE)

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit?

Moon face

A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation?

Most cases are typically diagnosed in infancy.

The nurse recognizes which statement as accurately reflecting a risk factor for breast cancer?

Mother affected by cancer before 60 years of age

A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate?

Myxedema coma

A client who is suspected of having trichomoniasis is scheduled for laboratory testing. Which test would the nurse prepare the client to undergo to confirm the diagnosis?

NAAT

A client has a history of dysmenorrhea. During monthly menses, the client experiences incapacitating cramping and passes large clots. The client's primary care physician initiates conservative treatment. What interventions would the physician to recommend?

NSAIDs

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?

Nasogastric tube insertion

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Naturally acquired active immunity

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Naturally acquired active immunity

The nurse is performing detailed patient education with a 40-year-old woman who will be soon discharged following a Roux-en-Y gastric bypass. The nurse and other members of the interdisciplinary team have been emphasizing the need for eating small amounts of food at a sitting and eating food slowly. What is the rationale for the nurse's advice?

Nausea and esophageal distention can result from eating too fast.

A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?

Nausea and vomiting

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?

Neutrophils

Chapter 32

Nursing Assessment- Female and Male Reproductive Function

Chapter 26

Nursing Assessment- Renal and Urinary Tract Function

Chapter 30

Nursing Management- Diabetes Mellitus

Chapter 38

Nursing Management- Patients With Allergic Disorders

Chapter 33

Nursing Management- Patients With Breast and Female Reproductive Disorders

Chapter 31

Nursing Management- Patients With Endocrine Disorders

Chapter 23

Nursing Management- Patients With Gastric and Duodenal Disorders

Chapter 25

Nursing Management- Patients With Hepatic and Biliary Disorders

Chapter 37

Nursing Management- Patients With Immunodeficiency, HIV Infection, and AIDs

Chapter 24

Nursing Management- Patients With Intestinal and Rectal Disorders

Chapter 34

Nursing Management- Patients With Male Reproductive Disorders

Chapter 27

Nursing Management- Patients With Renal Disorders

Chapter 39

Nursing Management- Patients With Rheumatic Disorders

Chapter 35

Nursing Management- Patients With Sexually Transmitted Infections

Chapter 28

Nursing Management- Patients With Urinary Disorders

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

The nurse is seeing a client in the community health clinic who reports finding "sores" in the mouth. On assessment, the nurse notes the lesions appear flat, flesh colored and papillary. What should the nurse do next?

Obtain a health history that includes inquiring about sexual health practices

The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?

One part of the intestine telescopes into another portion of the intestine.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?

Only use the nasal spray for 3 to 4 days once every 12 hours.

Which term refers to the surgical removal of one or both testes?

Orchiectomy

A patient with a history of type 1 diabetes is being assessed for possible diabetic nephropathy, and a component of the ordered diagnostic evaluation is a urinalysis. This patient's ability to concentrate urine would be reflected in what component of urinalysis?

Osmolality

An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2° F. Otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?

Palpate the patient's parotid glands to detect swelling and tenderness.

A 37-year-old male patient presents at the emergency department complaining of nausea and vomiting and severe abdominal pain. While the nurse is assessing the patient, the patient's wife informs the nurse that the patient ingested 24 ounces of vodka last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. What is the patient exhibiting signs of?

Pancreatitis with possible peritonitis

A hospital patient's most recent blood work reveals a Ca2+ level of 14.2 mg/dL (normal 8.5 to 10.5 mg/dL) and a phosphorus level of 1.4 mg/dL (normal 3.0 to 4.5 mg/dL). What hormone has the potential to cause this alteration in the patient's electrolyte levels?

Parathyroid hormone

A nurse practitioner examines a 23-year-old woman from the Middle East. She documents that the patient has type I female genital mutilation (FGM) and examines her for signs of vaginal cellulitis and infection. Type I FGM refers to which of the following?

Partial or total removal of the clitoris

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition?

Peptic ulcers

A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

Perforation of the peptic ulcer

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?

Perform meticulous perineal care daily with soap and water

The nurse is preparing a teaching plan for a client with a vulvovaginal infection. Which of the following would be least appropriate for the nurse to include?

Performing douching with a dilute vinegar solution twice a day

The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include?

Performing perineal exercises frequently throughout the day

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?

Peritonitis

The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?

Peritonitis

The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication?

Peritonitis

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit the client to drink only clear liquids.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right?

Pigment

An adult patient has admitted to his primary care provider that he has been experiencing an unprecedented loss of libido in recent months. This complaint should prompt the clinician to assess the patient for dysfunction of what endocrine gland?

Pituitary gland

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurence) in persons with AIDS?

Pneumocystis pneumonia

Which is the most common cause of esophageal varices?

Portal hypertension

A 54 year-old man is postoperative day 1 following neck dissection surgery. Which of the following nursing actions should the nurse prioritize in the care of this patient?

Positioning the patient in a high Fowler's position to protect the airway

While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following?

Positive Chvostek's sign

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported.

Potassium of 2.8 mEq/L

A 30-year-old obese female patient who underwent gastric banding 3 days ago is getting ready to go home. Essential postoperative teaching for this patient should include instruction related to the importance of abstaining from what for the next 2 years?

Pregnancy

The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for?

Prepare for a cesarean section.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?

Presence of autoantibodies against islet cells

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Presence of islet cell antibodies

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?

Pressure on the optic nerve

Following a radical vulvectomy, the nurse is preparing the client for discharge to home. Which care intervention would be considered the priority for this client?

Prevention of wound complications

A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply.

Probenecid Corticosteroid therapy Pain medication Serum uric acid concentration

A client is diagnosed with hypertension. The client also reports skin discoloration, weight gain, and nausea. Which contraceptive preparations would the nurse practitioner recommend for this client?

Progestin-only

The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply.

Provide careful perineal care. Assist the patients with frequent toileting. Perform hand hygiene prior to patient care.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?

Pyloric sphincter

A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms?

Pyridium

The nurse earlier infused the prescribed quantity of dialysate into the peritoneal dialysis catheter of an adult patient and has now drained the fluid. Upon examination, the nurse observes that there is significantly less fluid removed than was earlier infused. How should the nurse follow up this observation?

Reposition the patient to facilitate drainage from the peritoneal cavity.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?

Respiratory assessment related to increased thoracic pressure

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids

A client has been diagnosed with an enlarged prostate. What information should the nurse explain to the client about the effects of an enlarged prostate?

Retention of urine

A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about?

Reverse transcriptase inhibitors

A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client' s stage of disease?

Review the client's medical record.

A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

Risk for impaired skin integrity

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury

A patient's vasa recta have detected a precipitous drop in the patient's blood pressure. In response to feedback from the vasa recta, the patient's kidneys will:

Secrete renin

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?

