nsg 252 test 4 questions

What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis?

- Diarrhea

List the common clinical manifestations of jaundice

- Yellow sclera - Dark urine - Clay-colored stools

In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions

- Avoid injections - Use small-bore IV needles for IV insertion - Maintain pressure for 5 minutes on all venipuncture sites - Use electric razor - Use soft-bristle toothbrush - Check stools and emesis for occult blood

A neighbor calls the neighborhood nurse stating that his very hyperactive dog knocked him hard to the floor. He is wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do?

- Call his PCP now and inform them of the fall - Symptoms needing medical attention would include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia (imbalance), or seizure

What is the most important indicator of increased ICP?

- A change in the level of responsiveness

Define stroke

- A disruption of blood supply to a part of the brain, which results in sudden loss of brain function

What activities and situations that increase ICP should be avoided?

- Change in bed position - Extreme hip flexion - Endotracheal suctioning - Compression of jugular veins - Coughing - Vomiting - Straining of any kind

Complications of immobility include the potential for thrombus development. State three nursing interventions to prevent thrombi

- Frequent ROM exercise - Frequent (every 2 hours) position changes - Avoidance of positions that decrease venous return

How should the nurse administer pancreatic enzymes?

- Give with meals or snacks - Powder forms should be mixed with fruit juices

List four groups who have a high risk for contracting hepatitis

- Homosexual males - IV drug users - Those who have had recent ear piercings or tattooing - Healthcare workers

What are the symptoms of spinal shock?

- Hypotension - Bladder and bowel distention - Total paralysis - Lack of sensation below lesion

What vital sign changes are indicative of increased ICP?

- Increased BP - Widening pulse pressure - Increased or decreased pulse - Respiratory irregularities - Increased temperature

What teaching should parents of a newly shunted child receive?

- Information about signs of infection and increased ICP - Understanding that shunt should not be pumped - Child will need revisions with growth - Guidance concerning growth and development

List the signs and symptoms of increased ICP in older children

- Irritability - Change in LOC - Motor dysfunction - Headache - Vomiting - Unequal pupil response - Seizure

A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion?

- Left

State the three main goals in providing nursing care for a child experiencing a seizure

- Maintain patent airway - Protect from injury - Observe carefully

Is paralysis always a consequence of spinal cord injury?

- No

Who is at risk for stroke?

- Persons with history of hypertension - Previous TIAs - Cardiac disease (atrial flutter or fibrillation) - Diabetes - Oral contraceptive use - Older adults

What are two nursing priorities for a newborn with myelomeningocele?

- Prevention of infection of the sac - Monitoring for hydrocephalus (measure head circumference, check fontanel, assess neurologic functioning)

A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? SATA A. "Avoid places with crowds and individuals who have infection" B. "Report increased bruising to your doctor because the drug can cause bleeding" C. "Get your lab work done regularly because the drug can affect your kidneys" D. "Be careful and avoid falls because the drug can cause fractures" E. "Follow up with the dietitian to ensure that you adhere to your special diet"

A. "Avoid places with crowds and individuals who have infection" C. "Get your lab work done regularly because the drug can affect your kidneys"

Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A. "I'm glad I can keep eating protein like red meat" B. "I'll try to walk at least 20 to 30 minutes each day" C. "I'm going to talk to my doctor about a weight loss plan" D. "I plan to include more fruits and vegetables in my diet"

A. "I'm glad I can keep eating protein like red meat"

The nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinson disease. What health teaching will the nurse include for the client and family? SATA A. "Move slowly when changing positions from sitting to standing" B. "Take your medication after meals to help prevent nausea" C. "Report any hallucinations that the client may have" D. "Note any changes in mental or emotional status" E. "Pay attention to whether your tremors improve or worsen"

A. "Move slowly when changing positions from sitting to standing" C. "Report any hallucinations that the client may have" D. "Note any changes in mental or emotional status" E. "Pay attention to whether your tremors improve or worsen"

*Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Administering oxygen therapy B. Lowering the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids

A. Administering oxygen therapy

*The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? SATA A. Alcohol B. Protein C. Sodium D. Acetaminophen E. Smoking F. Illicit drugs

A. Alcohol D. Acetaminophen E. Smoking F. Illicit drugs

Which response would the nurse expect to find in a patient with phenytoin level of 25? A. Ataxia B. Hypertension C. Seizures D. No unusual response; this level is therapeutic

