MS 1
If a client experienced a cerebrovascular accident (CVA) that damaged the thalamus, the nurse would anticipate that the client has problems with: a. Pain sensation b. Breathing pattern c. Wakefulness d. Thinking and reasoning
a. Pain sensation
A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? a. Ulcerative colitis b. Blood dyscrasia c. Intestinal obstruction d. Spinal cord injury
c. Intestinal obstruction
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate? a. A gelatin dessert b. Yogurt c. orange d. peanuts
a. A gelatin dessert
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a. A positive Tensilon test b. Kernig's sign c. A positive sweat chloride test d. Brudzinski's sign
a. A positive Tensilon test
A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a. Hypoxia b. fever c. visual disturbance d. gait alteration
a. Hypoxia
For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis which one of the following nursing interventions would be appropriate? a. Institute seizure precautions b. Weigh the child twice per shift c. Encourage the child to eat protein-rich foods d. Relieve boredom through physical activity
a. Institute seizure precautions
In the oliguric phase of acute failure, the nurse should anticipate the development of which of the following complications? a. Pulmonary edema b. Metabolic alkalosis c. Hypotension d. Hypokalemia
a. Pulmonary edema
The nurse is assessing a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? a. Vision changes b. Absent DTR c. Tremors at rest d. Flaccid muscles
a. Vision changes
If a client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control b. balance and equilibrium c. visual acuity d. thinking and reasoning
a. body temperature control
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent? a. succinylcholine (Anectine) b. vecuronium (Norcuron) c. pancuronium (Pavulon) d. atracurium (Tracrium)
a. succinylcholine (Anectine)
The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with: a. thyroid disorders b. poor nutrition c. chemotherapy d. a viral infection
a. thyroid disorders
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? a. "Avoid taking daytime naps." b. "Avoid hot baths and showers." c. "Limit your fruit and vegetable intake." d. "Restrict fluid intake to 1,500 ml/day."
b. "Avoid hot baths and showers."
A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis when communicated? a. "My partner's breathing rate is usually below 12" b. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with" c. "It seems our sex life is nonexistent over the past 6 months" d. "In the morning and evening I hear complaints that reading is next to impossible from blurred print"
b. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with"
The client with chronic renal failure complains of feeling nauseated every day. The nurse should explain that the nausea is the result of: a. Acidosis caused by the medications. b. Accumulation of waste products in the blood. c. Chronic anemia and fatigue. d. Excess fluid load.
b. Accumulation of waste products in the blood
A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPDP) program. The nurse should explain that the major advantage of this approach is that it: a. Is relatively low in cost. b. Allows the client to be more independent. c. Is faster and more efficient than standard peritoneal dialysis. d. Has fewer potential complications than standard peritoneal dialysis.
b. Allows the client to be more independent.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following signs and symptoms would indicate that the client has developed a complication after the cystoscopy? a. Dizziness b. Chills and fever c. Pink-tinged urine d. Bladder spasms
b. Chills and fever
Which of the following assessment data would most likely be related to a client's current complaint of stress incontinence? a. The client's intake of 2 to 3 L of fluid per day b. The client's history of three full-term pregnancies c. The client's age of 45 years d. The client's history of competitive swimming
b. The client's history of three full-term pregnancies
A nurse is caring for clients having a common theme of knowledge deficit related to the needs for teaching to prevent pyelonephritis. This concept is not commonly related to which of the following? a. A bedridden grandmother, with an indwelling catheter b. A toddler with a history of vesicoureteral reflux c. A 28-year-old, sexually active man d. A woman who has been treated for urinary tract infection and retention
c. A 28-year-old, sexually active man
A male client presents to the emergency department with complaints of fatigue, anorexia, nausea, and vomiting, and states that his urine is coffee-colored. The nurse notes periorbital edema, and the blood pressure is elevated. The nurse suspects the client is experiencing a. nephrotic syndrome b. bladder cancer c. AGN d. polycystic kidney disease
c. AGN
The nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the plan of care to reduce ICP? a. Encourage coughing and deep breathing b. Position with head turned toward side of brain tumor c. Administer stool softeners d. Provide sensory stimulation
c. Administer stool softeners
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? a. Ask family members to dress the client b. Encourage the client to dress more quickly c. Allow the client the time needed to dress d. Demonstrate methods on how to dress more quickly
c. Allow the client the time needed to dress
An increase in BUN and creatinine levels in clients with renal failure is known as: a. Encepalopathy b. Asterixis c. Azotemia d. Uremic frost
c. Azotemia
The nurse observes a comatose client's response to painful stimuli. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. This type of posturing as a response to pain indicates which of the following? a. Dysfunction in the cerebrum b. Risk for increased intracranial pressure c. Dysfunction in the brain stem d. Dysfunction in the spinal column
c. Dysfunction in the brain stem
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? a. Diencephalon b. Medulla c. Midbrain d. Cortex
c. Midbrain
After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? a. Give him a barbiturate b. Place him on mechanical ventilation c. Perform a lumbar puncture d. Elevate the head of his bed
c. Perform a lumbar puncture
Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The nurse should anticipate that the doctor will order which of the following medication to treat this medical emergency? a. Epinephrine b. Dilantin c. Valium d. Calcium gluconate
c. Valium
The nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XI (spinal accessory), the nurse should instruct the client to: a. smell and identify a nonirritating, aromatic odor b. read an eye chart from a distance of 20′ c. elevate the shoulders, both with and without resistance d. stick out the tongue and move it rapidly from side to side and in and out
c. elevate the shoulders, both with and without resistance
Damage to which area of the brain results in receptive aphasia? a. Parietal lobe b. Occipital lobe c. Temporal lobe d. Frontal lobe
d. Frontal lobe
Following a diagnosis of acute glomerulonephritis in their 6 year-old child, the parents remark: "We just don't know how he caught the disease!" The nurse's response is based on an understanding that: a. AGN is a streptococcal infection that involves the kidney tubules b. The disease is easily transmissible in schools and camps c. The illness is usually associated with chronic respiratory infections d. It is not "caught" but is a response to a previous B-hemolytic strep infection
d. It is not "caught" but is a response to a previous B-hemolytic strep infection
The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true? a. It may be mixed with other drugs in an infusion. b. It should be administered in a small vein to minimize irritation. c. It rarely causes adverse reactions. d. It should be administered no faster than 5 mg/minute in an adult.
d. It should be administered no faster than 5 mg/minute in an adult.
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? a. Pain related to vertigo b. Imbalanced nutrition: Less than body requirements related to nausea and vomiting c. Risk for deficient fluid volume related to vomiting d. Risk for injury related to vertigo
d. Risk for injury related to vertigo
During recovery from a cerebrovascular accident (CVA), a client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: a. cranial nerves I and II b. cranial nerves III and V c. cranial nerves VI and VIII d. cranial nerves IX and X
d. cranial nerves IX and X
The nurse is collecting data from a hospital patient who has been admitted with pyelonephritis. He is acutely ill with a high fever, chills, nausea, and vomiting. He also has severe pain in the flank area. The primary goal of his treatment is to: a. provide adequate nutrition with a stable body weight b. provide adequate hydration with pulse and blood pressure within patient norms c. give pain relief with analgesics and antispasmodics d. prevent further damage to his kidneys that could lead to renal failure
d. prevent further damage to his kidneys that could lead to renal failure
When the 16-year-old patient with acute glomerulonephritis complains of boredom with bed rest and asks when he can become more active, the nurse states that bed rest will continue until: a. dialysis starts b. antibiotic protocol is completed c. potassium levels are normal d. the blood pressure reaches normal levels
d. the blood pressure reaches normal levels
Which of the following is the most significant sign of peritoneal infection? a. Cloudy dialysate fluid b. Poor drainage of the dialysate fluid c. Swelling in the legs d. Redness at the catheter insertion site
a. Cloudy dialysate fluid
The nurse initiates the client's first hemodialysis treatment. The client develops a headache, confusion and nausea. These symptoms indicate which of the following potential complications? a. Disequilibrium syndrome b. Myocardial infarction c. Air embolism d. Peritonitis