Sedation

A perimenopausal woman informs the nurse that she is having irregular vaginal bleeding. What should the nurse encourage the patient to do?

See her gynecologist as soon as possible.

A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record: Total serum IgE levels: 2.8 mg/mL White blood cell count: 5,100/cu mm Eosinophil count: 4% Erythrocyte sedimentation rate: 20 mm/h The nurse identifies which result as suggesting an allergic reaction?

Serum IgE level

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test?

Serum amylase

As glomerular filtration decreases, which of the following occurs? Select all that apply.

Serum creatinine increases Blood urea nitrogen (BUN) increases Creatinine clearance decreases

A client with acquired immune deficiency syndrome (AIDS) is experiencing pain secondary to Kaposi's sarcoma. How would the nurse most likely expect the client to describe the pain?

Sharp, throbbing pressure

A patient is recovering in the PACU following gastric surgery. The nurse who is providing this patient's care is performing frequent assessments of the character and quantity of the patient's nasogastric (NG) drainage. What are the nurse's expected findings during these assessments?

Small amounts of blood-tinged output

The nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data below should the nurse consider most significantly related to the etiology of the patient's health problem?

Smokes two packs of cigarettes daily

A nurse who provides care in a college medical clinic is involved in numerous initiatives that aim to promote sexual health among students. When performing health assessments of male students, the nurse should be aware of which of the following functions of the testes? Select all that apply

Spermatogenesis Testosterone secretion

Nursing students are reviewing information about natural family planning methods in preparation for a quiz the next day. The students demonstrate a need for additional study when they identify which of the following as an example?

Spermicide

A hospital educator is reiterating the importance of Standard Precautions to a group of nursing students who will soon begin a clinical rotation on the unit. Which of the following statements best describes the application of Standard Precautions?

Standard Precautions should be applied to patients regardless of diagnosis or presumed infectious status.

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?

Stomach

In teaching clients with osteoarthritis about their condition, it would be important for the nurse to focus on:

Strategies for remaining active

Which type of incontinence is the involuntary loss of urine through an intact urethra as a result of coughing?

Stress

Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:

Synthesis of glucose from noncarbohydrate sources.

A client with AIDS develops pneumocystis pneumonia. The nurse would most likely expect to include administration of which agent in the client's plan of care?

TMP-SMZ

A client is being screened for a thyroid disorder. The nurse would anticipate that the client would most likely undergo which test?

TSH (thyroid-stimulating hormone)

The nursing educator is teaching a group of nurses about constipation and the elderly. What recommendation for this population should a nurse can make about treating chronic constipation?

Take a stool softener, such as docusate sodium (Colace), daily.

Which should be included as part of the home care instructions for a client with epididymitis and orchitis?

Take prescribed antibiotics

The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do?

Take the antibiotic for 3 days as prescribed.

A patient is taking NSAIDs for the treatment of osteoarthritis. What education should the nurse give the patient about the medication?

Take the medication with food to avoid stomach upset.

A patient comes to the emergency department and tells the nurse, "I took a pill to help me perform and then passed out." The nurse is assessing the patient and finds a nitroglycerin patch on his back. What is the first intervention the nurse must perform?

Take the patient's blood pressure.

Which nursing intervention should the nurse caring for the client with pyelonephritis implement?

Teach client to increase fluid intake up to 3 liters per day.

A community health nurse is well-aware that the incidence and prevalence of chronic renal failure (CRF) has increased significantly in recent years. In a recent strategic planning meeting, the nurse has proposed health promotion activities to address this problem. Which of the following health promotion campaigns addresses the most common cause of CRF?

Teaching individuals with diabetes to manage their disease

A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make?

Testicular cancer is a highly curable type of cancer.

A nurse is reviewing a laboratory order for a client who is scheduled to be tested for a suspected endocrine disorder. The client was recently seen in the office for bronchitis, and you note that he is still taking cough medication. The nurse explains to the client that he will not be able to get his lab testing done today. Why has the testing been postponed?

The client is being tested for a thyroid disorder

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?

The client's immune system cannot mount a response to the skin test.

A client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. What is the most important factor related to the client's assessment?

The client's use of other drugs

The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?

The costovertebral angle

A 34-year-old man has been diagnosed with HSV-2 and is preparing to begin treatment with acyclovir (Zovirax). When providing health education about his new medication regimen, what information should the nurse provide to this patient?

The drug may relieve his symptoms but it will not cure him of herpes.

A patient has been prescribed sildenafil citrate. What should the nurse teach the patient about this medication?

The drug should be taken 1 hour prior to intercourse.

The school health nurse is conducting a teaching session for parents to provide information about the human papillomavirus (HPV) vaccination. What prevention information should the nurse include in the session?

The effect of the vaccination is optimized if it is administered before the child becomes sexually active.

A client is scheduled for a diagnostic test to measure blood hormone levels. The nurse expects that this test will determine which of the following?

The functioning of endocrine glands

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?

The immune system recognizes one's own tissues as "foreign."

The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?

The nursing assistant places the drainage bag on the client's abdomen for transport.

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?

The pancreas secretes digestive enzymes.

The pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar:

The pancreatic hormone glucagon will stimulate the liver to release stored glucose.

In consultation with her care team, a woman with a diagnosis of cancer has had a continent urinary diversion (Indiana pouch) created. The patient is discussing the advantages and disadvantages of this procedure with her nurse. The nurse should be aware of which of the following advantages of an Indiana pouch?

The patient does not have to wear an external collection bag.

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?

Thymus

Which of the following hormones would the nurse identify as being secreted by the thyroid gland?

Thyroxine

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?

Tickle in the throat

The client states to the nurse that he is very anxious about having prostate cancer ever since his prostate-specific antigen (PSA) test came back elevated. The client asks, "Which diagnostic test produces definitive results if cancer is present?" The nurse is most correct to state which of the following?

Tissue biopsy

Which of the following is the only definitive test that can determine if cancer of the testis is present?

Tissue biopsy

The gynecologist tells the nurse that the patient she just examined was complaining of tenderness over the area known as the "tail of Spence." The doctor asks the nurse to verify her findings. The nurse knows to palpate the:

Top of the breast near the axilla.

The nurse is conducting a gastrointestinal assessment. When the client reports the presence of mucus and pus in the stool, the nurse assesses for additional signs/symptoms of which disease/condition?

Ulcerative colitis

The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse understand will activate the renin-angiotensin aldosterone and sympathetic nervous system and decrease responsiveness to diuretic therapy?

Upright

A group of students is reviewing for a test on the urinary and renal system. The students demonstrate understanding of the information when they identify which of the following as part of the upper urinary tract?

Ureters

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances?

Uric acid

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?

