Med surg test 3
1. Which statement by a patient diagnosed with a primary thyroid disorder indicates the need for further teaching? A."Having a brain tumor is so scary." B. "My thyroid gland is not working." C. "Now I understand why the nurse keeps measuring my neck." D. "My energy level may be affected by this disorder."
A
2. A nurse is reviewing the laboratory client who might have findings for a hyperthyroidism. The nurse should identify an elevation which of the following substances as an indication that the client has this disorder A Triodothyronine B. Plasma-free metanephrine C Urine cortisol D. Urine osmolality
A
2. At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A Weight gain B. Fatigue C. Fragile skin D. Joint pain
A
A nurse in a client is teaching a client who has UC. Which of the following statements by the client indicated understanding of the teaching? A. i will plan on limiting my fiber intake B. i will restrict the fluid intake during meals C. i will switch to black tea instead of coffee D. i will try to eat three moderate to large meals a day
A
A nurse in a provider's office is assessing a client who has hypothyroidism and recently began treatment with thyroid hormone replacement therapy. Which of the following findings should indicate to the nurse that the client might need a decrease in the dosage of the medication? A. Hand tremors B. Bradycardia C. Pallor D. Slow speech
A
A nurse is assessing a client who has SIADH. Which of the following assessment findings indicate a dangerous complication of SIADH? A. rales to both lower lobes B. increased urine output C. sodium level of 140 D. diarrhea
A
A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure.? A. widened pulse pressure B. tachycardia C.periorbital edema D. decrease in urine output
A
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter
A
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.
A
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform? A. Keep the client in a side lying position B. Document the duration of the seizure C. Reorient the client to the environment D. Provide hygiene
A
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.
A
A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A. dysphagia B. positive Babinski sign C. decreased deep-tendon reflexes D. ataxia
A
A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger this? A. brownie with nuts B. bowl of mixed fruit C. grilled turkey D. baked potato
A
A patient arrives in the ICU with the diagnosis of cervical spine fracture at the C6 level after a car crash. The patient has no motor movement below the shoulders, is intubated on mechanical ventilation, and is receiving a continuous infusion of an alpha-receptor agonist and a fluid bolus of 1 liter normal saline. In planning care for this patient dur- ing the next 12 hours, the nurse should anticipate and prepare for: A. Bradycardia B. Hypervolemia C. Pulmonary edema D. Renal failure
A
A patient has been receiving doses of prednisone for treatment for RA for the past 3 months. If this med is suddenly stopped, for which complication is the patient at risk for? A. Hypovalemia B. Hypernatremia C. Hypoglycemia D. hyperglycemia
A
A patient has been receiving doses of prednisonefor treatment of rheumatoid arthritis for the past3 months. If this medication is suddenly discontinued, for which complication is the patient at risk? A. Hypovolemia B. Hypernatremia C. Hypothermia D. Hyperglycemia
A
For which of the following medical histories should the nurse be on the lookout for an abrupt onset of Diabetes insipidus? A. patient that is just postop from a transsphenoidal hypophysectomy B. patient that is just postop from a coronary artery bypass graft C. patient that just been diagnosed with atrial fibrillation with rapid ventricular response D. patient in diabetic ketoacidosis
A
In administering Orlistat to a patient for weight loss, the nurse recognizes which as the mechanism of action for this med? A. reduced fat absorption B. suppressing appetite C. Increased satiety D. accelerating metabolic rate
A
Increased secretion of ADH results in which action? A. Decreased urine output B. Increased urine output C. Decreased serum potassium D. Increased serum potassium
A
Restricting free water would be included in the nursing care for a patient with which of the following endocrine disorders? A. SIADH B. Addison's disease C. Pheochromocytoma D. low thyroid levels
A
The nurse assesses for which clinical manifestation in the patient with cholecystitis? A. Murphy's sign B. Trousseau's sign C. Cullen's sign D. Grey Turner's sign
A
The nurse assesses for which finding in a patient with a positive Cullen's sign? A. Periumbilical bruising B. Rebound tenderness C. RUQ pain with radiation to shoulder D. Flank bruising
A
The nurse correlates an increase in which laboratory value to the diagnosis of primary hyperthyroidism? A. Thyroxine (T4) B. Thyroid Stimulating Hormone (TSH) C. Serum calcium D. Serum iodine
A
The nurse correlates which clinical manifestation to the pathophysiology of decreased ACTH production from the anterior pituitary gland? A. Hypotension B. Polyuria C. Diarrhea D. Pruritus
A
The nurse correlates which laboratory value as an indication that desmopressin is effective in the treatment of diabetes insipidus (DI)? A. Serum sodium of 140 mEq/L B. Serum osmolality of 305 mOsm/kg C. Urine specific gravity of 1.004 D. Serum hematocrit of 48%
A
The nurse is caring for a patient status post craniotomy for resection of a right frontal tumor. Upon admission, the patient was alert and oriented X 3, moving all extremities symmetrically, and the cranial nerves were intact. Three hours after admission, the nurse notes that the patient is slower to awaken than during previous assessments, requiring vigorous shaking, and cannot recall location. The patient also exhibits a left pronator drift. What are the nurse's next actions? A. Notify the patient's provider and prepare the patient for a computed tomography (CT) scan. B. Record vital signs and prepare to draw blood for serum osmolality. C. Notify the patient's provider and prepare the patient for a magnetic resonance imaging (MRI) scan. D. Prepare to hang a fluid bolus and notify the patient's provider.