a. Disequilibrium syndrome
To assess a client's cranial nerve function, the nurse should: a. Assess hand grip b. Assess orientation to person, time, and place c. Assess arm extension d. Assess winking
d. Assess winking
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority? a. Disturbed sensory perception (visual) related to neurologic trauma b. Self care deficient: Feeding related to neurologic trauma c. Impaired verbal communication related to confusion d. Risk for injury related to neurologic deficit
d. Risk for injury related to neurologic deficit
A fluid challenge of 250 ml of NS infused over 15 minutes is ordered on a client with suspected acute renal failure. The reason for this is: a. Promote the transfer of intravascular fluid to the intracellular space b. Increase cardiac output and fluid volume c. Dilute the level of waste products in the intravascular fluid d. Rule out dehydration as the cause of oliguria
d. Rule out dehydration as the cause of oliguria
A client, newly diagnosed with chronic renal failure, has recently begun hemodialysis. The nurse, establishing the client's plan of care, includes monitoring the client for disequilibrium syndrome. Which of the following symptoms will the nurse assess the client for? a. Headache, nausea and vomiting, altered level of consciousness, and hypotension b. Headache, nausea and vomiting, altered LOC, and hypertension c. Muscle cramps, seizure activity d. Chills, fever, shortness of breath
a. Headache, nausea and vomiting, altered level of consciousness, and hypotension
A client with nephrotic syndrome is being admitted to the unit. The nurse includes which of the following in planning the care for this client? a. Interventions for client with generalized edema b. Interventions for frank blood loss through urine c. Interventions for polyuria and fluid volume deficit d. Interventions for cardiovascular effects including hypotension
a. Interventions for client with generalized edema
What is the function of cerebrospinal fluid (CSF)? a. It cushions the brain and spinal cord b. It acts as an insulator to maintain a constant spinal fluid temperature c. It acts as a barrier to bacteria d. It produces cerebral neurotransmitters
a. It cushions the brain and spinal cord
Family members would like to bring in birthday cake for a client with nerve damage. What cranial nerve needs to be functioning so the client can chew? a. Cranial nerve II b. Cranial nerve V c. Cranial nerve IX d. Cranial nerve X
b. Cranial nerve V
In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation? a. Decreased heart rate b. Increased restlessness c. Increased blood pressure d. Decreased level of consciousness
b. Increased restlessness
What is the most potentially dangerous complication of peritoneal dialysis? a. Abdominal pain b. Peritonitis c. Gastrointestinal bleeding d. Muscle cramps
b. Peritonitis
While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? a. The client may be less sensitive to the effects of a neuromuscular blocking agent. b. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. c. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. d. Pancuronium and succinylcholine both require cautious administration.
d. Pancuronium and succinylcholine both require cautious administration.
A nurse is caring for a client with intracranial aneurism. The nurse interprets that which of the following is related to dysfunction of cranial nerve III? a. Mild drowsiness b. Less frequent spontaneous speech c. Slight slurring of speech d. Ptosis of the left eyelid
d. Ptosis of the left eyelid
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? a. Imbalanced nutrition: Less than body requirements b. Ineffective airway clearance c. Impaired urinary elimination d. Risk for injury
b. Ineffective airway clearance
Which of the following symptoms would most likely indicate pyelonephritis? a. Ascites b. Polyuria c. CVA tenderness d. Nausea and vomiting
c. CVA tenderness
When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a. shock b. encephalitis c. increased intracranial pressure d. status epilepticus
c. increased intracranial pressure
After completion of peritoneal dialysis, the nurse should expect the client to exhibit which of the following characteristics? a. Hematuria b. Hypertension c. Weight loss d. Increased urine output
d. Increased urine output
A patient is admitted to the hospital with a diagnosis of acute renal failure. The nurse understands that which of the following explanations is the MOST accurate description of the patient's condition? a. A sudden loss of kidney function due to failure of the renal circulation or to glomerular or tubular damage. b. A progressive deterioration in renal function that ends fatally when uremia develops. c. An inflammation of the renal pelvis, tubules, and interstitial tissues of one or both kidneys. d. An inflammation process precipitated by chemical changes in the renal glomeruli of both kidneys.