Urinary calculi

The most frequent reason for admission to skilled care facilities includes which of the following?

Urinary incontinence

The nurse understands that a client with diabetes mellitus is at greater risk for developing which of the following complications?

Urinary tract infections

The nurse is caring for a client who is describing urinary symptoms of needing to go to the bathroom with little notice. When the nurse is documenting these symptoms, which medical term will the nurse document?

Urinary urgency

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Urine output of 20 ml/hour

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?

Urine output of 250 ml/24 hours

The nurse is reviewing the client's lab results. Which lab result requires follow up by the nurse? Select all that apply.

Urine: RBC 20 BUN 28 mg/dL

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?

Use a topical skin moisturizer daily.

A nurse who works on a busy medical unit has been experiencing dry, itchy, reddened hands that she believes are a result of the frequent hand-washing that her job requires. What should the nurse's colleague recommend for the relief of this problem?

Use of a different type of soap

A 38-year-old client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. Which is the most important factor related to the client's assessment?

Use of other drugs

The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation?

Usual pattern of elimination

A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy?

Viral load and T4-cell counts will be performed every 2 to 3 months.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:

Western blot test for confirmation of diagnosis.

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?

White blood cell (WBC) count 22.8/mm3

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?

White blood cell (WBC) count of 20,000/mm3

Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia?

Widespread chronic pain

The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?

With food

A nurse is preparing a presentation about STIs for a local community group. When describing chlamydia, which age group would the nurse identify as being at greatest risk for this infection?

Women younger than 24 years of age

A patient has been diagnosed with a Trichomoniasis vaginal infection. The nurse would expect which color of discharge?

Yellow-green

Atopic allergic disorders are characterized by

a hereditary predisposition.

A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy for osteoarthritis?

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

alcohol abuse and smoking.

A nurse is providing care to a client who is experiencing a dysfunction of the adrenal cortex. The nurse would anticipate issues involving which hormone? Select all that apply.

aldosterone cortisol

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

at least three times per week.

An older female client reports pain during intercourse, disrupting the intimacy that she and her husband are accustomed to sharing. What might be the cause of her pain?

atrophy of Bartholin glands

A nurse is developing a teaching plan for a client diagnosed with hyperparathyroidism that explains this condition. When describing the underlying problem, the nurse would most likely include a discussion about which mineral?

calcium

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration.

Which manifestation would most likely be identified when assessing a client with primary syphilis?

chancre

A client is being tested for gonorrhea. Based on the nurse's understanding of this STI, the nurse would anticipate that the client will also be tested for:

chlamydia

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout?

colchicine

A client has undergone a Pap smear and the results are suspicious. When planning the client's care, which test would the nurse anticipate as being done next?

colposcopy

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

consuming a low-carbohydrate, high-protein diet and avoiding fasting.

The nurse is teaching a client diagnosed with peptic ulcer disease about how to make the necessary dietary changes to decrease acid secretion. The client demonstrates understanding of the information by identifying the need to avoid which substance? Select all that apply.

creamy sauces milk products decaffeinated coffee

A female client comes to the clinic because of painful blisters on her genitalia. The nurse suspects genital herpes. Which test would the nurse anticipate as being used to confirm the diagnosis?

culture of the lesion

A client is concerned about the lumps that have developed in her breasts and is fearful of cancer. The client reports variability in the size of the lumps. What could be causing this condition?

cyclical hormonal changes

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response?

decompression

During a client education session, the nurse describes the mechanism of hormone level maintenance. What causes most hormones to be secreted?

decrease in hormonal levels

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:

decreased body temperature and cold intolerance.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

deposits of adipose tissue in the trunk and dorsocervical area.

Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies

develop early in life after protection from maternal antibodies decreases.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?

diaphoresis, vomiting, and diarrhea.

During physical examination of the male reproductive system, which method would best provide the nurse information about the prostate's size as well as evidence of tumor?

digital rectal examination

The nurse is conducting an assessment on a client that has acute irritant contact dermatitis. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply.

edema redness

A nurse is reading a journal article about STIs and risk factors. The nurse demonstrates understanding of the article by identifying which factor as increasing the risk? Select all that apply.

engagement in sex at an early age multiple sex partners use of illicit drugs

A nurse is reviewing a journal article about the menstrual cycle. The nurse demonstrates understanding of the article by identifying which hormone as being elevated at the time of ovulation? Select all that apply.

estrogen luteinizing hormone

Which structure is referred to as the vulva?

external female genitalia

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:

fatigue and weakness.

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:

filter bacteria from tissue fluid.

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a:

fissure.

A client has been experiencing a decrease in serum calcium. After diagnostics, the physician proposes the calcium level fluctuation is due to altered parathyroid function. What is the typical number of parathyroid glands?

four

The nurse is presenting a community lecture about STIs, and emphasizes that some STIs are easily cured with early and adequate treatment. Which is not among these easily treated diseases?

genital herpes

A nurse is providing care to a client who is experiencing low blood glucose levels. The nurse understands that the body attempts to raise the level by secreting which hormone?

glucagon

A client is experiencing some secretion abnormalities, for which diagnostics are being performed. Which substance is typically reabsorbed and not secreted in urine?

glucose

The major carbohydrate that tissue cells use as fuel is

glucose.

A nurse is caring for a client with hypoparathyroidism. During assessment, the nurse elicits a positive Trousseau's sign. What does the nurse observe to verify this finding?

hand flexing inward

A nurse is teaching a client with an endocrine disorder how the nervous system and endocrine system are linked. Which structure would the nurse identify as the link between the two systems.

hypothalamus

Bladder retraining following removal of an indwelling catheter begins with

instructing the client to follow a 2- to 3-hour timed voiding schedule.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

interferons

A client who has just undergone an appendectomy reports the need to urinate but is unable to do so. What is the nurse's response to this client's situation as ordered by the physician?

intermittent catheterization

A nurse is teaching a group of young adults about STIs. As part of the teaching session, the nurse emphasizes the need for practicing safe sex. The nurse is addressing which component of the chain of infection?

mode of transmission

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:

myxedema coma.

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

A client has a suspected bladder tumor. What is the most common first symptom of a malignant tumor of the bladder?

painless hematuria

A client is very concerned about possibly having breast cancer, especially after caring for a close family member who recently died from the disease. The nurse informs the client that the primary and most common sign of breast cancer is a:

painless mass in the breast, most often in the upper outer quadrant.

A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:

paralytic ileus.

Which cancer ranks second as the cause of death in American men?

prostate

The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?

To relax colonic musculature and reduce spasm.

A patient with gallbladder disease was being treated for blockage of the common bile duct due to a large gallstone. The nurse recognizes which of the following as an abnormal laboratory result?