A
The nurse monitors for which effects of daily cortisol therapy on a patient's circulating levels of adrenocorticotropic hormone (ACTH) and aldosterone? A. Decreased ACTH, decreased aldosterone B. Decreased ACTH, increased aldosterone C. Increased ACTH, decreased aldosterone D. Increased ACTH, increased aldosterone
A
The nurse prioritizes which nursing diagnosis in the patient after partial parathyroidectomy? A. High risk for ineffective airway clearance related to hypocalcemia B. High risk for ineffective breathing pattern related to hypercalcemia C. High risk for hyperventilation related to hypersecretion of triiodothyronine D. High risk for airway compromise related to insufficient iodine stores
A
What pathophysiologic processes occur in the first stage, or the acute phase, of GBS? A. Peripheral nerve demyelination, edema, and inflammation B. Depolarization of the spinal nerves C. Destruction of the myelin-producing oligodendrocytes D. Regeneration of the myelin sheath
A
What substance is administered in a GH suppression test, which should lead to a decrease in GH levels as a normal findings? A. glucose B. Cortisol C. sodium D. albumin
A
While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia
A
You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. agraphia B. alexia C. hemianopia D. apraxia
A
You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as: A. Hemianopia B. Opticopsia C. Alexia D. Dysoptic
A
Which of the following bariatric surgeries does not lead to impaired absorption of nutrients from the duodenum? SATA A. gastric banding B. gastric sleeve C. Roux En Y bypass D. BPD, Bilopancreatic diversion
A, B
Which of the following clients data are a result of or are worse because of the clients weight gain? SATA A. painful knees B. hypertension C. sore back D. increased stress E. bloating after meals
A, B
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding? SATA A. i plan to eat small frequent meals B. i will eat easy to digest foods with limited spice C. i will use skim milk when cooking D. i plan to drink regular cola E. i will limit alcohol intake to two drinks her day
A, B, C
The nurse is reviewing triggers that can cause a seizure. Which of the following info should the nurse review? SATA A. Avoid overwhelming fatigue B. Remove caffeine C. Limit looking at flashing lights D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended
A, B, C
4. A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply.) A. Observe cardiac monitor for dysrhythmias B. Observe for evidence of urinary tract infection. C. Initiate IV fluids using 0.9% sodium chloride. D. Administer a levothyroxine IV bolus. E. Provide warmth using a heating pad.
A, B, C, D
A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? (Select all that apply.) A. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL D. Blood urea nitrogen (BUN) 28 mg/dL E. Fasting blood glucose 148 mg/dL
A, B, C, D
The nurse correlates which finding to a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH)? A. Polyuria B. Polyphagia C. Decreased urine output D. Glucosuria
A, B, C, D
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. What should the nurse do? SATA A. Provide privacy B. Ease the client to the floor C. Move furniture away D. Loosen the patient's clothes E. Protect he clients head F. Restrain the client
A, B, C, D, E
3. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) A. Have suction equipment available for use. B. Feed the client thickened liquids. C Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed.
A, B, C, E
A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for this client? (Select all that apply.) A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocyte count 35% E. Fasting glucose 145 mg/dl
A, B, C, E
Which of the following are true statements about migraine headaches? Select all that apply. A) Is related to poor posture. B) Starts with a prodromal phase and ends with a postdromal phase. C) Doing a headache diary may show triggers. D) Affects mostly men. E)Can debilitate a person for 72 hours.
A, B, C, E
4. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply) A. Headache B Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension
A, B, D
5.A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Monitor CBC. B. Monitor triiodothyronine (T). C. Instruct the client to increase consumption of shellfish. D. Advise the client to take the medication at the same time every day. E. Inform the client that an adverse effect of this medication is iodine toxicity.
A, B, D
A nurse in a critical care unit is completing an admission assessment following a GSW. Which of the following assessment findings are indicated for increased ICP? SATA A. headache B. dilated pupils C. tachycardia D. decorticated positioning
A, B, D
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? Select all that apply. A) headache B) constricted pupils C) bradycardia D) decorticate posturing E) hypotension
A, B, D
A nurse is caring for a client who has cirrhosis . Which of the following medications can the nurse expect to administer to the client? SATA A. Diuretic B. beta blockers C. opioid analgesics D. lactulose E. sedative
A, B, D
A nurse is planning care for a client who has Cushing's disease. The nurse should recognize that clients who have Cushing's disease are at increased risk for which of the following? (Select all that apply.) A. Infection B. Gastric ulcer C.Renal calculi D. Bone fractures E. Dysphagia
A, B, D
A nurse is planning care for a client who has bushings disease. The nurse should recognize the client who has this are at risk for which? SATA A. infection B. gastric ulcer C. renal calculi D. bone fractures E. dysphagia
A, B, D
A nurse is preparing to receive a client from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply.) A. Suction equipment B. Humidified oxygen C. Flashlight D. Tracheostomy tray E. Chest tube tray
A, B, D
For which of the following can lead to ICP? SATA A. hypoventilation B. tracheal suctioning C. positioned in high fowlers D. constipation E. positioning the patients head in a neutral position
A, B, D
. The nurse has received the following provider orders for a patient who was recently admitted to the emergency department with acute stroke symptoms and time of symptom onset of 70 minutes prior to presentation. Which actions are of highest priority in evaluating this patient and preparing to adminis- ter IV rt-PA? (Select all that apply.) A. Establish two peripheral intravenous catheters B. Check blood glucose C. Perform bedside swallow screen D. Check temperature E. Assist with transport of the patient to CT scan
A, B, E
4. A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A Speak to the client at a slower rate. B. Assist the client to use flash cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.