A. Ataxia

The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? SATA A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes E. Abdominal abscess

A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes E. Abdominal abscess

The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? SATA A. Blood pressure increase to 196/100 B. Heart rate of 88 C. Respiratory rate of 22 D. New-onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 mL since admission

A. Blood pressure increase to 196/100 D. New-onset headache reported as 8/10 intensity E. Increased drowsiness and dozing frequently

*A client has undergone the Whipple procedure (radial pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? SATA A. Check blood glucose often B. Check bowel sounds and stools C. Ensure that drainage color is clear D. Monitor mental status E. Place the client in the supine position

A. Check blood glucose often B. Check bowel sounds and stools D. Monitor mental status

*The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? A. Eating contaminated food or water B. Sharing needles for illicit drugs C. Having unprotected sex D. Being exposed to blood or blood products

A. Eating contaminated food or water

*When caring for a client with portal hypertension, the nurse assesses for which potential complications? SATA A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A. Esophageal varies D. Ascites E. Hemorrhoids

*The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? SATA A. Increased serum bilirubin B. Increased aspartate aminotransferase C. Increased serum alanine amniotransferase D. Decreased serum albumin E. Increased serum ammonia F. Increased lactate dehydrogenase

A. Increased serum bilirubin B. Increased aspartate aminotransferase C. Increased serum alanine amniotransferase D. Decreased serum albumin E. Increased serum ammonia F. Increased lactate dehydrogenase

*The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse's priority intervention when caring for this client? A. Keeping the biliary drainage bag below the level of the catheter-insertion site B. Managing pain with continuous opioid patient-controlled analgesia (PCA) C. Checking the client's blood glucose frequently to monitor for diabetes D. Capping the catheter if it starts to leak around the insertion site

A. Keeping the biliary drainage bag below the level of the catheter-insertion site

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? SATA A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to the side, if possible, with the head flexed forward E. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

A. Loosening restrictive clothing C. Removing the pillow and raising padded side rails D. Positioning the client to the side, if possible, with the head flexed forward Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client

The nurse is administering an anti-epileptic drug and will follow which guidelines? SATA A. Monitor the patient for drowsiness B. Medications may be stopped if seizure activity disappears C. Give the medication at the same time every day D. Give the medication on an empty stomach E. Notify the prescriber if the patient is unable to take the medication

A. Monitor the patient for drowsiness C. Give the medication at the same time every day E. Notify the prescriber if the patient is unable to take the medication

The nurse is assessing a patient who has begun therapy with amantadine (Symmetrel) for Parkinson's disease. The nurse will look for which possible adverse effects? SATA A. Nausea B. Palpitations C. Dizziness D. Insomnia E. Fatigue

A. Nausea C. Dizziness D. Insomnia

A patient is taking entacapone (Comtan) as part of the therapy for Parkinson's disease. Which intervention by the nurse is appropriate at this time? A. Notify the patient that this drug causes discoloration of the urine B. Limit the patient's intake of tyramine-containing foods C. Monitor the results of renal studies because this drug can seriously affect renal function D. Fore fluids to prevent dehydration

A. Notify the patient that this drug causes discoloration of the urine

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? SATA A. Padding the side rails of the bed B. Placing an airway at the bedside C. Placing the bed in the high position D. Putting a padded tongue blade at the head of the bed E. Placing oxygen and suction equipment at the bedside F. Flushing the intravenous catheter to ensure that the site is patent

A. Padding the side rails of the bed B. Placing an airway at the bedside E. Placing oxygen and suction equipment at the bedside F. Flushing the intravenous catheter to ensure that the site is patent Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

A patient is taking pregabalin (lyrica) but does not have a history of seizures. The nurse recognizes that this drug is also indicated for which of these? A. Postherpetic neuralgia B. Viral infections C. Parkinson's disease D. Depression

A. Postherpetic neuralgia

*When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? SATA A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen D. Elevated magnesium E. Currant jelly stool F. Elevated amylase level

A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen

The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory value(s) will the nurse expect to be abnormal? SATA A. Prothrombin time B. Serum bilirubin C. Albumin D. AST E. Lactate dehydrogenase F. Acid phosphatase

A. Prothrombin time B. Serum bilirubin C. Albumin D. AST E. Lactate dehydrogenase

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

A. Purulent drainage from the pin sites on the client's forehead

A client was admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this client? SATA A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting D. Decreased serum amylase level E. Leukocytosis F. Dyspnea