Total bilirubin level of 1.5 mg/dL

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n)

chancre

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?

clear liquids day before

Which response is a parasympathetic response in the GI tract?

increased peristalsis

During postoperative neck dissection assessment, the nurse notices excessive bleeding from the dressing site. She suspects possible carotid artery rupture and takes the immediate first step to:

Apply pressure to the bleeding site or major associated vessel.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium?

Colonoscopy

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.

Inspection Auscultation Percussion Palpation

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?

Liver function studies

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color.

A patient is to receive parenteral nutrition. The duration of therapy is planned for 4 weeks. The nurse develops a teaching plan for the patient to prepare for insertion of which of the following as most likely?

Nontunneled central catheter

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal.

Chapter 21

Nursing Assessment- Digestive, Gastrointestinal, and Metabolic Function

Chapter 22

Nursing Management- Patients With Oral and Esophageal Disorders and Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition

A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times?

Semi-Fowler's with the head of the bed elevated 30 to 45 degrees

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location?

Sigmoid colon

The nurse is reviewing the chart of a client with swallowing problems. Which factors would raise suspicion that the client has cancer of the esophagus? Select all that apply.

Smoking history of 20 years Male gender Previous treatment for gastroesophageal reflux disease

A client comes to the clinic complaining of a sore throat. When assessing the client, the nurse observes a reddened ulcerated lesion on the lip. The client tells the nurse that it has been there for a couple of weeks but it does not hurt. What should the nurse consult with the health care provider about testing for?

Syphilis

Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance?

Tarry-black

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

duodenum

Which procedure is performed to examine and visualize the lumen of the small bowel?

small bowel enteroscopy

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response?

small intestine

The nurse recognizes which change of the gastrointestinal system is an age-related change?

weakened gag reflex

Which of the following cell types are involved in humoral immunity?

B lymphocytes

A 33-year-old man with AIDS is being treated for cytomegalovirus retinitis and has been prescribed ganciclovir. The nurse who is participating in this patient's care should recognize that this treatment necessitates which of the following assessments?

Close monitoring of the patient's WBC differential

Which of the following is the most frequent route of exposure to a latex allergy?

Cutaneous

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?

Edema and inflammation

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

Elevated erythrocyte sedimentation rate

An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?

Hypokalemia

A nurse is preparing to palpate the thyroid gland. Where would the nurse expect to find this gland?

In the lower neck, anterior to the trachea

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain

The nurse is relating health education to male students when asked where sperm is actually made. Which location is most correct?

In the testes within the scrotum

A 58-year-old man who leads a busy lifestyle managing his own business has been diagnosed with a gastric ulcer. The man has told the nurse, "My wife warned me that my job stress would eventually catch up with me!" How should the nurse best respond to the patient's statement?

"Actually, it's been found that stress doesn't really cause ulcers."

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

"Although AIDS is an immune deficiency, your child's condition is different from AIDS."

The nurse is reviewing the results of a hemoccult test with the client. Which question asked by the nurse is important in screening for the potential of a false-positive result. Select all that apply.

"Are you prescribed regular strength aspirin daily?" "Can you tell me the amount of alcohol that you drink on an average week?" "When was the last time that you included red meat in your diet?"

The nurse is conducting a health history when a middle-aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations. Which question should the nurse ask next?

"Are you taking any hormone replacement therapy?"

The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:

"As the disease progresses, you will most likely require renal replacement therapy."

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

"Avoid coffee and alcoholic beverages."

A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?

"Even a perfect match does not guarantee organ success."

Endoscopy of a 60-year-old woman has revealed the presence of an esophageal peptic ulcer. The nurse who is providing this woman's care is assessing for risk factors that may have contributed to the development of this disease. What question most directly addresses these risk factors?

"Have you ever been diagnosed with reflux?"

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?

"Have you ever received a blood transfusion?"

A 52-year-old male patient has acknowledged to his primary care provider that he has been experiencing difficulty maintaining an erection in recent months. Which of the following assessment questions most directly addresses a risk factor for this problem?

"How much alcohol do you typically drink in one day?"

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

"I can eat whatever I want as long as it's low in fat."

The nurse is giving discharge instructions to the client following a bladder ultrasound. Which statement by the client indicates the client understands the instructions?

"I can resume my usual activities without restriction."

The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?

"I can take my child to the beach, as long as we play in the sand rather than swim in the water."

A client with erectile dysfunction is being treated with alprostadil urethral suppository. After teaching the client about this treatment, the nurse determines that additional education is needed based on which client statement?

"I should inject the medication about 20 minutes before intercourse."

Cone biopsy describes a procedure in which cervical tissue is removed as result of detection of abnormal cells. Which statements by the client demonstrates that the client undergoing a cone biopsy understands the discharge instructions?

"I will avoid having sexual relations until I see the doctor again."

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

"I won't donate blood because I don't want to get AIDS."

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin."

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present."

A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer?

"Pace yourself and rest frequently, especially after activities."

A client with diabetes mellitus must learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

"Rotate injection sites within the same anatomic region, not among different regions."

A nursing student asks the nurse why older adults are at risk for renal disease. The best response by the nurse is:

"The glomerular filtration rate decreases as we age."

An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?

"This type of dialysis will provide more independence."

A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse?

"Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."

A patient who is scheduled for a gynecologic examination and Pap smear informs the nurse that she just began her menstrual cycle. What is the best response by the nurse?

"We will reschedule your examination when you have finished menstruating."

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.

When fluid intake is normal, the specific gravity of urine should be:

1.010 to 1.025

The nurse practitioner counsels a patient about being a candidate for bariatric surgery. The patient is 5?4? tall and weighs 300 pounds (IBW is 125 lbs). The nurse tells the patient that, based on the average weight loss after surgery, she should expect to eventually weigh:

120 lbs.

A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:

138 mg/dL, 2 hours postprandial.

A patient sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this patient?

Curling's ulcer

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested?

3 days

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male patient. How many grams will the nurse administer?

30 g

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL

A client who is being treated for pyloric obstruction has a nasogastric (NG) tube in place to decompress the stomach. The nurse routinely checks for obstruction which would be indicated by what amount?

450 mL

A nurse is conducting a health promotion class for a group of younger middle-aged men. When discussing the need for a digital rectal exam, the nurse would recommend this exam for every man over age:

50.

Nutritional guidance is part of health education for a patient with nephrotic syndrome. To prevent urinary protein loss in an 84-kg male, the nurse would recommend a minimum daily intake of:

58.8 g/kg/24h.

Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?

6

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?

6 weeks

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5%

A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:

A massive release of histamine

The nurse has cared for four patients with type 1 diabetes over the past few shifts. Based upon components of managing diabetes, which patient will likely have the greatest success in maintaining tight glucose control of his or her type 1 diabetes?

A patient who adheres to a meal plan and meal schedule.