A, B, E
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply.) A Areas of paresthesia B Involuntary eye movements C. Alopecia D. Increased salivation E Ataxia
A, B, E
A nurse is teaching a client who has hep b about home care. Which of the following instructions should the nurse include in the teaching? SATA A. limit physical activity B. avoid alcohol C. take acetaminophen for comfort D. wear a mask when in public places E. eat small frequent meals
A, B, E
In caring for a patient with elevated secretion of triiodothyronine and thyroxine, the nurse assesses for which findings? (Select all that apply.) A. Increased heart rate B. Increased gastric motility C. Increased cholesterol D. Increased urine output E. Increased respiratory rate
A, B, E
Which of the following are clinical manifestations of pheochromocytoma? Select all that apply. A) headache B) palpitations C) hypoglycemia D hypotension E) tachycardia
A, B, E
1. A nurse is caring for a client who has syndrome of inappropriate tidiuretic hormone (SIADH). Which f the following findings should the nurse expect? (Select all that apply) A Decreased serum sodium B Urine specific gravity 1.001 C Serum osmolarity 230 mOsm/ D. Polyuria E. Increased thirst
A, C
For SIADH (syndrome of inappropriate antidiuretic hormone) you would expect which of the following? Select all that apply A) concentrated urine chemistry B) dilute urine chemistry C) dilute blood chemistry D) concentrated blood chemistry
A, C
The nurse correlates which assessment findings to the patient diagnosed with hyperaldosteronism? (Select all that apply.) A. Blood pressure, 160/90 mm Hg B. Heart rate, 60 bpm C. Potassium, 3.0 mEq/L D. Glucose, 250 mg/dL E. Sodium, 130 mEq/L
A, C
A nurse is assessing for the presence of Brudzinksis signs in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? SATA A. Place the client in supine position B. Flex the clients hips and knees C. Place hands behind the clients neck D. Bend clients head towards chest E. Straighten the clients flexed knees
A, C, D
A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following lab findings should the nurse expect? Select all that apply A)Na+ of 128 B)K+ of 5.3 C)increased urine osmolality D)high urine sodium E)decreased urine specific gravity
A, C, D
The nurse correlates which clinical manifestations to the pathophysiology of obesity? (Select all that apply.) A. Increased waist circumference B. Increased basal metabolic rate C. Binge eating D. Joint pain E. Yellowish skin
A, C, D
A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke: Select all that apply. A) confusion on date, time and place B) aphasia C) unilateral neglect D) impulsive E) short attention span
A, C, D, E
Which of the following foods promote bone health? SATA A. Egg yolks B. Orange slices C. Salmon D. Yogurt E. Broccoli
A, C, D, E
A nurse is collecting an admission history from a female client who has hypothyroidism. Which of the following findings should the nurse expect? Select all that apply. A)constipation B)weight loss C)hoarse, raspy voice D)increased libido E)slow thought processes and speech
A, C, E
The nurse recognizes which as a risk factor for cholecystitis? (Select all that apply.) A. Obesity B. Male C. Female D. African American E. Caucasian
A, C, E
Which of the following are age-related changes of the endocrine system in a 55-year-old female? Select all that apply. A) perineal and vaginal dryness B) increased libido C) insomnia D increased bone density E) elevated blood glucose and weight gain
A, C, E
A nurse is planning care for a client who has meningitis and is at risk for ICP. Which of the following actions should the nurse plan to take? SATA A. Implement seizure precautions B. Perform neuro checks 4 times a day C. Admin morphine for the report of neck pain D. Turn off room lights and TV E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently
A, D, E
During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable A) smoking B) family history C) advanced age D) obesity E) sedentary lifestyle
A, D, E
The nurse assesses for which clinical manifestations of dumping syndrome in the patient after bariatric surgery? (Select all that apply.) A. Nausea B. Increased urine output C. Hypoglycemia D. Diarrhea E. Abdominal cramping
A, D, E
The nurse monitors for which findings in the patient with hyperthyroidism? (Select all that apply.) A. Weight loss B. Cold intolerance C. Constipation D. Tachycardia E. Exophthalmos
A, D, E
Which specific risk do the results of the clients lab tests indicate? SATA A. T2DM B. renal disease C. Liver cirrhosis D. heart attached E. stroke
A, D, E
1. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) A impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E Lack of situational awareness
A, b, c, e
3. A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings should the nurse expect? (Select all that apply) A. Low sodium B. High potassium C Increased urine osmolality D. High urine sodium EI. ncreased urine specific gravity
A, c, d, e
What does mineralcorticoids test for?
Aldosterone, checks to see the levels in the blood
Secondary headaches
Arise from other conditions
1. A nurse is caring for a client who. asks why the provider bases his medication regimen on his HbA1c instead of his log of morning fasting blood glucose results Which of the following responses should the nurse make? A "HbA1c measures how well insulin is regulating your blood glucose between meals." B. "HbA1c indicates how well your have regulated your blood glucose over the past 120 days. C. "HbA1c is the first test your doctor prescribed to determine that you have diabetes." D. "HbA1c determines if the your doctor should adjust your insulin dosage."
B
1. Anurse is caring for a client Which of the following findings who has multiple sclerosis should the nurse expect? A Fluctuations in blood pressure B. LOSS of cognitive function C Ineffective cough D. Drooping eye lids
B
2. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B Place the bedside table on the right side of the bed C. Orient the client to the food on her plate using the clock method D. Place the wheelchair on the client's left side.
B
2A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? A Presence of glucose B. Decreased specific gravity C. Presence of ketones D. Presence of red blood cells
B
3. A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol. Which of the following information should the nurse include? A. "An adverse effect of this medication is jaundice." B."Take your pulse before each dose." C. "The purpose of this medication is to decrease production of thyroid hormone." D."You should stop taking this medication if you have a sore throat."
B
5. A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
B
A growth hormone suppression test would be done to diagnose which of the following endocrine disorders A. SIADH B. acromegaly C. Grave's disease D. pheochromocytoma
B
A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected for a client who has this condition? A. Elevated serum T4 B. Decreased serum T3 C.Elevated serum thyroid stimulating hormone D.Decreased serum cholesterol
B
A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Grave's disease. The nurse should identify that which of the following laboratory results is an expected finding? A. decreased thyrotropin receptor antibodies B. decreased thyroid-stimulating hormone C. decreased thyroxine index D. decreased triiodothyronine
B
A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves' disease. The nurse should identify that which of the following laboratory results is an expected finding? A. Decreased thyrotropin receptor antibodies B. Decreased thyroid-stimulating hormone (TSH) C. Decreased free thyroxine index D. Decreased triiodothyronine
B
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. reduced left-sided motor function B. difficulty with speech C. impulsive behavior D. neglect of the left side of the body
B
A nurse is assessing a client during a water deprevation state. What shoukd the nurse monitor for? A. Bradycardia B. Orthostatic hypotension C. Neck vein distention D. Crackles in lungs
B
A nurse is assessing a client who reports pins and needles sensation of their right hand. Which of the following terms should the nurse use to describe the sensations? A. Proprioception B. Paresthesia C. Dysesthesia D. Sprain
B
A nurse is assessing a client who reports severe HA and a stiff neck. The nurse assessment reveals positive Kerning's and Brudzinski's signs. Which of the following actions should the nurse perform? A. Admin antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights
B
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D.Administer antihypertensive medication.
