Intro

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? "How many alcoholic drinks do you typically consume in a week?" "To the best of your knowledge, are your immunizations up to date?" "Have you ever worked in an occupation where you might have been exposed to toxins?" "Has anyone in your family ever experienced symptoms similar to yours?"

"How many alcoholic drinks do you typically consume in a week?"

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states what? "I read that a pancreas transplant will provide a cure for my diabetes." "I will take my oral antidiabetic agents when my morning blood sugar is high." "I will make sure to follow the weight loss plan designed by the dietitian." "I will make sure I call the diabetes educator when I have questions about my insulin."

"I will make sure to follow the weight loss plan designed by the dietitian."

A client with long-standing obesity has been prescribed phentermine/topiramate-ER. What statement by the client suggests that further health education is necessary? "I'm so relieved to start this medication. I really don't like having to exercise or change what I eat." "It's hard to believe that there are actually medications that can treat obesity." "I'm a bit nervous to start this medication because I know I'll need blood tests sometimes." . "I'm going to have to do some rearranging of my finances to make sure I can afford this medication."

"I'm so relieved to start this medication. I really don't like having to exercise or change what I eat."

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond? "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." "Your small intestine will adapt over time to the absence of your appendix."

"Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery."

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A 45-year-old teacher who stands for 6 hours per day A pregnant woman at 28 weeks' gestation A 37-year-old construction worker who does heavy lifting A 60-year-old professional who is under stress

A pregnant woman at 28 weeks' gestation

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? Mobilization with assistance at least 4 times daily Administration of beta-adrenergic blockers as prescribed Vitamin B12 injections as prescribed Administration of diuretics as prescribed

Administration of diuretics as prescribed

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? Homonymous hemianopsia Receptive aphasia Agnosia Hemiplegia

Agnosia

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? Take the medication on an empty stomach. Take up to one extra dose per day if stomach pain persists. Take at bedtime to mitigate the effects of drowsiness. Avoid drinking alcohol while taking the drug.

Avoid drinking alcohol while taking the drug.

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? Use glycerin suppositories on a regular basis. Limit physical activity in order to promote bowel peristalsis. Consume high-residue, high-fiber foods. Resist the urge to defecate until the urge becomes intense.

Consume high-residue, high-fiber foods.

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? Administer a Fleet enema as prescribed and remain with the client. Contact the primary care provider promptly and report these signs of perforation. Position the client supine and insert an NG tube. Page the primary provider and report that the client may be obstructed.

Contact the primary care provider promptly and report these signs of perforation.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? Contact the care provider to have the client's hemoglobin and hematocrit measured. Document these expected assessment findings. Apply barrier ointment to the stoma as prescribed. Cleanse the stoma with alcohol or chlorhexidine.

Document these expected assessment findings.

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? Inflammation of the lining of the stomach Erosion of the lining of the stomach or intestine Bleeding from the mucosa in the stomach Viral invasion of the stomach wall

Erosion of the lining of the stomach or intestine

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a client with this condition? Risk for peripheral neurovascular dysfunction Excess fluid volume Hypothermia Ineffective airway clearance

Excess fluid volume

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? Stool will be yellow for the first 24 hours' postprocedure. The barium may cause diarrhea for the next 24 hours. Fluids must be increased to facilitate the evacuation of the stool. Slight anal bleeding may be noted as the barium is passed.

Fluids must be increased to facilitate the evacuation of the stool

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? Following proper hand-washing techniques Avoiding chemicals that are toxic to the liver Wearing a condom during sexual contact Limiting alcohol intake

Following proper hand-washing techniques

A nurse is caring for a client after bariatric surgery and is assessing for hemorrhage. What is a sign of hemorrhage? Increase in blood pressure Frank red bleeding from the surgical site Clear drainage from the surgical wound decrease in heart rate

Frank red bleeding from the surgical site

The nurse's assessment of a client with thyroidectomy suggests tetany, and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? Oral calcium chloride and vitamin D IV calcium gluconate STAT levothyroxine Administration of parathyroid hormone (PTH)

IV calcium gluconate

A client has recently been diagnosed with type 2 diabetes. The client is clinically obese and has a sedentary lifestyle. How can the nurse best begin to help increase the client's activity level? Set up appointment times at a local fitness center for the client to attend. Have a family member ensure the client follows a suggested exercise plan. Construct an exercise program and have the client follow it. Identify barriers with the client that inhibit his lifestyle change.

Identify barriers with the client that inhibit his lifestyle change.

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries? Hormonal changes brought on by the stress response cause an acidic oral environment Systemic infections frequently migrate to the teeth Hydration that is received intravenously lacks fluoride Inadequate nutrition and decreased saliva production can cause cavities

Inadequate nutrition and decreased saliva production can cause cavities

The school nurse is working with a high school junior whose BMI is 31. When planning this client's care, the nurse should identify what goal? Continuation of current diet and activity level Increase in exercise and reduction in calorie intake Possible referral to an eating disorder clinic Increase in daily calorie intake

Increase in exercise and reduction in calorie intake

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? Ineffective tissue perfusion related to bowel ischemia Imbalanced nutrition: Less than body requirements related to impaired absorption Anxiety related to bowel obstruction and subsequent hospitalization Impaired skin integrity related to bowel obstruction

Ineffective tissue perfusion related to bowel ischemia

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? Insertion of a nasogastric tube Insertion of a central venous catheter Administration of a mineral oil enema Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? Inspection, auscultation, percussion, and palpation Inspection, palpation, auscultation, and percussion Inspection, percussion, palpation, and auscultation Inspection, palpation, percussion, and auscultation

Inspection, auscultation, percussion, and palpation

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes? Have blood glucose levels checked annually. Stop using tobacco in any form. Undergo eye examinations regularly. Lose weight, if obese.

Lose weight, if obese.

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? In a knee-chest position (lithotomy position) Lying prone with legs drawn toward the chest Lying on the left side with legs drawn toward the chest In a prone position with two pillows elevating the buttocks

Lying on the left side with legs drawn toward the chest

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? Maintaining accurate records of intake and output Maintaining a patent airway Inserting a nasogastric (NG) tube as prescribed Providing appropriate pain control

Maintaining a patent airway

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Change the client's position as indicated. Monitor serum electrolytes. Maintain NPO status. Monitor arterial blood gas (ABG) values.

Monitor serum electrolytes.

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? Ensure that the client's sodium intake does not exceed recommended levels. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. Inform the primary provider that the client should be assessed for alcoholic hepatitis. Implement interventions aimed at ensuring a calm and therapeutic care environment.

Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? Side-lying with one pillow under the head Head of the bed elevated 30 degrees and no pillows placed under the head Semi-Fowler with the head supported on two pillows Supine, with a small roll supporting the neck

Semi-Fowler with the head supported on two pillows

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? Consumes one or more protein drinks daily. Takes over-the-counter antacids frequently throughout the day. Smokes one pack of cigarettes daily. Reports a history of social drinking on a weekly basis.

Smokes one pack of cigarettes daily.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? Tachycardia, hypotension, and tachypnea Tarry, foul-smelling stools Diaphoresis and sudden onset of abdominal pain Sudden thirst, unrelieved by oral fluid administration

Tachycardia, hypotension, and tachypnea

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? The nurse gives direction to get out of bed but the client does not understand. The client points and gestures to an object needed on the overhead table. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. The client sits up and turns to one side to see the object and states what is needed.

The client starts by saying "good morning" but finishes with saying "good day" to the nurse.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? The client will be monitored closely to detect malignant changes. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in the stools and are not cause for concern. Antacids may be discontinued when symptoms of heartburn subside.

The client will be monitored closely to detect malignant changes.

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? The client will obtain measurement of drainage from the T-tube. The client will exercise three times a week. The client will take immunosuppressive agents as required. The client will monitor for signs of liver dysfunction.

The client will take immunosuppressive agents as required.

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? Gastric cancer does not cause signs or symptoms until metastasis has occurred. Adherence to screening recommendations for gastric cancer is exceptionally low. Early symptoms of gastric cancer are usually attributed to constipation. The early symptoms of gastric cancer are usually not alarming or highly unusual.

The early symptoms of gastric cancer are usually not alarming or highly unusual.

A client is admitted to a surgical unit after a thyroidectomy. The nurse takes and maintains the inflated blood pressure cuff on the client and observes a carpopedal spasm. What does this result indicate? Chvostek sign and hypocalcemia Thyroid storm and elevated triiodothyronine Homans sign and deep vein thrombosis Trousseau sign and overt tetany

Trousseau sign and overt tetany

A client has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the client may have developed liver metastases? persistent fever and cognitive changes abdominal pain and hepatomegaly peripheral edema unresponsive to diuretics spontaneous bleeding and jaundice

abdominal pain and hepatomegaly

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by: cleaning and drying regularly within the client's skin folds. avoiding the use of pillows to position the client. making a referral to physical therapy. ensuring the client receives a high-calorie, high-protein diet.

cleaning and drying regularly within the client's skin folds.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? assessment of blood pressure and headaches assessment of venous thromboembolism daily weights and abdominal girth blood glucose monitoring Q4H

daily weights and abdominal girth

A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? decisional conflict knowledge deficit death anxiety disturbed thought process

death anxiety

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? confusion uncertainty depression disassociation

depression

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that the client is at increased risk for what complication in the postoperative period? hyperglycemia azotemia falls: infection

infection

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for: jaundice bleeding malnutrition hypokalemia

jaundice

Diagnostic testing has revealed that a client's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this client's plan of care will focus on what intervention? cryosurgery liver transplant lobectomy laser hyperthermia

lobectomy

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? HCTZ mannitol furosemide spironolactone

mannitol

The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem? trunkal obesity hypertension muscle weakness moon face

muscle weakness

A nurse is promoting increased protein intake to enhance a client's wound healing. What is the enzyme that will initiate the digestion of the protein that the client consumes? pepsin intrinsic factor lipase amylase

pepsin

A client presents at the walk-in clinic reporting diarrhea and vomiting. The client has a documented history of adrenal insufficiency. Considering the client's history and current symptoms, the nurse should anticipate that the client will be instructed to increase intake of: sodium potassium simple carbohydrates calcium

sodium

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. annual vitamin B12 injections consumption of vitamin-rich diet use of standard precautions annual vitamin K injections immunization

use of standard precautions immunization