A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting E. Leukocytosis F. Dyspnea

*The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Sodium B. Potassium C. Magnesium D. Calcium

A. Sodium

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? SATA A. The client is aphasic B. The client has weakness on the right side of the body C. The client has complete bilateral paralysis of the arms and legs D. The client has weakness on the right side of the face and tongue E. The client has lost the ability to move the right arm but is able to walk independently F. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance

A. The client is aphasic B. The client has weakness on the right side of the body D. The client has weakness on the right side of the face and tongue Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating

A patient with Parkinson's disease will start taking entacapone (Comtan) along with the carbidopa-levodopa (Sinemet) he has been taking for a few years. The nurse recognizes that which of these is an advantage of taking entacapone? A. The entacapone can reduce on-off effects B. The levodopa may be stopped in a few days C. There is less GI upset with entacapone D. It does not cause the cheese effect

A. The entacapone can reduce on-off effects

A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? SATA A. Time the seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to preseizure status E. The drugs that are administered during the seizure

A. Time the seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to preseizure status

*After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/minute B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose of 235

A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/minute

*The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? SATA A. Calcium B. Amylase C. Lipase D. Trypsin E. Elastase F. Glucose

B. Amylase C. Lipase D. Trypsin E. Elastase F. Glucose

The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider? A. Client has a new-onset mild headache B. Client's blood pressure is 194/120 C. Client has left hemiparesis D. Client continues to be drowsy

B. Client's blood pressure is 194/120

*The nurse is caring for a client who has cirrhosis of the liver. The client's laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. Deep vein thrombosis B. Hematemesis C. Pressure injury D. Jaundice

B. Hematemesis

*When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A. Encourage the client to take deep breaths and cough B. Ask the client to void prior to the procedure C. Position the client with the head of the bed flat D. Assist the provider to insert a trocar catheter into the abdomen

B. Ask the client to void prior to the procedure

*The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A. Platelet count B. Blood glucose C. Phosphorus D. Blood urea nitrogen

B. Blood glucose

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? A. "Alcohol is not contraindicated while taking this medication" B. "Good oral hygiene is needed, including brushing and flossing" C. "The medication dose may be self-adjusted depending on side effects" D. "The morning dose of the medication should be taken before a serum medication level is drawn"

B. "Good oral hygiene is needed, including brushing and flossing" Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a primary health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a medicalert bracelet

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? A. "I will use a straw for drinking" B. "I will drive only during the daytime" C. "I will be careful because the device alters balance" D. "I will wash the skin daily under the lamb's wool liner of the vest"

B. "I will drive only during the daytime" The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the best to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision.

*A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test? A. "I need to know if you are allergic to shellfish because the contrast will be iodine-based" B. "You will have to lie still for some time while the camera is very close to your body" C. "You may eat and drink as much as you'd like before you have this test" D. "This test measures how inflamed your gallbladder and liver may be"

B. "You will have to lie still for some time while the camera is very close to your body"

The nurse is reviewing the drugs currently taken by a patient who will be starting drug therapy with carbamazepine (tegretol). Which drug may raise a concern for interactions? A. Digoxin B. Acetaminophen C. Diazepam (valium) D. Warfarin (coumadin)

B. Acetaminophen

The nurse is preparing to give medications. Which is an appropriate nursing action for IV phenytoin? SATA A. Give IV doses via rapid IV push B. Administer in normal saline solutions C. Administer in dextrose solutions D. Use a filter for IV infusions E. Ensure continuous infusion of the drug

B. Administer in normal saline solutions D. Use a filter for IV infusions

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur

*The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Hypertension B. Infection C. Pulmonary edema D. Acute kidney injury

B. Infection

A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds B. Manage the client's airway C. Check oxygen saturation level D. Perform a neurologic assessment

B. Manage the client's airway

*When providing community education, the nurse emphasizes that which group needs to receive immunization for Hepatitis B? A. Clients who work with shellfish B. Men who engage in sex with men C. Clients traveling to a third-world country D. Clients with elevations of aspartate amniotransferase and alanine amniotransferase