B
A nurse is developing the care plan for a clientafter bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent? A. Fluid overload B. Wound infection C. Depression D. Anastomosis leak
B
A nurse is preparing to administer pancrelipase to a client who has pancreatitis. which of the following actions should the nurse take? A. instruct the client to chew the medication before swallowing it B. offer a glass of water following med admin C. admin the medication 30 min before meals D. sprinkle the contents on peanut butter
B
A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? A. sensory dysfunction B. weakness of the distal extremities C. decreased vision D. altered temperature regulation
B
A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is not eligible for thrombolytic therapy. The nurse recognizes that this patient is at a high risk for which complication? A. Delirium B. Aspiration C. Bronchospasm D. Palpitations
B
A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis
B
A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. vision problems B. balance impairment C. language difficulty D. impaired short-term memory
B
During the edrophonium or Tensilon test, a short- acting AChE inhibitor is administered intravenously, and the provider observes the patient for improvement in which function? A. Level of consciousness B. Muscle strength C. Muscle tone D. Hearing
B
In a patient with cirrhosis, the nursing diagnosis "risk for injury and bleeding related to prolonged clotting factors" is most appropriate related to which disorder? A. Pruritus B. Vitamin K deficiency C. Hyponatremia D. Ascites
B
In evaluating the therapeutic effects of vasopressin, the nurse monitors for which finding? A. Urine specific gravity of 1.050 B. Urine output of 30 to 50 mL/hr C. Serum sodium of 148 mEq/L D. Serum osmolality of 310 mOsm/kg
B
The most specific laboratory result in the patient with acute pancreatitis is an elevation in which laboratory value? A. Serum bilirubin B. Serum lipase C. Serum trypsin D. Serum lactase
B
The nurse correlates which rationale to the use of hyperventilation to decrease intracranial pressure in a patient after traumatic head injury? A. To maximize oxygenation B. To promote vasoconstriction C. To decrease cerebral perfusion D. To decrease ventilatory effort
B
The nurse incorporates the nursing diagnosis "Fluid volume deficit related to excessive secretion of vasopressin" in the plan of care for the patient with which disorder? A. Acromegaly B. Diabetes insipidus C. Hypopituitarism D. SIADH
B
The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis? A. Hypothyroidism B. Pheochromocytoma C. Diabetes insipidus D. Adrenal insufficiency
B
The nurse questions which order for a patient who has undergone transphenoidal hypophsectomy for a pituitary tumor? A. offer clear fluids once alert and oriented B. oxygen 2 L via NC C. maintain head of bed about 45-60 degrees D. apply lip balm as needed
B
The nurse questions which order in the patient who has undergone transsphenoidal hypophysectomy for a pituitary tumor? A. Offer clear fluids once alert and awake. B. Oxygen 2 L via nasal cannula. C. Maintain head of bed at 45 to 60 degree angle. D. Apply lip balm as needed.
B
The nurse recognizes which explanation as the pathophysiological basis for MG? A. There are an inadequate number of muscarinic receptors. B. Antibodies to AChRs block neuromuscular junction transmission. C. Thymomas are present in 80% of patients with MG. D. There is an abundance of ACh, which binds to viable receptors.
B
The nurse recognizes which patient is at greatest risk for adrenal insufficiency? A. A 19-year-old male B. A 35-year-old female C. A 45-year-old male D. An 80-year-old female
B
The patient experiencing DI is ordered to receive DDAVP. The nurse monitors for which therapeutic effect of these medications? A. Increased urine output B. Increased urine specific gravity C. Increased serum sodium D. Increased serum potassium
B
What is a leading cause of pancreatic cancer? A. Low-fat diet B. Smoking C. History of cancer D. Heart disease
B
Which position does the nurse place the patient in to minimize complications in the patient with OHS? A. Prone with hips elevated B. Head of bed elevated 30 to 45 degrees C. Side lying with head flat D. Head of bed elevated 90 degrees
B
Which statement by a patient diagnosed with liver trauma indicates understanding of the prescribed plan of care? A. "I will need a liver transplant." B. "I will need a blood transfusion." C. "I am at increased risk for infection." D. "I will never be able to drink alcohol again."
B
Which statement by the patient with MG indicates the need for further teaching? A. "My weakness will get worse when I exercise too much." B. "It is important that I take my medications 30 minutes before or after eating." C. "My eyes will get tired if I read too much." D. "I need to wait for 30 minutes after taking medication to eat or drink."
B
Which type of shock is exhibited in the patient with pancreatitis? A. Cardiogenic shock B. Hypovolemic shock C. Septic shock D. Hemorrhagic shock
B
You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30′. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.
B
A nurse is reviewing the serum lab date for a client who has an cute exacerbation of crohns disease. Which of the following lab tests should the nurse expect to be elevated? SATA A. Hct B. ESR C. WBC D. Folic acid E.Albumin
B, C
A nurse is providing discharge teaching to a client who is post of following open cholecystectomy with T tube placement. Which of the following instructions should the nurse include in the teaching? SATA A. take baths rather than showers B. clamp T tube for 1 hour before and after meals C. keep the drainage system above the level of the abdomen D. expect to have the t tube removed 3 days post op E. Report brown green drainage to the provider
B, C,
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? SATA A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Admin antipyretic medication D. Perform a skin assessment E. Keep the HOB elevated
B, C, D
A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply) A. Take the medication on an empty stomach. B. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness. D. Do not discontinue the medication suddenly E. Eat a low-sodium diet
B, C, D
A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Weight gain is expected while taking this medication. B. Medication should not be discontinued without the advice of the provider. C. Follow-up serum TSH levels should be obtained D.Take the medication on an empty stomach. E. Use fiber laxatives for constipation.