A group of students are reviewing material in preparation for a test on the male and female breasts. The students demonstrate understanding of the material when they identify which of the following?

A primary function of the female breast is to produce milk.

A nurse is caring for a 73-year-old male patient with a urethral obstruction related to prostatic enlargement. The nurse is aware this may result in what?

A urinary tract infection (UTI)

The nurse knows to assess the patient with a history of diarrhea for fluid volume deficit (FVD). Which of the following is a characteristic sign of FVD?

A weak, thready pulse

The nurse is conducting a focused assessment of a male patient who has a history of poorly controlled hypertension. Which of the following findings would indicate the presence of renal artery bruits?

A whooshing sound over the kidneys

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Administer epinephrine, as ordered, and prepare to intubate the client, if necessary.

The nurse reviews the laboratory values for a patient being evaluated for alcoholic cirrhosis. The nurse is aware that a diagnostic indicator present in greater than 70% of cases is which of the following?

AST/ALT ratio >3.0

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage

A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

Acromegaly

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?

Acute gastritis

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?

Acute glomerulonephritis

Which of the following medications are used to suppress viral load of the HSV-2 infection?

Acyclovir (Zovirax)

After a thyroidectomy, the client develops a carpopedal spasm while the nurse is taking a BP reading on the left arm. Which action by the nurse is appropriate?

Administer IV calcium gluconate as ordered.

A middle-aged woman suffers from debilitating seasonal allergies and has sought care because over-the-counter remedies do not adequately relieve her symptoms. The clinician's understanding of the patient's problem should include the fact that hypersensitivity is a result of what pathophysiological process?

An exaggerated, inappropriate response to an antigen

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?

An exercise routine that includes range-of-motion (ROM) exercises

An older woman has been receiving enteral feeds by nasogastric (NG) tube for the past several days due to a decrease in her level of consciousness. How can the nurse best assess the patient's tolerance of the current formula and rate of delivery?

Aspirate and measure the stomach contents on a regular basis.

A patient with a recent diagnosis of esophageal cancer has undergone an esophagectomy and is currently receiving care in a step-down unit. The nurse in the step-down unit is aware of the specific complications associated with this surgical procedure and is consequently monitoring the patient closely for signs and symptoms of:

Aspiration pneumonia

A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?

Assess for ataxia using the finger-to-nose test and heel-to-shin test

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

Assess vital signs.

A nurse in a campus medical clinic is meeting with a 23-year-old student who states that she has been experiencing malodorous vaginal discharge over the past several days. The nurse should recognize that this patient is describing a sign that is characteristic of:

Bacterial vaginosis (BV)

The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care?

Baking soda and water

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?

Bank autologous blood.

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?

Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL

The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?

Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20.

The nurse is caring for a client after a cystoscopic examination. Following the procedure, the nurse informs the client that which effect may occur?

Blood-tinged urine

Which treatment involves implantation of interstitial radioactive seeds under anesthesia to treat prostate cancer?

Brachytherapy

In women, which of the following types of cancer exceeds colorectal cancer?

Breast

After teaching a group of students about the signs and symptoms of breast cancer, the instructor determines that additional teaching is needed when the group identifies which of the following?

Breast symmetry

A client with Stage IV prostate cancer is to receive hormone therapy. The nurse would inform the client about possible adverse effects including which of the following?

Breast tenderness

A 56-year-old presented to her nurse practitioner because she had been experiencing unprecedented constipation and the passage of pencil-like stools despite her high fluid and fiber intake. The nurse recognized the need to assess the patient for colorectal cancer and ordered diagnostic evaluations. What component of the patient's blood work would be most indicative of the presence of cancer?

Carcinoembryonic antigen (CEA)

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts

When high levels of plasma calcium occur, the nurse is aware that the following hormone will be secreted:

Calcitonin

A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?

Calcium

Surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. During the immediate postoperative period, the nurse knows to evaluate serum levels of __________ to assess for a serious and primary postoperative complication of thyroidectomy.

Calcium

The nurse is discussing nutritional needs for a postmenopausal patient. What dietary increase should the nurse recommend to the patient?

Calcium

A client with severe hypoparathyroidism is experiencing tetany. What medication, prescribed by the physician for emergency use, will the nurse administer to correct the deficit?

Calcium gluconate

The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action by the nurse is most important prior to the test?

Calculate drop per minute for intravenous fluids and infuse by gravity.

A patient newly diagnosed with type 2 diabetes is attending a nutrition class specifically designed for type 2 diabetics. What general guideline would it be important to teach the patients at this class?

Calorie intake should support a reasonable body weight.

Which is inconsistent with a digital rectal examination (DRE)?

Can reveal a hydrocele

The nurse is collecting assessment data on a client who is reporting a vaginal discharge that is cottage cheese-like in appearance. Which pathogen is the most likely cause for this symptom?

Candida albicans

Which stage or period of syphilis occurs when the infected person has no signs or symptoms of syphilis?

Latency

A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?

Caregiver cleans the client's anal area without wearing gloves

Trousseau's sign is elicited by which of the following?

Carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre

The nurse is encouraging the client with recurrent urinary tract infections to increase his fluid intake to 8 large glasses of fluids daily. The client states he frequently drinks water and all of the following. Which of the following would the nurse discourage for this client?

Coffee in the morning

The treatment of gout involves managing the acute inflammatory stage, preventing flare-ups, and controlling hyperuricemia. Select the agent of first choice when an acute inflammatory attack begins.

Colchicine

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker?

Dietitian

Which is the primary symptom of achalasia?

Difficulty swallowing

The nurse is caring for a client who has been admitted to hospital for uterine bleeding after incomplete miscarriage. The nurse knows what will be included in this client's treatment?

Dilation and curettage

After initially presenting to a campus medical clinic after the emergence of a wart on her vulva, a 21-year-old woman is distraught to receive a diagnosis of human papillomavirus (HPV). The woman states, "I know I'm supposed to, but I really have no idea how I'm going to break this to my boyfriend. What will happen if I don't tell him?" What nursing diagnosis should the clinic nurse identify in this woman's care?

Decisional conflict

Which is an age-related change of the hepatobiliary system?

Decreased blood flow

The nurse is completing a routine urinalysis using a dipstick. The test reveals an increased specific gravity. The nurse should suspect which condition?

Decreased fluid intake

A geriatric nurse is performing an assessment of an 85-year-old patient. The nurse realizes that what particular change is an age-related effect on the renal or urinary system?

Decreased glomerular filtration rate

A patient with chronic renal failure has frequent blood work ordered so that the care team can monitor the progression of his disease. The nurse has noted a consistent downward trend in the patient's levels of hemoglobin, hematocrit, and red blood cells (RBCs). The nurse understands that this is likely attributable to what pathophysiologic phenomenon?

