Med surg exam 1 NCLEX

The nurse is performing discharge teaching for a client diagnosed with Cushing'sdisease. Which statement by the client demonstrates an understanding of theinstructions?1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1

Which finding would the nurse expect in the urinalysis of a patient with DI? a) pH of 9 b) spec grav of 0.4 c) RBC in urine of 6 d) WBC in urine of 8

B (low because of lack of ADH)

The nurse is caring for a client who is prescribed desmopressin. Which is the expected outcome? a) sodium 136 b) spec grav 1.005 c) urine output 3L/ day d) osmolarity 100

C (used for DI)

Which electrolyte replacement should the nurse anticipate being ordered by thehealth-care provider in the client diagnosed with DKA who has just been admitted tothe ICU? a) glucose b) potassium c) calcium d) sodium

B

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? a) serum sodium of 139 mEq/L b) serum chloride of 100 mEq/l c) serum calcium of 10.2 mg/dL d) serum potassium of 7.2 mEq/L

D

the elderly client is admitted to the intensive care department diagnosed w/severe HHNS. which collaborative intervention should ht nurse include in the plan of care? a) infuse 0.9% normal saline IV b) administer intermediate acting insulin c) perform blood glucose checks daily d) monitor ABGs

A

A client with a pituitary tumor develops a urine output of 300mL/h, dry skin, and dry mucous membranes. Which intervention would the nurse perform for this client? a) evaluate urine specific gravity b) implement fluid restrictions c) provide emollients to the skin to prevent breakdown d) slow down the IV fluids

A (urine output of 300/he may indicate DI)

The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."

ANS: 2. Medication for DI is usually taken every 8 to 12 hours, depending on the client. The client should keep the medication close at hand.

The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I & O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.

ANS: 3. The first action should be to determine if the client is experiencing polyuriaand polydipsia as a result of developing diabetes insipidus, a complication of the head trauma.

The client diagnosed with a pituitary tumor developed syndrome of inappropriateantidiuretic hormone (SIADH). Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.

2

The nurse writes a problem of "altered body image" for a 34-year-old clientdiagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3

A client with central diabetes insipidys has a serum osmolarity of 600. Carbamazepine is prescribed. Which is an effective outcome of this med? a) decreased thirst b) decreased seizures c) decreased urine output d) increased calcium levels

A

The nurse reviews the serum lab values of a client. The nurse suspects hypofunctioning of the adrenal gland based on which results? SATA a) increased calcium b decreased cortisol c decreased sodium d decreased potassium e increased glucose

A, B, C

The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.

ANS: 1. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low sodium level.

The nurse is caring for clients on a medical floor. Which client should be assessed first? A) The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. B) The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. C) The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. D) The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.

ANS:. C. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wantssomething else to eat for lunch. Which intervention should the nurse implement? a) instruct the UAP to get the client food b) notify the dietician about the patients requests c) request the HCP increase client caloric intake d) tell the UAP the client can't eat anymore

B

The nurse is planning care for a client with diabetes insipidus. Which intervention made by the nurse requires correction? a) assessing sodium levels b) measuring urine output c) restricting fluids at night d) changing positions slowly

C

The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness? a) He will need to take exogenous steroids for several months b) His condition will indicate improvement when he gains weight c) he may have mood swings or depression as a result of his illness d) His physical changes are permanent but may improve with therapy

C

the charge nurse is making client assignments in the ICU. which client should be assigned to the most experienced nurse? a) the client with type 2 diabetes who has a BG of 348 b) the client diagnosed with type 1 diabetes who is experiencing hypoglycemia c) the client with DKA who has multi focal premature ventricular contractions d) the client with HHNS who has a plasma osmolarity of 290

C

which arterial blood gas results should the nurse expect in the client diagnosed w/DKA? a) pH 7.34, pao2 99, paco2 48, HCO3 24 b) pH 7.38, pao2 95, paco2 40, HCO3 22 c) pH 7.46, pa02 85, paco2 30, HCO3 18 d) pH 7.30, pao2 90, paco2 30, HCO3 18

D

Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.

1

The nurse is planning the care of a client diagnosed with Addison's disease. Whichintervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1 . Clients diagnosed with Addison's dis-ease have adrenal gland hypofunction.The hormones normally produced bythe gland must be replaced. Steroidsand androgens are produced by the adrenal gland.

The client diagnosed with Addison's disease is admitted to the emergency departmentafter a day at the lake. The client is lethargic, forgetful, and weak. Which interventionshould the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1 . The client was exposed to wind and sunat the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisoniancrisis. Rapid IV fluid replacement is necessary.

49. The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency(Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.

ANS: 4. The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently.