B, C, D
Which interventions should the nurse provide to a patient with a T-tube? (Select all that apply.) A. Routinely flush with preservative saline solution B. Routinely monitor drainage output Provide T-tube maintenance teaching to the patient C. Monitor stool for color and consistency D. Clamp the T-tube when the patient is sleeping
B, C, D
A nurse in an acute care facility is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse anticipate? (Select all that apply) A. IV therapy with 0.45% sodium chloride B Regular insulin C. Hydrocortisone sodium succinate D. Sodium polystyrene sulfonate E. Furosemide
B, C, D, E
2. A nurse is collecting an admission history from a female client who has hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply) A.Diarrhea B. Menorrhagia C. Dry skin D. Increased libido E. Hoarseness
B, C, E
3. A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply) A. Pain is bilateral across the posterior occipital area. B. Client experiences altered sleep-wake cycle. C. Headache occurs at approximately the same time of the day. D. Client describes headache pain as dull and throbbing. E. Nasal congestion and drainage occur
B, C, E
A nurse is assessing a client who has advanced cirrhosis. the nurse should identify which of the following findings as indicates of hepatic encephalopathy? SATA A. anorexia B. changes in orientation C. Asterixis D. ascities E. fector hepaticus
B, C, E
You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke: Select all that apply A) impulsive B) aphasia C) impaired math skills D) disoriented E) agraphia
B, C, E
3. A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener E Keep the client well hydrated.
B, D
3. The nurse correlates which effects to the stimulation of alpha receptors? (Select all that apply.) A. Increased heart rate B. Vasoconstriction C. Bronchiole relaxation D. Pupil dilation E. Increased gastrointestinal motility
B, D
A nurse is caring for a client who has closed head injury, with ICP ranging from 16-22. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? SATA A. suction the patient B. decrease the noise in the room C. elevate the clients head on 2 pillows D. admin a stool softer E. keep the client well hydrated
B, D
The nurse recognizes that which hormones are produced by the posterior pituitary gland? (Select all that apply.) A. ACTH B. Vasopressin C. Thyroid stimulating hormone D. Oxytocin E. Growth hormone
B, D
Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? Select all that apply. A) A patient with a CT scan that is negative. B) A patient whose blood pressure is 200/110. C) A patient who is showing signs and symptoms of ischemic stroke. D) A patient who received Heparin 24 hours ago.
B, D
You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A) TIAs are caused by a temporary decrease in blood flow to the brain. B) TIAs produce signs and symptoms that can last for several weeks to months. C) A TIAs is a warning sign that an impending stroke may occur. D) TIAs don't require medical treatment.
B, D
A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply.) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia
B, D, E
The nurse correlates which findings to age-related changes of the endocrine system in a 55-year-old female? (Select all that apply.) A. Breast enlargement B. Decreased libido C. Increased sweating D. Vaginal dryness E. Insomnia
B, D, E
The client is diagnosed with hyperthyroidism. Which of the following findings should the nurse expect? SATA A. dry skin B. heat intolerance C. consipation D. exopthalmos E. palpitations F. weight loss G. Low BP H. Bradycardia
B, D, E, F
Which hormones are released from the posterior pituitary gland? (Select all that apply). A. Aldosterone B. Antidiuretic hormone C. Follicle-stimulating hormone D. Luteinizing hormone E. Oxytocin
B, E
The nurse assesses for which clinical manifestations in the patient diagnosed with liver cancer? (Select all that apply.) A. Periumbilical pain B. Anorexia C. Hemoptysis D. Fatigue E. Jaundice
B,D,E
2. A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring. C."I should expect facial flushing when I take this medication." D."This medication will lower my sensitivity to food triggers."
C
2. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response
C
5. A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception
C
A nurse in a clinic is reviewing the lab reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. serum amylase 80 B. WBC out of 9000 C. direct bilirubin 2.1 D. alkaline phosphatase 25 units
C
A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. metered-dose inhaler B. continuous passive motion machine C. oral-nasal suction equipment D. external defibrillator pads
C
A nurse is assesing a client who has SIADH. Which of the following assessments indicates a dangerous complication of this? A. decrease central venous pressure B. Increase urine output C. distended neck veins D. extreme thirst
C
A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? A. tonic-clonic seizures B. report of a severe headache C. weakness of the lower extremities D. decreased level of consciousness
C
A nurse is assessing a client who has pancreatitis. which of the following actions should the nurse take to assess the presence of Cullens sign? A. tap lightly at the costovertebral margin on the clients back B. palpate the right lower quadrant C. inspect the skin around the umbilicus D. Auscultate the area below the scapula
C
A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurology status? A. vital signs B. body posture C. level of consciousness D. examination of pupils
C
A nurse is caring for a client who is 6 hr postoperative following a transsphenoidal hypophysectomy The nurse should test the client's nasal drainage for the presence of which of the following? A. RBCS B. Ketones C. Glucose D. Streptococci
C
A nurse is completing discharge teaching to a client who has seizures and receives vagal nerve stimulation. Which of the following statements should the nurse include in the teaching? A. It is safe to use a microwave of 1200 watts or less B. You should avoid the use of CT scans C. You should place a magnet over the implantable devise when you feel an aura coming D. It is recommended that you use US for pain management
C
A nurse is planning to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base her instructions to the client on which of the following? A. The ACTH stimulation test measures the response by the kidneys to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH. C. ACTH is a hormone produced by the pituitary gland. D. The client is instructed to take a dose of ACTH by mouth the evening before the test.