a. A sudden loss of kidney function due to failure of the renal circulation or to glomerular or tubular damage.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? a. Observe for edema proximal to the site b. Palpate for a thrill over the fistula c. Irrigate with 5 mls of 0.9% Normal Saline d. Check color and warmth in the extremity
b. Palpate for a thrill over the fistula
A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome
b. Powerlessness
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? a. Follow-up on lab values before the visit b. Observe client findings for the effectiveness of antibiotics c. Ask for a log of urinary output d. As for the log of the oral intake
c. Ask for a log of urinary output
The nurse is performing a mental status examination on a client diagnosed with subdural hematoma. This test assesses which of the following? a. Cerebellar function b. Intellectual function c. Cerebral function d. Sensory function
c. Cerebral function
A client is having tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed b. Restrain the client's arms and legs c. Place a tongue blade in the client's mouth d. Take measures to prevent injury
d. Take measures to prevent injury
When communicating with a client who has sensory (receptive) aphasia, the nurse should: a. Allow time for the client to respond b. Speak loudly and articulate clearly c. Give the client a writing pad d. Use short, simple sentences
d. Use short, simple sentences
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: a. Electromyography b. Doppler scanning c. Doppler ultrasonography d. Electroencephalogram
a. Electromyography
The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 lb in dat. Based on these data, which of the following nursing diagnoses is appropriate? a. Excess fluid volume related to the kidney's inability to maintain fluid balance. b. Ineffective breathing pattern related to fluid in the lungs. c. Ineffective tissue perfusion related to interrupted arterial blood flow. d. Ineffective therapeutic regimen management related to lack of knowledge about therapy.
a. Excess fluid volume related to the kidney's inability to maintain fluid balance.
A client with seizures disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction? a. Excessive gum tissue growth b. Drowsiness c. Hypertension d. Tinnitus
a. Excessive gum tissue growth
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes absence of a bone flap at the operative site. How should the nurse position the client's head? a. Flat b. Turned onto the operative side c. Elevated no more than 10 degrees d. Elevated 30 degrees
d. Elevated 30 degrees
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client? a. Lung auscultation and measurement of vital capacity and tidal volume b. Evaluation for signs and symptoms of increased intracranial pressure c. Evaluation of pain and discomfort d. Evaluation of nutritional status and metabolic state
a. Lung auscultation and measurement of vital capacity and tidal volume
The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure? a. High-carbohydrate, high protein b. Low-protein, low-sodium, low-potassium c. High-calcium, high-potassium, high-protein d. Low-protein, high-potassium
b. Low-protein, low-sodium, low-potassium
In addition to nausea and severe flank pain, a female client with renal calculi complains of pain in the groin and bladder. The nurse should determine that these symptoms most likely result from which of the following? a. Nephritis b. Referred pain c. Urine retention d. Additional stone formation
b. Referred pain
If disequilibrium syndrome occurs during dialysis which of the following would be the priority nursing action? a. Administer oxygen per nasal cannula b. Slow the rate of dialysis c. Reassure the client that the symptoms are normal d. Place the client Trendelenburg's position
b. Slow the rate of dialysis
The nurse teachers the client how to recognize signs and symptoms of infection in the shunt by telling the client to assess the shunt each day for : a. Absence of a bruit b. Sluggish capillary refill time c. Coolness of the involved extremity d. Swelling at the shunt site
b. Sluggish capillary refill time
The nurse admits a 50 year-old client with a 3 day history of fever, flank pain, and elevated blood pressure. Which of the following data obtained in the admission interview alerts the nurse that this may be acute glomerulonephritis? a. Travel to a foreign country b. Sore throat 3 weeks ago c. DM1 since age 15 d. History of mild hypertension
b. Sore throat 3 weeks ago
The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? a. Give the medication on an empty stomach c. Schedule the medication before meals b. Warn the client that he'll experience mouth dryness d. Administer the medication for complaints of muscle weakness or difficulty swallowing