Which assessment data indicate the client diagnosed with DKA is responding to treatment? a) the client has tented skin turgor and dry mucous membranes b) the client is A&O to date time and place c) the clients ABG results are pH 7.29, paco2 44, HCO3 15 d) the clients serum potassium is 3.3

B

Which intervention would the nurse include in the plan of care for a client with Addison disease? a) encourage exercise b) protect from exertion c) restrict fluid intake d) monitor for hypokalemia

B

Which is the primary fluid shift that occurs with diabetes mellitus? a) intravacular to interstitial because of glycosuria b) interstitial to extracellular because of hypoproteinemia c) Intracellular to intravascular because of hyper osmolarity d) Intercellular to intravascular because of increased hydrostatic pressure

C

the ED nurse is caring for a client diagnosed w/HHNS who has BG of 680 mg/dL. which question should the nurse ask the client to determine the cause of this acute complication? a) when is the last time you took your insulin b) when did you eat last c) have you had any infections lately d) how long have you had diabetes

C

the client diagnosed w/type 2 diabetes is admitted to the intensive care unit w/hyperosmolar hyperglycemic nonketonic syndrome coma. which assessment data should the nurse expect the client to exhibit? a) kussmauls respirations b) diarrhea and epigastric pain c) dry mucous membranes d) ketone breath Odor

C

the nurse is discussing ways to present DKA w/the client diagnosed w/type 1 diabetes. which instruction is most important to discuss w/the client? a) refer the client to the American diabetes association b) do not take OTC meds c) take the prescribed insulin even when unable to eat d) explain the need to get annual flu and pneumonia vaccines

C

The nurse is reviewing the MAR of a client admitted with SIADH. Which medication order would the nurse question? a) furosemide b) Tolvaptan c) IV sodium chloride d) demeclocycline

C ( can worsen fluid overload)

The nurse is teaching a nursing student how to care for a pituitary adenoma. Which statement made by the student indicates effective learning? a) I will assess for bleeding b) I will monitor cardiac output c) I will monitor serum osmolarity d) I will assess for glucose levels in nasal discharge

C ( pt may experience diabetes insipidus post op)

The nurse is caring for a client hospitalized with SIADH. Which action performed by the nurse may result in a positive outcome? a) obtaining weekly weights b) elevating the head of the bed to 2.0 degrees c) changing the position of the client frequently d) restricting fluids

C ( skin integrity)

The home health nurse is educating a client with adrenal insufficiency regarding the disease process and medication safety. Which statement made by the client indicates a need for further teaching? a) I should not skip any doses of my meds b) It is important to never switch brands of meds c) I should weigh myself every day and report weight gain d) I only need a medical alert bracelet when in the hospital

D

the client diagnosed w/HHNS was admitted yday w/blood glucose level of 780 mg/dL.the client's blood glucose level is now 300 mg/dL. which intervention should the nurse implement a) increase the regular insulin drip b) check the urine for ketones c) provide the client with a meal d) notify the HCP to obtain an order to decrease insulin

D

Which clinical findings correspond with the secretion of ADH? SATA a) edema b) polyuria c) bradycardia d) muscle cramps e) hyponatremia

D, E

the client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. which intervention should the nurse implement first? a) administer 50% dextrose IVP b) notify the dr c) transfer to the ICU d) check the serum glucose level

A

The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.

ANS: 3. This is an example of autonomy (the client has the right to decide for himself).

The nurse is admitting a client to the neurological intensive care unit who ispostoperative transsphenoidal hypophysectomy. Which data warrant immediateintervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.

2. The output is more than double theintake in a short time. This clientcould be developing diabetes insipidus,a complication of trauma to the head.

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) day

1, 2, 4

The client is admitted to rule out Cushing's syndrome. Which laboratory testsshould the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells.

2

The charge nurse of an intensive care unit is making assignments for the night shift.Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requiresfrequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease withABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomytwo (2) days ago and has a negative Trousseau's sign.

3

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy.Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications asprescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-careprovider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should performevery (2) hours.

3

The nurse is developing a plan of care for the client diagnosed with acquiredimmunodeficiency syndrome (AIDS) who has developed an infection in the adrenalgland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.

4

The registered nurse teaches a student regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? a) administering sodium polystyrene sulfonate b) instructing a client to increase potassium and sodium intake c) monitoring glucose levels hourly d) providing potassium-sparing diuretics

A

The client is admitted to the unit with a diagnosis of rule out DI. Which instructions should the nurse teach regarding a fluid deprivation test? a) the client will be asked to drink 100mL of fluid as rapidly as possible and then will not be allowed fluids for 24 hours b) the client will be administered an injection of ADH and urine output will be measured for 4-6 hours c) the client will be NPO and vital signs and weights will be done hourly until the end of the test d) an IV will be started with normal saline and the client will be asked to try to hold the ursine until a sonogram can be done

ANS: C The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? SATA a) maintain adequate ventilation b) assess fluid volume status c) administer IV potassium d) check for urinary ketones e) monitor intake and output

All of the above