Decreased synthesis and release of erythropoietin

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?

Decreases in the physiologic function of major organs

A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?

Diphenhydramine

The nurse educator is teaching a class about the chain of infection. The nurse educator correctly states that sexually transmitted infections are passed on through which route of transmission?

Direct transmission

A patient experiences hypotension, lethargy, and muscle spasms while receiving bladder irrigations after a transurethral resection of the prostate (TURP). What is the first action the nurse should take?

Discontinue the irrigations.

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics

A 48-year-old man has presented to the outpatient radiology department for a scheduled transrectal ultrasound (TRUS). The nurse in this department should be aware that this patient has likely had:

Elevated prostate-specific antigen (PSA)

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels

Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to:

Encourage high fluid intake

A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?

Follow the same sexual precautions as someone who has been diagnosed with AIDS.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects

Postoperatively, a client with a radical neck dissection should be placed in which position?

Fowler

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

Frequent changes of positions

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Frequent vomiting, leading to loss of fluid volume

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?

Gently washing the area surrounding the stoma using a facecloth and mild soap

A nursing midwife delivered a baby whose mother had a sexually transmitted disease. The nurse knows that of the six sexually transmitted diseases, only two can be transmitted via the perinatal route. What are those two diseases?

Herpes simplex and syphilis

The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder?

High IgE concentration

A 66-year-old man who originally sought care because of increasing pain in his great toe has subsequently been diagnosed with gout. In addition to pharmacological interventions, what dietary regimen should the nurse recommend to this patient?

High fluid intake and low protein intake

Which of the following protective responses begin with the B lymphocytes?

Humoral

What type of immunoglobulin is most likely involved with allergic reactions?

IgE

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

Increases ability for glucose to get into the cell and lowers blood sugar

Which of the following is one of the first clinical manifestations of esophageal cancer?

Increasing difficulty in swallowing

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?

Increasing fluid intake to prevent dehydration

The nurse caring for a patient who is being discharged home after a radical neck dissection has worked with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection?

Indicates acceptance of altered appearance and demonstrates positive self-image

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.

Ingestion of strong acids Irritating foods Overuse of aspirin

A nurse is reading a journal article about medications used to treat allergic rhinitis. The nurse demonstrates understanding of the information when identifying which medication as being the most effective maintenance therapy for chronic allergic rhinitis?

Intranasal corticosteroids

The nurse assesses a patient who has an obvious goiter. What type of deficiency does the nurse recognize is most likely the cause of this?

Iodine

Which statement is correct regarding glargine insulin?

It cannot be mixed with any other type of insulin.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

HIV is harbored within which type of cell?

Lymphocyte

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

A 49-year-old man has been brought to the emergency department by his wife, who states that her husband is experiencing a repeat episode of kidneys stones. When planning interventions for this patient's immediate care, what problem is likely to be the priority?

Pain

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed?

Pernicious anemia

A nurse knows that more than 50% of clients with CVID develop the following disorder.

Pernicious anemia

Which medication may be ordered to relieve discomfort associated with a urinary tract infection?

Phenazopyridine

Which of the following glands is considered the master gland?

Pituitary

A patient comes to the clinic with complaints of a painless sore on her lip 2 weeks after she had oral sex with her boyfriend. The nurse observes a chancre on the lips and the physician orders testing for syphilis. If results are positive, what is the likely stage the patient is in?

Primary

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Primary infection

The period from infection with HIV to the development of antibodies to HIV is known as which of the following?

Primary infection

Sympathomimetics have which of the following effects on the body?

Relaxation of bladder wall

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain

Which of the following is the most successful treatment for gastric cancer?

Removal of the tumor

A client with a history of anaphylactic reactions to insect stings has just been stung by a wasp. Place the steps in the correct order that the client will follow for self-administration of an EpiPen. Use all options.

Remove the gray safety-release cap Inject the black tip into the outer thigh Massage the injection area Call the emergency medical response number (911)

A nurse is describing the renal system to a client with a kidney disorder. Which structure would the nurse identify as emptying into the ureters?

Renal pelvis

A group of students is reviewing for a test on hormones. The students demonstrate understanding of the material when they state which of the following as being secreted by the kidneys?

Renin

The nurse is aware, when caring for patients with renal disease, that which substance made in the glomeruli directly controls blood pressure?

Renin

The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?

Report the incident to the supervisor.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?

Rh-hemolytic disease

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced

Rhinitis medicamentosa

A middle-aged female patient has received a diagnosis of scleroderma with a chronic course and has been informed by her primary care provider that the disease has no cure. When considering the characteristic signs and symptoms of scleroderma, what nursing diagnosis should the nurse prioritize?

Risk for disturbed body image related to the integumentary effects of scleroderma

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy

A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. The surgery is scheduled for the following week. That afternoon, the patient calls the nurse and tells her he wants to cancel the surgery because he thinks he might be better off dead. The nurse asks him why he feels that way. The patient states "My wife won't want to have sex with me anymore. He says he feels like he's spoiled a happy, satisfying sex life with his wife and he starts to cry. Based on these statements, which nursing diagnosis would be most appropriate for creating a plan of care for this patient?

Situational low self-esteem

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 mL fluid between meals

Scleroderma typically starts with which type of organ involvement?

Skin

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss?

Skipping meals out of fear of painful attacks

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?

SpO2 at 90% with fine crackles in the lung bases

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

Sweating, tremors, and tachycardia

What are the primary participants in the immune system?

T- and B- cell lymphocytes

The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?

The client appears mildly ill, listless, and disheveled.

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin.

The nurse is obtaining health histories from women at a busy low-income clinic. Which of the following clients should the nurse follow closely as being at high risk for developing breast cancer?

The client has relatives with the BRCA1 mutated gene

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?

The client is free from esophagitis and achalasia.

Total parenteral nutrition (TPN) has been ordered for a male patient who has been experiencing a severe and protracted exacerbation of Crohn's disease. Before TPN can be initiated, the patient requires:

The insertion of a central venous access device

The nurse is providing supportive care to a client receiving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure?

The kidneys can improve over a period of months.

An individual has had a snack consisting of half a bagel with cream cheese, lox (smoked salmon), red onions, and capers. Stimulation of the person's gastrointestinal tract has resulted in the secretion of numerous digestive enzymes into the small intestine, including trypsin. What component of this person's snack will be primarily digested by the action of trypsin?

The lox

The nurse is conducting a community education program on allergies and anaphylactic reactions. The nurse determines that the participants understand the education when they make which statement about anaphylaxis?

The most common cause of anaphylaxis is penicillin.

The nurse teaches the client with allergies about anaphylaxis, including which statement?

The most common cause of anaphylaxis is penicillin.