b. Warn the client that he'll experience mouth dryness
The patient on dialysis asks why he is receiving aluminum hydroxide gel (Amphojel) for his renal disorder. The nurse explains that Amphojel will: a. calm the frequent upset stomach experienced by dialysis patients b. bind with phosphorus to increase the serum calcium level c. increases appetite d. correct the pH of the bowel
b. bind with phosphorus to increase the serum calcium leve
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: a. hold the client's arm still to keep him from hitting anything b. carefully move him to a flat surface and turn him on his side c. allow him to remain in the chair but move all objects out of his way d. place an oral airway in his mouth to maintain an open airway
b. carefully move him to a flat surface and turn him on his side
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath b. rest in an air-conditioned room c. increase the dose of muscle relaxants d. avoid naps during the day
b. rest in an air-conditioned room
If the nurse notes cloudy drainage 2 days post insertion of a Tenckhoff catheter for peritoneal dialysis, what other data does the nurse need to collect before reporting this finding? a. bowel sounds b. temperature c. breath sounds d. urine output
b. temperature
The nurse includes in the discharge teaching of a patient who has had a lithotripsy that the patient should: a. check for edema of the legs and ankles b. watch for stone debris in the urine in 1 to 4 weeks c. decrease fluid intake to 1000 mL/day d. remain on restricted activity for a week
b. watch for stone debris in the urine in 1 to 4 week
During the client's dialysis, the nurse observes that the solution draining from the abdomen is consistently blood-tinged after several exchanges. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct? a. Bleeding is expected with a permanent peritoneal catheter b. Bleeding indicates abdominal blood vessel damage c. Bleeding can indicate kidney damage d. Bleeding is caused by too-rapid infusion of the dialysate
c. Bleeding can indicate kidney damage
During peritoneal dialysis, the nurse notes that the outflow is less than the inflow. What should the nurse do? a. Notify the physician b. Reposition the dialysis catheter c. Change the client's position d. Irrigate the catheter with 30 ml of saline
c. Change the client's position
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and a. Increased retention of albumin in the vascular system c. Fluid shift from interstitial spaces into the vascular space b. Decreased colloidal osmotic pressure in the capillaries d. Reduced tubular reabsorption of sodium and water
c. Fluid shift from interstitial spaces into the vascular space
The client with acute pyelonephritis wants to know the possibility of developing chronic pyelonephritis. The nurse's response is based on knowledge that which of the following disorders most commonly leads to chronic pyelonephritis? a. Acute pyelonephritis b. Acute renal failure c. Recurrent urinary tract infections d. Glomerulonephritis
c. Recurrent urinary tract infections
While performing a dialysate exchange for a client on peritoneal dialysis, which finding would alert the nurse that the client has developed an acute complication? a. Pulse 86 and blood pressure 112/74 b. Client sleeps throughout fluid exchange c. Respiration rate of 30 with rales d. Catheter dressing saturated with clear fluid
c. Respiration rate of 30 with rales
Which of the following groups of laboratory test is most important for assessing the client's renal status? a. Serum sodium and potassium levels b. Arterial blood gases and hemoglobin c. Serum blood urea nitrogen and creatinine levels d. Urinalysis and urine culture
c. Serum blood urea nitrogen and creatinine levels
A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes Benztropine (Cogentin), 0.5 mg P.O. daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take Benztropine? a. "I take the medication when I get up in the morning" b. "I take the medication with a meal" c. "I take the medication after a meal" d. "I take the medication at bedtime"
d. "I take the medication at bedtime"
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." c. "It must be hard to accept the permanency of your paralysis." d. "You'll first regain use of your legs and then your arms."
d. "You'll first regain use of your legs and then your arms."
A client has renal colic due to renal calculi. What is the nurse's first priority in managing care for this client? a. Do not allow the client to ingest fluids b. Encourage the client to drink at least 500 ml of water each hour. c. Request the central supply department to send supplies for straining urine. d. Administer an opioid analgesic as prescribed.
d. Administer an opioid analgesic as prescribed.
The client asks the nurse, "How did I get this urinary tract infection? " The nurse should explain that in most instances, cystitis is caused by : a. Congenital strictures in the urethra b. Urinary stasis in the urinary bladder c. An infection elsewhere in the body d. An ascending infection from the urethra
d. An ascending infection from the urethra
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the following signs first? a. Pupillary asymmetry b. Irregular breathing pattern c. Involuntary posturing d. Declining level of consciousness
d. Declining level of consciousness
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? a. Warm, dry skin b. Urine output of 40 ml/hour c. Soft, nondistended abdomen d. Even, unlabored respirations
d. Even, unlabored respirations
Which of the following factors would put the client at increased risk for pyelonephritis? a. History of hypertension b. Fluid intake of 2,000 ml/day c. Increase intake of cranberry juice d. History of diabetes mellitus
d. History of diabetes mellitus
The nurse formulates a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a cerebrovascular accident (CVA) after surgery. When developing expected outcomes, the nurse incorporates assessment of the client's temperature to detect abnormalities. The thermoregulatory centers are located in which part of the brain? a. Pons b. Cerebellum c. Temporal lobe d. Hypothalamus
d. Hypothalamus
A client with a history of chronic cystitis comes to the outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? a. Cranberry juice b. Coffee c. Prune juice d. Milk
d. Milk
Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? a. Assess for generalized edema b. Monitor for increased urinary output c. Encourage rest during hyperactive periods d. Note patterns of increased blood pressure
d. Note patterns of increased blood pressure
Which of the following urinary symptoms is the most common initial manifestation of acute renal failure? a. Dysuria b. Anuria c. Hematuria d. Oliguria
d. Oliguria
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding? a. Fluid retention b. Hemolysis of red blood cells c. Below normal metabolic rate d. Reduced renal blood flow
d. Reduced renal blood flow
A client has chronic renal failure with persistent hypertension. The nurse's actions are guided by the knowledge that this hypertension is from which one of the following mechanisms? a. Activation of the aldosterone-estrogen system. b. Erythropoietin system. c. Prostaglandin synthesis inhibition. d. Renin-angiotensin-aldosterone system.
d. Renin-angiotensin-aldosterone system.
The client, who is a newlywed, is afraid to discuss her diagnosis of cystitis with her husband. Which would be the nurse's best approach? a. Arrange a meeting with the client, her husband, the physician and the nurse. b. Insist that the client talk with her husband because good communication is necessary for a successful marriage. c. Talk first with the husband alone and then with both of them together to share the husband reactions. d. Spend time with the client addressing her concerns and then stay with her while she talks with her husband
d. Spend time with the client addressing her concerns and then stay with her while she talks with her husband
A client diagnosed with nephrolithiasis arrives at the clinic for a follow up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of Calcium oxalate. On the basis of this analysis, the nurse should tell the client that it is best to avoid which food to minimize the risk of recurrence? a. Pasta b. Lentils c. Lettuce d. Spinach
d. Spinach
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? a. Sphygmomanometer b. Padded tongue blade c. Nasal cannula and oxygen d. Suction machine with catheters
d. Suction machine with catheters
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate? a. Intention tremors and urgency with voiding b. Echolalia and a shuffling gait c. Muscle spasm and a bent over posture d. Unintentional tremor and jerky movement of the elbows
d. Unintentional tremor and jerky movement of the elbows
. A client is to receive a prescribed peritoneal dialysis treatment. To prepare for the procedure, the nurse should first? a. Assess the dialysis access for a bruit and thrill b. Insert an indwelling urinary catheter and drain all urine from the bladder c. Ask the client to turn toward the left side d. Warm the solution in the warmer
d. Warm the solution in the warmer
The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: a. genetic dysfunction b. upper and lower motor neuron lesions c. decreased conduction of impulses in an upper motor neuron lesion d. a lower motor neuron lesion
d. a lower motor neuron lesion
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: a. place the client on his back, remove dangerous objects, and insert a bite block b. place the client on his side, remove dangerous objects, and insert a bite block c. place the client on his back, remove dangerous objects, and hold down his arms d. place the client on his side, remove dangerous objects, and protect his head
d. place the client on his side, remove dangerous objects, and protect his head