C
A nurse is providing discharge instructions to a female client who has been rx phenytoin. Which of the following info should the nurse include? A. Consider taking oral BC B. Watch for receding gums C. Take the med at the same time daily D. Provide urine samples to determine therapeutic levels
C
A nurse is reviewing the use of the MCV4 for the prevention of meningitis with a newly license nurse. Which of the following info should the nurse include? A. The vaccine is indicated to reduce the risk for respiratory infections B. The vaccine is administered in a series of 4 doses C. The vaccine is recommended for adolescents before starting school D. The vaccine is initially given at 2 months old
C
A nurse is teaching a client who has a new rx for sulfasalazine. Which of the following instructions should the nurse include in the teaching? A. Take the med 2 hours after eating B. discontinued this med if your skin turns yellow orange C. notify the provider if you experience a sore throat D. Expect your stool to turn black
C
A patient is admitted to the neuroscience intensive care unit (NICU) after a TBI. If the goal of ICP monitor insertion is to measure ICP and drain CSF to control ICP, what device should the nurse anticipate being inserted? A. Intraparenchymal sensor B. Epidural sensor C. Intraventricular catheter D. Subarachnoid bolt
C
A patient is undergoing a stimulation test to assess adrenal function. After the administration of cortisol, which laboratory result indicates normal function? A. Decreased blood glucose B. Decreased serum sodium C. Decreased serum potassium D. Decreased serum calcium
C
A patient undergoes bariatric surgery. Immediately following surgery in the post-anesthesia care unit, which intervention has the highest priority? A. Assessing the surgical site for signs of infection B. Educating the patient on postoperative dietary restrictions C. Monitoring respiratory status for signs of hypoventilation D. Repositioning the nasogastric tube for optimal drainage
C
A patient undergoes surgical resection of a thyroid tumor. Immediately following surgery, which intervention has the highest priority? A. Assessing the surgical site for hemorrhage B. Supporting the head to prevent stress on the suture line C. Monitoring respiratory status for sign of obstruction D. Asking the patient to speak to assess for hoarseness
C
A patient with a BMI of 37 kg/m2 asks a nurse about whether or not to have bariatric surgery. Which statement by the nurse is best? A. "Bariatric surgery is an option for patients with a BMI of 25 kg/m2." B. "Many patients have terrible complications from bariatric surgery." C. "Bariatric surgery in obese patients has been shown to increase life expectancy." D. "If you are unable to lose weight by dieting, bariatric surgery is the easy way out."
C
Elevated ammonia levels can lead to hepatic encephalopathy. Which provider order best reduces this risk in patients with cirrhosis? A. Administer furosemide and spironolactone. B. Administer antibiotics. C. Restrict protein intake. D. Restrict caloric intake.
C
Hypotonic IV fluids would be indicated for which of the following endocrine disorders? A. SIADH B. Grave's disease C. Diabetes Insipidus D. Cushing's syndrome
C
In evaluating a respiratory status in the patient with MG, the nurse correlates vital capacity measurement to which parameter? A. Amount of gas that the lungs can hold B. Amount of oxygen contained in the lungs C. Amount of air that can be forcibly exhaled after maximal inhalation D. Amount of oxygen that can be exhaled at a slow rate
C
In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of symptoms B. 24 hours after onset of symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours after the onset of symptoms
C
The nurse assesses for which of the following in the patient with hypersecretion of parathyroid hormone (PTH)? A. Increased serum sodium B. Increased serum glucose C. Increased serum calcium D. Increased serum potassium
C
The nurse correlates an increase in the secretion of which hormone as a result of the release of TRH? A. Triiodothyronine (T3) B. Thyroxine C. Thyroid stimulating hormone (TSH) D. Thyrocalcitonin
C
The nurse correlates respiratory compromise in GBS to which pathophysiological process? A. Decreased protein in the CSF B. Progressive limb weakness C Diaphragmatic weakness D. Decreased acetylcholine at the neuromuscular junction
C
The nurse correlates which finding to a diagnosis of SIADH? A. polyuria B. polyphagia C. decreased urine output D. glucosuria
C
The nurse is providing a patient with postopera- tive instructions following an adjustable gastric banding. Which information should be included in the education? A. Importance of vitamins due to malabsorption B. Small meals to prevent anastomosis leak C. Date and location of support group D. Instructions for injecting saline into the port
C
The nurse monitors for which preventable complica- tion in a patient hospitalized for treatment of obesity? A. Hyperventilation B. Tachycardia C. Skin breakdown D. Hypertension
C
The nurse monitors the patient with SIADH for which complication secondary to a serum sodium level of 120 mEq/L? A. Hypotension B. Hyperglycemia C. Seizures D. Bradycardia
C
The nurse receives report on a patient in the ICU with an SAH and clarifies that the date of the patient's initial bleed was 4 days before. The nurse needs this information to gauge the patient's risk of which complication of SAH? A. Hydrocephalus B. Aspiration C. Vasospasm D. Myocardial ischemia
C
The nurse recognizes which patient is at greatest risk for death secondary to stroke? A. A 36-year-old Caucasian male B. A 45-year-old Asian male C. A 56-year-old African American female D. A 62-year-old Hispanic female
C
The patient just diagnosed with acromegaly is scheduled for a transsphenoidal hypophysectomy. Which statement made by the patient indicates a need for clarification regarding this treatment? A. "I will get to drink fluids once I am awake after surgery." B. "I'm glad there will be no visible incision from this surgery." C. "I hope I can go back to wearing size 8 shoes instead of size 12." D. "I will wear slip-on shoes after surgery so I don't have to bend over."
C
What patient education is most important for the patient with trigeminal neuralgia prior to eating a meal? A. Avoid using a straw in beverages. B. Avoid brushing your teeth for 2 hours after a meal. C. Avoid iced beverages and ensure that food is soft and easy to chew. D. Close the door to provide privacy for meals.
C
Which action is critical when administering a pyridostigmine 60-mg tablet to a patient with MG? A. Administer with milk and crackers to minimize gastrointestinal distress. B. Administer 2 hours after meals because food slows gastric absorption. C. Administer 30 to 60 minutes before meals to optimize strength of the chewing and swallowing muscles. D. Administer with orange juice because vitamin C facilitates gastric emptying.
C
Which diagnostic result does the nurse assess in the patient with obesity to evaluate for concomitant Cushing's disease? A. Growth hormone B. Thyroid-stimulating hormone C. Urine cortisol excretion D. Hemoglobin A1c
C
Which is the initial and primary purpose of having the client start a food journal? A. pattern identifies B. renewed focus on self C. heightened awareness
C
Which of the following is a ball and socket joint? A. Elbow B. Knee C. Shoulder D. Wrist
C
Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.
C
Which safety measure is most important for the nurse to institute for a patient who has Cushing's (hypercortisolism) disease? A. Padding the siderails of the patient's bed B. Assisting the patient to change positions slowly C. Using a lift sheet to change the patient's position D. Keeping suctioning equipment at the patient's bedside
C
Which surgical approach is most effective for the patient with trigeminal neuralgia? A. Stereotactic radiosurgery B. Cervical decompression C. Microvascular decompression D. Percutaneous ablation
C
You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.
C
n reviewing admission orders for a patient admitted with SIADH, the nurse should question which order? A. IV 3% NS at 10 mL/hr B. Seizure precautions C. Sodium-restricted diet D. Fluid restriction of 1000 mL/day
C
5.A nurse is providing discharge reaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply.) A.Brush teeth after every meal or snack. B. Avoid bending at the knees. C. Eat a high-fiber diet D. Notify the provider of any sweet-tasting drainage. E. Notify the provider of a diminished sense of smell.
C, D
You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient: Select all that apply. A) Fill in the words for the patient they can't say. B) Don't repeat questions. C) Ask questions that require a simple response. D) Use a communication board. E) Discourage the patient from using words.
C, D
6.A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis? (Select all that apply.) A. Bradycardia B. Hypothermia C. Dyspnea D. Abdominal pain E Mental confusion
C, D, E
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22 (normal is 5-15). Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply. A) Suction the endotracheal tube frequently. B) Turn on the TV to provide background noise. C) Raise the head of bed to 45 degrees. D) Administer a stool softener. E) Limit fluid intake.
C, D, E
Cushing's Triad includes which of the following? Select 3. A) nausea and vomiting B) posturing C) low respiratory rate D) bradycardia E) widening pulse pressure
C, D, E
The nurse is monitoring a patient receiving rt-PA who develops a sudden headache. Which are the priority actions in evaluating this change in assessment? (Select all that apply.) A. Decrease the rate of the rt-PA infusion. B. Administer Tylenol for pain. C. Stop the rt-PA infusion. D. Notify the provider of the change. E. Perform a neurologic assessment.
C, D, E
Glucocorticoids checks for what?
Cortisol Which affects glucose, fat metabolism, and the bodies stress
4. A nurse is caring for a client who clarify with the provider? medications should the nurse types of prescribed injury 24 hr ago. Which of the experienced a cervical spine following A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants
D
4. A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache. B. Increase physical activity when a headache is present. C. Drink beverages that contain artificial sweeteners to prevent headaches D. Apply a cool cloth to the face during a headache.
D
4. Which patient statement indicates a need for further clarification regarding medications after a bilateral adrenalectomy? A. "I will take my cortisol replacement with food." B. "I will avoid aspirin and aspirin-containing products." C. "If I have any kind of stress, I will need my cortisol dose increased." D. "If I have nausea or vomiting, I will skip the medication until is it resolved."
D
A nurse in a medical surgical unit is admitting a client who has Hep B and ascites. Which of the following actions should the nurse include in the plan of care? A. initiate contact precautions B. weight the client weekly C. measure abd girth above the umbilicus D. provide a high calorie, high carbohydrate diet
D
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hour. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? A. BUN B. Blood Glucose C. Urine Ketones D. Specific Gravity
D
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D.Respiratory compromise
D
A nurse is caring for a client who has a new diagnosis of Hep C. which of the following lab findings should the nurse expect? A. presence of IgG B. Positive EIA test C. AST level of 35 units D. Alanine aminotransferase of 15
D
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. pain in RUQ radiation to the right shoulder B. report of pain being worse when sitting up C. pain relived with defecation D. epigastric pain radiation to the left shoulder
D
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to report? A. history of cholelithiasis B. elevated serum amylase level C. Decreased in bowel sounds upon auscultation D. hand spasms present when blood pressure is checked
D
A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches Which of the following questions should the nurse ask to identify the findings of migraine headaches? A. "Do the headaches occur at the same time each day?" B. "ls your headache accompanied by profuse facial sweating?" C."Does your headache occur on one side of your head?" D."Is there a pattern of headaches among family members?"
D
A nurse is planning care for a client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan of care? A. Maintain the client in low-Fowler's position. B. Encourage deep breathing and coughing. C. Encourage the client to brush his teeth when awake and alert. D. Observe dressing drainage for the presence of glucose.
D
A nurse is planning care for a patient who has acromegaly and is post op following transphenoidal hypophysecomy. Which of the following interventions should the nurse include in the plan of care? A. maintain the client in low fowlers B. encourage deep breathing and coughing C. encourage the client to brush his teeth when awake and alert D. observe the dressing for drainage of glucose
D
A nurse is planning care for client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy Which of the following interventions should the nurse include in the plan? A. Maintain the client in a low-Fowler's position. B Encourage deep breathing and coughing. C. Encourage the client to brush his teeth when awake and alert. D.Observe dressing drainage for the presence of glucose
D
A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? A. A TIA can cause irreversible hemipareis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.
D
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A. "I can drink up to 2 quarts of fluid a day." B. "I will need to use insulin to control my blood glucose levels. C. "I should expect to gain weight during this illness." D."Muscle weakness is a symptom of diabetes insipidus."
D
A nurse is providing teaching to the family of a client who has stage 2 Alzheimer's disease. Which of the following information should the nurse include in the teaching? A. Place abstract pictures on the wall in the client's room. B. Provide music for the client using headphones. C. Reorient the client to reality frequently. D. Limit choices offered to the client.