B. Men who engage in sex with men

The nurse is reviewing the medication orders for a patient who has been taking selegiline (Eldepryl). Which of these medications or medication classes, if ordered, would cause a problem due to an interaction? SATA A. Warfarin (coumadin) B. Meperidine (demerol) C. A cough syrup that contains dextromethorphan D. Serotonergic antidepressants E. Erythromycin

B. Meperidine (demerol) C. A cough syrup that contains dextromethorphan D. Serotonergic antidepressants

A patient will be taking selegiline (Eldepryl), 5mg daily, in addition to dopamine replacement therapy for Parkinson's disease. The nurse will implement which precautions regarding selegiline? A. Teach the patient to avoid foods containing tyramine B. Monitor for dizziness and orthostatic hypotension C. Inform the patient that this drug may cause urine discoloration D. Monitor for weight gain

B. Monitor for dizziness and orthostatic hypotension

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? A. Sternal rub B. Nailbed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle

B. Nailbed pressure Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle

*The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy ("lap chole"). What statement by the client indicates a need for further teaching? A. "I should only be hospitalized for 2 to 3 days after my surgery" B. "I will probably not be at risk for complications from this surgery" C. "I will likely need oral pain medications for the first few days after my surgery" D. "I should be able to go back to work in the next week or so"

C. "I will likely need oral pain medications for the first few days after my surgery"

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition

C. Acute pain

*A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift B. Do not administer food or fluids by mouth C. Administer opioid analgesic medication D. Assist the client to assume a position of comfort

C. Administer opioid analgesic medication

Which condition will alert the nurse to a potential caution or contraindication regarding the use of a dopaminergic drug for treatment of mild Parkinson's disease? A. Diarrhea B. Tremors C. Angle-closure glaucoma D. Unstable gait

C. Angle-closure glaucoma

*The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A. Fatigue and weakness B. Decreased pulse rate C. Changes in consciousness or behavior D. Decreased ascitic fluid

C. Changes in consciousness or behavior

*The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A. Abdominal assessment, including bowel sounds B. Cardiovascular assessment C. Cognitive and neurologic assessment D. Respiratory assessment

C. Cognitive and neurologic assessment

*The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A. Increased blood pressure B. Increased pulse C. Decreased weight D. Decreased pain

C. Decreased weight

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? A. Hyperreflexia B. Positive reflexes C. Flaccid paralysis D. Reflex emptying of the bladder

C. Flaccid paralysis Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder

*What teaching does the home health nurse give the family of a client with Hepatitis C to prevent the spread of the infection? A. The client must not consume alcohol B. Avoid sharing the bathroom with the client C. Members of the household must not share toothbrushes D. Drink only bottled water and avoid ice

C. Members of the household must not share toothbrushes

*The nurse is caring for a client who states that her mother had "gallbladder problems" and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease? A. Advanced age B. Birth control pills C. Obesity D. Infertility

C. Obesity

*A client who has a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A. Peptic ulcer disease B. Cirrhosis C. Peritonitis D. Crohn disease

C. Peritonitis

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110. What is the nurse's priority action at this time? A. Perform a bladder assessment B. Insert an indwelling urinary catheter C. Place the patient in a sitting position D. Turn on a fan to cool the patient

C. Place the patient in a sitting position

The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client? A. Refer the client to the speech language pathologist B. Speak loudly to help the client interpret what is being said C. Provide pictures to help the client understand D. Ask the client to read messages on a whiteboard

C. Provide pictures to help the client understand

The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

C. Seizure

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35. Which finding would be expected as a result of this laboratory finding? A. Hypotension B. Tachycardia C. Slurred speech D. No abnormal finding

C. Slurred speech The therapeutic phenytoin level is 10 to 20. At a higher level higher than 20 , involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30, ataxia and slurred speech occur

*When assessing a client with Hepatitis B, the nurse anticipates which assessment findings? SATA A. Recent influenza infection B. Brown stool C. Tea-colored urine D. Right upper quadrant tenderness E. Itching

C. Tea-colored urine D. Right upper quadrant tenderness E. Itching

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? A. Pregnancy must be avoided while taking phenytoin B. The client may stop the medication if it is causing severe gastrointestinal effects C. There is the potential of decreased effectiveness of birth control pills while taking phenytoin D. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together

C. There is the potential of decreased effectiveness of birth control pills while taking phenytoin Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options A, B, and D are inappropriate instructions. Pregnancy does not need to be "avoided" while taking phenytoin; however because phenytoin may cause some risk to the fetus, consultation with the PCP should be done if pregnancy is considered. Telling a client that there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A client should not be instructed to stop antiseizure medication.

*The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? A. Steak and french fries B. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread D. Sausage and scrambled eggs

C. Turkey sandwich on wheat bread

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? SATA A. Place client in a private room B. Wear a mask when handling patient bedpan C. Wear gloves when touching the client D. Wear a gown when providing personal care to this patient E. Wear eye goggles when providing care

C. Wear gloves when touching the client D. Wear a gown when providing personal care to this patient

*The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication? A. Administer pancrelipase before taking an antacid B. Chew tablets before swallowing C. Take pancrelipase before meals D. Wipe your lips after taking pancrelipase

D. Wipe your lips after taking pancrelipase

The nurse is providing education for a patient who will be taking an anti-epileptic drug for the first time. Which statement by the patient indicates that further teaching is indicated? A. "I will take the medicine at the same time every day" B. "I will check with my doctor before taking any over-the-counter drugs" C. "I will keep the appointments to check my bloodwork" D. "I can drive to work again once my drug levels are normal"

D. "I can drive to work again once my drug levels are normal"

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? A. "I can sit down to put on my pants and shoes" B. "I try to exercise every day and rest when I'm tired" C. "My son removed all loose rugs from my bedroom" D. "I don't need to use my walker to get to the bathroom"

D. "I don't need to use my walker to get to the bathroom The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use her or his walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? A. "I need to take enzymes at every meal and with snacks" B. "After taking the enzymes, I should drink a glass of water" C. "I should wipe my mouth in case any of the enzyme got on my lips" D. "I should chew each capsule carefully so that it works in my stomach"

D. "I should chew each capsule carefully so that it works in my stomach"

*Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver" B. "The scars on my liver create problems with blood circulation" C. "Because of the scars on my liver, blood clotting and blood pressure are affected" D. "My liver is scarred, but the cells can regenerate themselves and repair the damage"

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage"

*The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. "These interventions help to prevent heart failure" B. "These interventions help the client's jaundice improve" C. "These interventions help to prevent nausea and vomiting" D. "These interventions help to reduce the ammonia level"

D. "These interventions help to reduce the ammonia level"

*It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Polyuria C. Bone marrow suppression D. Bleeding

D. Bleeding

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? A. Gents angry with family if the interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self

D. Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyles changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options A and B are not adaptive behaviors; option C indicates a not yet successful attempt to adapt

A client was admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia, which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist to plan care to increase the client's mobility B. Contact the occupational therapist to assess the client's ADL ability C. Contact the unit social worker to talk with the family about the client's discharge D. Contact the speech language pathologist to schedule a swallowing study

D. Contact the speech language pathologist to schedule a swallowing study

The nurse is assessing a newly admitted patient who has a history of seizures. During the assessment, the patient has a generalized seizure that does not stop for several minutes. The nurse expects that which drug will be ordered for this condition? A. Valproic acid (depakote) B. Neurontin (gabapentin) C. carbamazepine (tegretol) D. Diazepam (valium)

D. Diazepam (valium)

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A. Blowing the nose B. Isometric exercises C. Coughing vigorously D. Exhaling during repositioning

D. Exhaling during repositioning Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which findings indicates that the client is experiencing an adverse effect? A. Pruritus B. Tachycardia C. Hypertension D. Impaired voluntary movements

D. Impaired voluntary movements Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of this medication.

*A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Carbohydrates B. High fat C. High fiber D. Protein

D. Protein

*How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A. Removes throw rugs to prevent falls B. Rearranges furniture to declutter the home C. Obtains a walker for the client D. Requests a bedside commode for the client

D. Requests a bedside commode for the client

*A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A. Pain intensity assessment B. Cardiovascular assessment C. Abdominal assessment D. Respiratory assessment

D. Respiratory assessment

A patient who has been taking carbidopa-levodopa for Parkinson's disease for over 1 year wants to start a low-carbohydrate/high-protein weight-loss diet. The nurse tells the patient that this type of diet may have what effect on his drug therpay? A. There will be no problems with this diet while on this medication B. The high-protein diet can slow or prevent absorption of this medication C. The high-protein diet may cause increased blood levels of this medication D. The high-protein diet will cause no problems as long as the patient also takes vitamin B6

D. The high-protein diet will cause no problems as long as the patient also takes vitamin B6