The nurse is conducting an abdominal assessment of a patient who is postoperative day 1 following an open cholecystectomy. During auscultation of the patient's abdomen, the nurse has noted that clicks and gurgles are audible approximately every 10 seconds. How should the nurse follow up this assessment finding?

The nurse should document normoactive bowel sounds.

The nurse is outlining the female internal reproductive structures on a diagram. Where on the diagram would the nurse highlight the typical site of ovum fertilization?

The nurse would highlight the fallopian tube.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information?

The possibility of surgery, chemotherapy and radiotherapy

When describing the difference between endocrine and exocrine glands, which of the following would the instructor include as characteristic of endocrine glands?

The secretions are released directly into the blood stream

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?

The short-acting insulin is withdrawn before the intermediate-acting insulin.

A patient has herpes simplex 2 viral infection (HSV-2). The nurse recognizes that which of the following should be included in teaching the patient:

Treatment is aimed at relieving symptoms.

During an internal vaginal examination, the nurse practitioner notes a frothy and malodorous discharge. What bacteria does the practitioner suspect is causing this disorder?

Trichomonas

A female patient tells the nurse that she thinks she has a vaginal infection because she has noted inflammation of her vulva and a yellow-green discharge. The nurse recognizes that the clinical manifestations described are typical of what vaginal infections?

Trichomonas vaginalis

A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?

Trimethoprim-sulfamethoxazole

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?

Vitamin K deficiency

The nurse recognizes that urinalysis results that most likely indicate a urinary tract infection include:

WBC 50

What interventions for the relief of pain and discomfort can the nurse educate the patient with a vulvovaginal infection about using? Select all that apply.

Warm perineal irrigations Sitz baths Cornstarch for chafed inner thighs

How often should women diagnosed with human papillomavirus (HPV) have Pap smears?

Yearly

After a routine physical exam, a female client is devastated to receive a diagnosis of the sexually transmitted infection, gonorrhea. What would contribute to the client's ignorance of this condition?

being asymptomatic

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack?

eating organ meats and sardines

A nurse explains the role of the ovaries. Which hormones would be included in that discussion?

estrogen and progesterone

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?

lack of free water intake

A client is experiencing symptoms associated with menopause. What is a likely recommendation to increase the client's interest in sexual activity?

low-dose androgens

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet

Which immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a:

supine position.

The nurses assesses the client for blood in the stool due to an upper GI condition. The nurse understands that if there is blood in the stool, the stool will be which color?

tarry black

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

The nurse is providing instructions to the client prior to an intravenous pyelogram. Which statement by the client indicates teaching was effective?

"I will feel a warm sensation as the dye is injected."

The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?

At the umbilicus

Which of the following is the leading cause of death among patients undergoing maintenance hemodialysis?

Atherosclerotic cardiovascular disease

Which symptom of thyroid disease is seen in older adults?

Atrial fibrillation

An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia?

Atrophy of the gastric mucosa

A nurse on a medical unit is caring for a patient who has experienced a recent exacerbation of HIV. The nurse is being vigilant in assessments and preventative measures related to the common complications of HIV infection. What assessment addresses the most common opportunistic infection related to HIV?

Auscultating the patient's lungs and monitoring oxygen saturation and respiratory rate

A 50-year-old woman is scheduled for discharge this morning following a left-sided simple mastectomy that was performed yesterday to treat noninvasive breast cancer. When providing this woman's care prior to discharge, what action should the nurse prioritize?

Avoid measuring the woman's blood pressure on her left arm.

Which of the following would the nurse prioritize as the most important action for the patient to take to prevent anaphylaxis?

Avoid potential allergens

A client with acquired immune deficiency syndrome (AIDS) reports diarrhea after every meal. What is the nurse's best response?

Avoid residue, lactose, fat, and caffeine.

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

Avoid taking aspirin to treat pain or fever

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?

Enuresis

A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching?

"I may stop taking this medication when I feel better."

A client is learning how to perform Kegel exercises. Which statement by the client indicates a need for additional teaching?

"I need to hold the position for at least 15 seconds."

What should a male client older than age 50 do to help ensure early identification of prostate cancer?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

The nurse is teaching a patient about nutrition and knows that the body needs specific nutrients in order to function normally. What element is essential to thyroid function?

Iodine

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client?

Nonsteroidal anti-inflammatory drugs

Following morning hygiene of an elderly client, the nurse is unable to replace the retracted foreskin of the penis. Which is the most likely outcome?

Painful swelling

Lispro (Humalog) is an example of which type of insulin?

Rapid-acting

A 20-year-old male client comes to the clinic for an evaluation. During the visit, the client mentions that he wants to make sure that he is using condoms properly. When reviewing the steps, which client statement would warrant additional instruction?

"I should put the condom on my penis before it becomes erect."

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which explanation from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

The nurse educator, who is teaching a class on sexually transmitted infections, recognizes that teaching has been effective when students indicate which statement is true about the difference between colonization and infection?

"Colonization becomes infection when the host and organism interact."

During an assessment of a client's functional health pattern, which question by the nurse directly addresses the client's thyroid function?

"Do you experience fatigue even if you have slept a long time?"

The nurse is obtaining a history from a client who states recurrent breast tenderness. The client inquires if there is something wrong with her breasts. Which question by the nurse is a priority?

"Does the tenderness occur around the same time each month?"

The nurse is educating a client about allergy management at home. What client statements indicate no further teaching is required? Select all that apply.

"I have pull shades on all of my windows." "I bought a wooden chair for my living room."

A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

"I will increase my fluid and calcium intake."

A client is scheduled for a renal ultrasound. Which of the following would the nurse include when explaining this procedure to the client?

"You don't need to do any fasting before this noninvasive test."

Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice?

"You should take your insulin after you eat breakfast and dinner."

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure?

"You will need to swallow a capsule."

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?

A canker sore of the oral soft tissues

A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?

A cell-mediated response

A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?

A change in bowel habits

An older adult patient with a diagnosis of chronic gastritis has achieved acceptable control of his condition with the use of an H2 receptor antagonist. This patient's symptom control is a result of what therapeutic action of this drug?

A decrease in HCl production by parietal cells

Contact dermatitis is considered a type IV hypersensitivity reaction. The nurse is aware that this classification is characterized by which of the following?

A delayed-type hypersensitivity that is mediated by T cells

The description of liquid discharge from the nipple of the breast can be diagnostic for certain conditions. If a woman describes nipple discharge as green in color, the nurse knows that this is usually associated with:

A fibroadenoma.

A community health nurse is performing a home visit to a 53-year-old patient who requires twice-weekly wound care on her foot. The patient mentions that she is currently having hemorrhoids, a problem that she has not previously experienced. What treatment measure should the nurse recommend to this patient?