D
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A "This medication will help you with your tremors." B"This medication will help you with your bladder function." C."This medication may cause your skin to bruise easily." D This medication may cause you to experience weakness.
D
Another name for vasopressin is which of the following? A. aldosterone B. cortisol C. thyroxine D. antidiuretic hormone
D
The benefit of a M2A test is that it is best visualized which of the following? A. Liver B. Stomach C. sigmoid colon D. Small intestine
D
The nurse admitting a patient with acute pancreatitis correlates this disease process with which etiology? A. Inflammation secondary to toxic substances B. Abuse of alcohol C. Destruction of the pancreas by viruses D. Digestion of the pancreas by enzymes
D
The nurse correlates an increase in the secretion of cortisol to an increase in the release of which of the following hormones? A. Growth hormone B. Epinephrine C. Corticotropin-releasing hormone D. Adrenocorticotropic hormone
D
The nurse correlates which clinical manifestation to cholecystitis? A. Retroperitoneal pain B. Absence of bowel sounds C. Diarrhea D. RUQ pain
D
The nurse correlates which clinical manifestation to the pathophysiology of adrenal insufficiency? A. Heat intolerance B. Weight gain C. Peripheral edema D. Hypoglycemia
D
The nurse is caring for a 78-year-old patient S/P traumatic brain injury resulting from a fall. Which of the following provider orders should the nurse question? A. Raise the head of bed up > 30 degrees B. Observe for any clear fluid drainage from nose or ears C. Colace 200 mg. po daily D. IV fluids of D5W at 100 mL/hour
D
The nurse receives a patient from the operating room after he undergoes a Whipple's procedure. The nurse understands that the patient has which disorder? A. Acute pancreatitis B. Peritonitis C. Cholecystitis D. Pancreatic cancer
D
The nurse recognizes which class of medications as most effective in the management of trigeminal neuralgia? A. Anticholinergics B. Antihistamines C. Antibiotics D. Antiepileptics
D
The nurse should question the administration of which medication in the patient admitted with cholecystitis? A. Acetaminophen B. Demerol C. Ibuprofen D. Morphine
D
The nursing diagnosis "acute pain related to ureteral pressure and obstruction secondary to calcium- containing renal stones" is most appropriate for the patient with which endocrine disorder? A. Hypothyroidism B. Hypoparathyroidism C. Hyperthyroidism D. Hyperparathyroidism
D
The patient with MG needs to be educated about medications that should be avoided because they can increase weakness. Which medication should the patient avoid? A. Acetaminophen B. Prednisone C. Azathioprine D. Maalox
D
When providing patient teaching about plasma- pheresis to a patient with MG, the nurse explains that the purpose of the procedure is which result? A. Reduce the levels of calcium and magnesium in the blood B. Remove excessive acetylcholinesterase from the plasma C. Deliver deficient proteins directly into the blood D. Remove ACh receptors antibodies from the blood
D
Which assessment maneuver is contraindicated in the patient suspected of having a pheochromocytoma? A. Having the patient attempt to touch the chin to the chest B. Inflating the blood pressure cuff above 200 mm Hg C. Attempting to dorsiflex the feet D. Palpating the abdomen
D
Which statement by the patient being discharged after gastric bypass surgery indicates the need for further teaching? A. "I may need to take a multivitamin every day." B. "I may develop constipation while I am taking pain medications." C. "I should not lift anything heavy until cleared by the surgeon." D. "I should drink at least one cup of fluids with every meal."
D
Match the clinical manifestation as to whether it is found in diabetes insipidus (DI) or syndrome of inappropriate antidiuretic hormone (SIADH) increased urine specific gravity decreased blood pressure increased hematocrit decreased sodium
DI: decreased BP Increase hematocrit SIADH: increase urine specific gravity decrease sodium
What is Cretinism?
Developed during infancy retardation of mental and physical growth
What 2 labs will be assessed for hypothyroidism?
Elevated cholesterol and anemic
Etiology of hyper adrenal medulla?
Genetic
methimazole is used for which?
Graves disease
Match the etiology to the nervous system disorder. Myasthenia Gravis meningitis embolic stroke seizures autoimmune bacterial, viral or fungal infection atrial fibrillation fever > 105 in a child
MG- autoimmune embolic stroke- a fib seizure- fever
What 2 hormones are secreted by the posterior pituitary?
Oxytocin ADH
Hyperthyroidism
T3 will be high
Match the gland to the hormone it produces. antidiuretic hormone TSH - thyroid stimulating hormone
TSH - Anterior pituitary ADH- Posterior pituitary
Match the diagnostic test used to the nervous disorder. multiple sclerosis Myasthenia Gravis
Tensilon test: MG MRI: MS
Match the clinical manifestations to the nervous system disorder: Multiple Sclerosis Parkinson's disease Guillain-Barre Syndrome meningitis nuchal rigidity bradykinesia and masklike expression Uhthoff's sign symmetrical ascending motor weakness and paralysis
Uhthoff sign: MS
Who is at greatest risk for hypothyroidism?
Women aged 40-50
Neurotransmitters
acetylcholine and serotonin
PNS (peripheral nervous system)
cranial nerves and spinal nerves
Match the medication to the neurosensory disorder it treats. cerebral edema myasthenia gravis glaucoma Parkinson's Disease timolol mannitol pyridostigmine (Mestinon) benztropine
edema: mannitol MG: pyridostigmine glaucoma: timolol parkinsons: Benztropine
adrenal medulla
epinephrine and norepinephrine
cephalgia
headache. Pain from dilation of cerebral arteries
What can cause hypothyroidism?
iodine deficiency, hoshimotos disease, use of lithium and amiodorone
Treatment for adrenal medulla dysfunction
meds to control HR and BP Adrenalectomy
Primary headaches
migraine, tension, cluster, and chronic daily headaches
Endoogenous cause of cushings
some cancers
Exogenous cause of cushings
steroid therapy