A high-fiber diet with increased fruit intake

A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon, the girl develops erythema and itching around her mouth. This is likely due to which of the following?

A latex allergy

The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest?

A low-purine diet

An emergency department (ED) nurse has provided care for many patients who have primary and secondary diagnoses of immune dysfunction. Which of the following patients likely has the highest risk of a disruption to normal immune functioning?

A man who has recently completed medical treatment for prostate cancer

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine.

A client with diabetic ketoacidosis has been brought into the ED. Which intervention is not a goal in the initial medical treatment of diabetic ketoacidosis?

Administer glucose.

A woman visits her primary health care provider with a complaint of pain and swelling in the vaginal area. The pain is present when she sits and walks; intercourse is painful. The nurse prepares the patient for an examination. The nurse and health care provider suspect that the patient may have an inflammation or infection of the:

Bartholin glands.

A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?

Below-normal urine osmolality level, above-normal serum osmolality level

During an allergic reaction, histamine is released in about 15 minutes. The patient usually takes an antihistamine that has an affinity for bronchiolar smooth muscle cells (an H2 receptor). Which of the following is most likely the drug described?

Benadryl

What is the most common presenting objective symptom of a urinary tract infection in older adults, especially in those with dementia?

Change in cognitive functioning

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin

More than 50% of individuals with this disease develop pernicious anemia:

Common variable immunodeficiency (CVID)

Which term describes a procedure in which cervical tissue is removed because abnormal cells are detected?

Cone biopsy (conization)

A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see?

Constipation

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

The nurse has been closely monitoring the blood work of a patient who recently experienced nephrotoxic effects from an over-the-counter medication. In the course of providing care, the nurse has been teaching the patient about the various roles that the kidney plays in the maintenance of homeostasis. Which of the following functions is performed by the kidneys?

Control of acid-base balance

The primary function of the thyroid gland includes which of the following?

Control of cellular metabolic activity

Which of the following is the gold standard for herpes simplex virus (HSV) diagnosis?

Culture

A nurse is assesing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment?

Deep purple cutaneous lesions

Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply.

Deficient knowledge: management of urinary diversion Disturbed body image Risk for impaired skin integrity

A client comes to the emergency department complaining of pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

Degenerative joint disease

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Delaying exercise for at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided.

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?

Desensitization

An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale?

Detects calculi, cysts, or tumors

The wall of the bladder is comprised of four layers. Which of the following is the layer responsible for micturition?

Detrusor muscle

A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak, and he has had an 8-lb weight loss since admission. What should the client be tested for?

Diabetes insipidus (DI)

Symptoms associated with pyloric obstruction include all of the following except:

Diarrhea

The nurse is performing an admission assessment on a patient with AIDS. When assessing the patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis?

Diarrhea

Which of the following appears to be a significant factor in the development of gastric cancer?

Diet

Which of the following would be considered a "free" item from the exchange list?

Diet soda

The nurse is assessing a patient admitted to the unit with kidney stones. What assessment parameters would be priorities for the nurse to address? Select all that apply.

Dietary history Family history of renal stones Medication history

A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be alright to relieve the nasal congestion he is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Do not overuse the medication as rebound congestion can occur.

Symptoms of pelvic infection usually begin with which of the following?

Dyspareunia

Which of the following causes should the nurse suspect in a client is diagnosed with intrarenal failure?

Glomerulonephritis

Which of the following may result if prostate cancer invades the urethra or bladder?

Hematuria

All prostatectomies include the risk of damage to the pudendal nerve. Therefore, postoperatively, the nurse assesses for:

Impotence.

The nurse is providing instruction for testicular self-examination to a group of young adolescents. Which is the most correct examination technique?

Palpate each testicle separately, following a warm shower.

Pelvic infection is most commonly caused by which of the following?

Sexual transmission

Which nursing assessment finding indicates the client has not met expected outcomes?

The client voids 75 cc four hours post cystoscopy.

The nurse is teaching the client about the upcoming endoscopic retrograde cholangiopancreatography (ERCP). Although the nurse instructs on several pertinent points of care, which is emphasized?

The client will change positions frequently throughout the procedure.

A male client, aged 42, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing.

Which is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance.

A man with severe ulcerative colitis has been informed by his health care provider that he will require a colectomy and an ileostomy. The patient has been told by his health care provider that he is candidate for a continent ileal reservoir (Kock pouch). The patient's nurse recognizes which of the following advantages to the use of a Kock pouch as an alternative to the creation of an ileal stoma?

The patient will not have to wear an external collection bag.

A patient with severe environmental allergies is scheduled for the first in a planned series of immunotherapy injections. What should be included in teaching the patient about the injection?

The patient will remain in the clinic to be monitored for 30 minutes following the injection.

The nurse is caring for a geriatric client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?

The small bowel

The nurse is caring for a client who is brought to the emergency department after being found unconscious outside in hot weather. Dehydration is suspected. Baseline lab work including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?

The specific gravity will be high.

A patient who is currently in the hospital recovering from orthopedic surgery has always considered herself to be a "borderline diabetic" who prides herself on maintaining acceptable blood glucose levels through diet and lifestyle modifications. Consequently, she is surprised that her primary care provider has ordered a sliding scale of insulin while she is in the hospital. Why might this patient require insulin at this particular time?

The stress of hospitalization and surgery may cause increased release of glucocorticoids.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

The ultrasonography should be scheduled before the GI procedure.

A nurse is caring for a newly admitted patient with a suspected gastrointestinal (GI) bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. The nurse recognizes that the bleeding is likely occurring where?

The upper GI tract

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:

infection because the spleen removes bacteria from the blood.

What types of cells are the primary targets of the healthy immune system? Select all that apply.

infectious cells foreign cells cancerous cells

The nurse prepares to administer the lavage solution to a client having a colostomy completed. The nurse stops and notifies the physician when noting that the client has which condition?

inflammatory bowel disease

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding?

testing the client for the presence of HIV

The lower the client's viral load,

the longer the survival time.

The nurse teach the client that osteoarthritis is

the most common and frequently disabling of joint disorders.

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:

there are usually no symptoms.

Hickman and Groshong are examples of which type of central venous access device?

tunneled central catheters

A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. What should the nurse discuss with the health care provider before catheterization?

type and size of the catheter to be used

Ataxia refers to

uncoordinated muscle movement.

A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has

uncoordinated muscle movements.

The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?

upper GI enteroclysis

A nurse is reviewing the history of a client diagnosed with erectile dysfunction. Which information would the nurse interpret as indicating that use of a PDE-5 inhibitor would be contraindicated.

use of nitroglycerin for angina

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:

usual pattern of elimination.

When caring for a client with diabetes insipidus, the nurse expects to administer:

vasopressin.

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex