NUR 2 Exam 6
What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. 1 Prolactin 2 Growth hormone 3 Luteinizing hormone 4 Antidiuretic hormone 5 Melanocyte-stimulating hormone
1 Prolactin 2 Growth hormone The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.
What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion? 1 Touch the client's arm gently to convey concern. 2 Maintain eye contact when talking with the client. 3 Attempt to disprove the client's delusional thoughts. 4 Speak softly when talking with others near the client.
2 Maintain eye contact when talking with the client. Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse should respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.
A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply. 1 Polyuria 2 Obese trunk 3 Hypotension 4 Sleep disturbance 5 Thin arms and legs
2 Obese trunk 4 Sleep disturbance 5 Thin arms and legs Truncal obesity is a key feature of Cushing syndrome. Sleep disturbance is caused by the altered diurnal secretion of cortisol. Thin arms and legs are caused by protein catabolism, which causes muscle wasting. Polyuria is associated with diabetes mellitus and primary aldosteronism, not Cushing syndrome. Obesity is caused by the overproduction of adrenal cortisol hormone associated with Cushing syndrome. Hypertension, not hypotension, is associated with Cushing syndrome because of sodium and water retention.
A nurse is assessing a client with a suspected pituitary tumor. Which assessment finding is consistent with a pituitary tumor? 1 Tetany 2 Seizures 3 Lethargy 4 Hyperreflexia
2 Seizures Seizures are common in clients who have pituitary tumors. Tetany is associated with severe hypocalcemia; that condition can be caused by hypoparathyroidism. Lethargy is found in clients with hypothyroidism. Hyperreflexia is observed in clients with hyperthyroidism and hypoparathyroidism.
A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. 1 Avoid solid food. 2 Take the oral medication. 3 Drink fluids throughout the day. 4 Monitor capillary glucose levels. 5 Do not take medication until tolerating food
2 Take the oral medication. 3 Drink fluids throughout the day. 4 Monitor capillary glucose levels. Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia.
Child maltreatment is suspected in a 3-year-old girl admitted to the hospital with many poorly explained injuries. Which statement by the mother further supports this suspicion? 1 "When I get angry, I take her for a walk." 2 "I have no problems with any of my other children." 3 "When she misbehaves, I send her to her room alone." 4 "I make her stand in the corner when she doesn't eat her dinner."
2 "I have no problems with any of my other children." Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt suspicions of physical abuse and warrant further investigation. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to his or her room alone is an acceptable punishment for misbehavior. Although making a child stand in the corner is demeaning, it is not physical abuse.
Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. 1 Impaired memory 2 Intolerance to cold 3 Difficulty breathing 4 Decreased blood pressure 5 Decreased body temperature
2 Intolerance to cold 5 Decreased body temperature Cold intolerance and decreased body temperature are the metabolic manifestations observed in a client with hypothyroidism. Impaired memory is the neuromuscular manifestation of hypothyroidism. Difficulty in breathing is the pulmonary manifestation observed in the client with hypothyroidism. Decreased blood pressure is the cardiovascular manifestation observed in the client with hypothyroidism.
A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that it is different from an infant with a meningocele? 1 Enlarged head 2 Sac over the lumbar area 3 Affected lower extremities 4 Infection of the spinal fluid
3 Affected lower extremities Failure of neural tube to close during the first 3 to 5 weeks of fetal development results in neural tube defects. Myelomeningocele is the most severe form; these children usually have lower extremity and bladder dysfunction. Hydrocephalus may occur after the repair of either a meningocele or a myelomeningocele. A saclike cyst containing meninges and spinal fluid may be present in either defect. Infection is possible with either defect because of the exposure of the meninges.
The nurse is assessing a client who reports frequent urination. Which inquiry made by the nurse will help determine diabetes insipidus? 1 "Do you have history of cancer?" 2 "Are you on fluoroquinolone therapy?" 3 "Are you on lithium carbonate therapy?" 4 "Do you have a history of lymphoma?"
3 "Are you on lithium carbonate therapy?" Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Therefore enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination. Inquiry about history of cancer helps in assessing syndrome of inappropriate antidiuretic hormone (SIADH) because some cancer therapy drugs result in SIADH. Treatment with fluoroquinolone antibiotics also can result in SIADH. Hodgkin's and Non-Hodgkin's lymphoma are causes of SIADH.
A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? 1 Hemorrhage 2 Hypovolemic shock 3 Gastrointestinal atony 4 Autonomic hyperreflexia
4 Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. While hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.
Which client condition is contraindicated for prescribing clozapine? 1 Seizures 2 Glaucoma 3 Dysrhythmias 4 Bone marrow depression
4 Bone marrow depression Clozapine is an atypical antipsychotic drug that is contraindicated in clients with bone marrow depression. Clozapine should be used with caution in clients with seizures. First-generation antipsychotics should be used with caution in clients with glaucoma. Ziprasidone is contraindicated in clients with a history of dysrhythmias.
A client is diagnosed with type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. For what side effect should the nurse teach this client to monitor? 1 Ketonuria 2 Weight loss 3 Ketoacidosis 4 Low blood sugar
4 Low blood sugar Oral hypoglycemic agents decrease serum glucose levels that may precipitate hypoglycemia. Ketonuria occurs with insulin-dependent diabetes. Weight gain usually is noted in adult-onset diabetes. Ketoacidosis occurs with insulin-dependent diabetes.
What is female athlete triad?
disordered eating, amenorrhea, osteoporosis Athletes with amenorrhea, irregular eating habits and reduced nutritional intake, and osteoporosis are said to have female athlete triad. Simple amenorrhea is not considered female athlete triad. Hypogonadotropic amenorrhea results from a problem in the central hypothalamic-pituitary axis, where there is a hypothalamic suppression resulting in amenorrhea.
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record? 1 "Has intact plantar reflexes" 2 "Exhibits a positive Babinski sign" 3 "Demonstrates normal sensory function" 4 "Able to perform active range of motion"
2 "Exhibits a positive Babinski sign" This is a positive Babinski sign; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.
What are glargine and detemir?
Glargine and detemir are both long acting insulins with an onset of 1 -2 hours with no pronounced peak plasma concentration and a duration of 24 hours. The mechanism of action of glargine and detemir is similar to regular insulin in that it promotes movement of glucose from the blood into body tissues and also inhibits hepatic glucose production, but the duration of action is longer than regular insulin.
A baby was born with a single-lobed brain and also had neural tube defects. Which drug treatment in the client during her gestation might have caused this condition? 1 Simvastatin 2 Isotretinoin 3 Carbamazepine 4 Cyclophosphamide
1 Simvastatin Neural tube defects and single-lobed brains are teratogenic effects in a newborn associated with simvastatin, an HMG-CoA reductase inhibitor. Isotretinoin may cause central nervous system (CNS) defects. Carbamazepine exposure may cause neural tube defects. Cyclophosphamide may cause CNS malformation as a teratogenic effect.
A nurse is working with a child who was physically abused by a parent. What is the most important goal for this family? 1 The child will live in a safe environment. 2 The parents will use verbal discipline effectively. 3 The family will feel comfortable in its relationship with the counselor. 4 The parents will gain an understanding of their abusive behavior patterns.
1 The child will live in a safe environment. The most important goal and top priority is to ensure the safety of the child. Once this is ensured, other goals can be identified and fulfilled, including the parents using verbal discipline effectively, the family feeling comfortable in its relationship with the counselor, and the parents gaining an understanding of their abusive behavior patterns.
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply. 1 The client should obtain a finger stick blood sugar reading before each meal. 2 The client does not need to follow a specific diet until insulin is required. 3 The teaching plan should include signs and symptoms of hypoglycemia. 4 The teaching plan does not need to include signs and symptoms of hypoglycemia, as the client is not on insulin. 5 The teaching plan should include sick day rules.
1 The client should obtain a finger stick blood sugar reading before each meal. 3 The teaching plan should include signs and symptoms of hypoglycemia. 5 The teaching plan should include sick day rules. All diabetic clients, regardless of type, should check finger stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day rules. All diabetic clients need to follow the American Diabetes Association diet
What behavioral findings correspond to intimate partner violence in young adolescents? Select all that apply. 1 Sexually acting out 2 Attempting suicide 3 Pattern of substance abuse 4 Fear of certain people or places 5 Preoccupation with others or one's own genitals
2 Attempting suicide 3 Pattern of substance abuse Adolescents undergoing intimate partner violence may attempt suicide or have patterns of substance abuse. The behavioral findings in children undergoing sexual abuse include sexually acting out, fear of certain people or places, and a preoccupation with genitalia.
A client who has been found to have bipolar disorder, manic episode, has been sleeping very little and had not eaten in the 2 weeks preceding hospitalization. What does the nurse conclude is a frequent cause of feeding problems in the overactive client? 1 Feeling of unworthiness 2 Inability to take the time to eat 3 Unconscious desire for punishment 4 Preoccupation with ritualistic behavior
2 Inability to take the time to eat During a manic episode the affected individual tries to keep active to prevent the feeling of depression from overtaking him or her; avoidance of feelings, not food, is the priority, and manic people do not take the time to eat. Feelings of grandeur have replaced unconscious feelings of unworthiness at this phase of the illness. The manic phase is not characterized by a desire for punishment. Manic clients are usually not aware of unconscious feelings. Clients in the manic phase do not control anxiety by the use of ritualistic behavior; ritualistic behavior is common in clients with an obsessive-compulsive disorder.
A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? 1 Insert a urinary retention catheter. 2 Institute measures to prevent constipation. 3 Encourage an increase in the intake of caffeine. 4 Suggest that a carbonated beverage be ingested daily
2 Institute measures to prevent constipation. A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence. Urinary retention catheters should not be used to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence. Caffeine acts as a diuretic and is a urinary bladder irritant; both promote urinary incontinence. Carbonated beverages irritate the urinary bladder, which promotes urinary incontinence.
Which clinical manifestation of hyponatremia suggests an associated decrease in ECF volume? 1 Seizures 2 Changes in LOC 3 Hypotension 4 Weight gain
3 Hypotension
What is Lispro?
Lispro is a rapid acting insulin with an onset of roughly 15 minutes with a peak plasma concentration of 1 - 2 hours and a duration of 3 - 5 hours. The mechanism of action of Lispro is that it lowers blood glucose by stimulating peripheral uptake of glucose from skeletal muscle and fat and by inhibiting hepatic glucose production. Aspart and glulisine are also rapid acting insulins with similar characteristics to Lispro.
What is NPH?
NPH (insulin isophane suspension) is an intermediate acting insulin with an onset of 1 - 2 hours with a peak plasma concentration of 4 - 8 hours and a duration of 10 - 18 hours. The mechanism of action of NPH is that it helps increase cellular intake of glucose in the liver, adipose tissue, and skeletal muscles. NPH promotes hepatic glycogen synthesis and fatty acid metabolism for lipoprotein synthesis. In skeletal muscles, NPH promotes glycogen and protein synthesis.
What is regular insulin?
Regular insulin is a short acting insulin with an onset of 30 - 60 minutes with a peak plasma concentration of 2.5 hours and a duration of 6 - 10 hours. The mechanism of action of regular insulin is that it stimulates hepatic glycogen synthesis. Regular insulin stimulates the cellular uptake of amino acids and increases cellular permeability to several ions, including potassium, magnesium, and phosphate.
A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? 1 "Exercise increases the need for carbohydrates and decreases the need for insulin." 2 "Exercise increases the need for insulin and increases the need for carbohydrates." 3 "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." 4 "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."
1 "Exercise increases the need for carbohydrates and decreases the need for insulin." Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased.
The parents of a school-age child tell the nurse, "My child seems very hot or red in the face, has abdominal pain, and appears jittery." What does the nurse suggest as the reason for the child's signs and symptoms? 1 "The child is experiencing stress in some area of life." 2 "The child is growing up and feels the need for autonomy." 3 "The child may be eating mostly junk food out of the house." 4 "The child may be staying up late at night to watch television."
1 "The child is experiencing stress in some area of life." Appearing hot or red in the face and jittery, along with abdominal pain, indicates that the child is experiencing stress. The parents need to talk about any stressors that the child is experiencing and should encourage the use of effective problem-solving and coping skills. Staying up late at night and watching television may cause fatigue, but not abdominal pain or jitteriness. The school-age child does not seek autonomy and shares most things with the family. Eating junk food out of the house may result in obesity or unhealthy eating habits.
An obese client with type 2 diabetes asks about the intake of alcohol or special "dietetic" food in the diet. What should the nurse include in teaching? 1 Alcohol can be consumed, with its calories counted in the diet. 2 Unlimited amounts of sugar substitutes can be used as desired. 3 Alcohol should not be used in cooking because it adds too many calories. 4 Special "dietetic" foods are needed because many regular foods cannot be used.
1 Alcohol can be consumed, with its calories counted in the diet. In the overweight individual with type 2 diabetes, occasional alcohol can be ingested with caloric substitution for equivalent fat exchanges in the diet because it is metabolized like fat. Moderation is vital; sugar substitutes may not be used in unlimited quantities, and they must be accounted for in the dietary calculations. Alcohol can be used as long as it is accounted for in the diet. The statement that special "dietetic" foods are needed because many regular foods cannot be used is untrue; regular foods can be used in the diet of individuals with diabetes.
Upon assessment, the primary healthcare provider finds that the client is experiencing weight gain as well as elevated lipid and blood glucose levels. Which drugs in the client's prescription list are most likely to cause these metabolic side effects? Select all that apply. 1 Clozapine 2 Asenapine 3 Quetiapine 4 Olanzapine 5 Ziprasidone
1 Clozapine 4 Olanzapine Clozapine and olanzapine are second-generation antipsychotic (SGA) drugs that may cause metabolic side effects such as diabetes and dyslipidemia. Asenapine and ziprasidone are SGAs that may cause torsades de pointes by prolonging the QT interval. Quetiapine is an antipsychotic and used to treat bipolar disorders and may cause loss of appetite, but also increased blood glucose levels and elevated cholesterol.
A healthcare provider prescribes divalproex for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit? 1 Dizziness, nausea, and vomiting 2 Photosensitivity, agitation, and restlessness 3 Abdominal cramps, tremor, and muscle weakness 4 Weight gain, drowsiness, and diminished concentration
1 Dizziness, nausea, and vomiting Divalproex, an anticonvulsant, causes gastric irritation and should be taken with food; it is available in an enteric-coated form. It may cause nausea, vomiting, indigestion, hypersalivation, diarrhea or constipation, anorexia or increased appetite, dizziness, headache, and confusion. Photosensitivity, agitation, and restlessness are all common side effects of phenothiazines. Abdominal cramps, tremor, and muscle weakness are signs and symptoms of lithium toxicity. Weight gain, drowsiness, and diminished concentration are common side effects of tricyclic antidepressants.
An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period? 1 Encouraging the parents to stroke their infant 2 Allowing the parents to hold their infant in their arms 3 Referring the parents to the Spina Bifida Association of America (Canada: Spina Bifida and Hydrocephalus Association of Canada) 4 Teaching the parents to use special techniques when feeding the infant
1 Encouraging the parents to stroke their infant Because the infant cannot be held, tactile stimulation helps meet the infant's needs and fosters bonding with the parents. An infant with an unrepaired myelomeningocele cannot be held in the arms. Referrals will be more appropriate at a later time. Although special feeding techniques are important in the postoperative period, they may not improve the parent-infant relationship.
A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? Select all that apply. 1 Fatigue 2 Nausea 3 Weakness 4 Nervousness 5 Increased thirst 6 Increased perspiration
1 Fatigue 3 Weakness 4 Nervousness 6 Increased perspiration Fatigue is related to hypoglycemia. Weakness is related to a decrease in glucose within the central nervous system. Nervousness is caused by increased adrenergic activity and increased secretion of catecholamines. Increased perspiration is related to increased adrenergic activity and increased secretion of catecholamines. Nausea is related to hyperglycemia, not hypoglycemia. Increased thirst with an excessive oral fluid intake (polydipsia) is associated with hyperglycemia and is one of the cardinal signs of diabetes mellitus.
During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess? 1 I 2 II 3 X 4 VII
1 I Cranial nerve I is the olfactory nerve that concerns the sense of smell; the ability to sense odors usually is affected when an intracranial lesion is present. Cranial nerve II is the optic nerve and is concerned with sight. Cranial nerve X is the vagus nerve and is concerned with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera. Cranial nerve VII is the facial nerve and is concerned with facial expressions, taste, and the salivary glands.
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? 1 Insulin needs will increase during the second trimester. 2 Insulin needs will decrease during the second trimester. 3 Insulin needs will not change during the second trimester. 4 Insulin will be switched to an oral antidiabetic medication during the second trimester.
1 Insulin needs will increase during the second trimester. The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks' gestation. The use of oral antidiabetes agents is currently not recommended by the American Diabetes Association for use during pregnancy.
Which hormone is crucial for ovulation and complete maturation of a client's ovarian follicles? 1 Luteinizing hormone 2 Follicle stimulating hormone 3 Gonadotropin releasing hormone 4 Human chorionic gonadotropin hormone
1 Luteinizing hormone Ovulation and complete maturation of ovarian follicles can only take place in the presence of luteinizing hormone. However, follicle stimulating hormone initiates maturation of the follicles. Gonadotropin releasing hormone stimulates the pituitary gland to release follicle stimulating hormone and luteinizing hormone. Human chorionic gonadotropin hormone is released after implantation and is responsible for secretion of progesterone and estrogen during pregnancy.
The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? 1 Nervous and weak 2 Thirsty with a headache 3 Flushed and short of breath 4 Nausea and abdominal cramps
1 Nervous and weak Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.
Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. 1 Pancreas 2 Thyroid gland 3 Adrenal cortex 4 Adrenal medulla 5 Parathyroid gland
1 Pancreas 2 Thyroid gland 3 Adrenal cortex The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T 3 and T 4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply. 1 Planning for future safety 2 Normalizing victimization 3 Validating the experiences 4 Promoting access to community services 5 Providing housing for the victim
1 Planning for future safety 3 Validating the experiences 4 Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.
A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply. 1 Polyuria 2 Polydipsia 3 Paralytic ileus 4 Respiratory rate of 26 breaths/min 5 Serum glucose of 105 mg/dL (5.8 mmol/L)
1 Polyuria 2 Polydipsia 4 Respiratory rate of 26 breaths/min Glucose that is being filtered in the kidney acts as an osmotic diuretic; glycosuria promotes polyuria. Polydipsia (excessive thirst) and fluid intake are the responses to excess fluid loss related to osmotic diuresis. With hyperglycemia, there may be hyperventilation in an attempt to blow off carbon dioxide if ketones are produced; 26 breaths/min per minute is characteristic of hyperventilation. Paralytic ileus is not associated with hyperglycemia. Serum glucose of 105 mg/dL (5.8 mmol/L), by most standards, is within the expected range of 60 to 110 mg/dL (3.3 to 6.1 mmol/L).
A nurse caring for a pregnant client at 28 weeks' gestation and her partner suspects intimate partner violence. Which assessments support this suspicion? Select all that apply. 1 The woman has injuries to the breasts and abdomen. 2 The partner refuses to come into the examination room. 3 The partner answers questions that are asked of the woman. 4 The woman has visited the clinic several times in the last month. 5 The partner is excessively attentive while the health history is being taken.
1 The woman has injuries to the breasts and abdomen. 3 The partner answers questions that are asked of the woman. 4 The woman has visited the clinic several times in the last month. During pregnancy, batterers may concentrate their anger at the pregnancy itself and focus their assaults on the breasts, buttocks, and abdomen. It is common for the abuser to control the conversation by answering for the client. Women who are battered are at risk for stress illnesses such as gastrointestinal distress and chest pain. They are also more likely to suffer from frequent headaches and depression. Control is a primary concern of the abuser, so it would be highly unlikely for him to leave the client alone with the care provider. Excessive attentiveness while the health history is being taken is not typical behavior of an abusive person.
Which adverse effect can be seen in a female client with gonadotropin deficiency and undergoing hormone replacement therapy? 1 Thrombosis 2 Hypotension 3 Dehydration 4 Increased thirst
1 Thrombosis A female client with gonadotropin deficiency is treated by replacement therapy of combined hormones, namely estrogen and progesterone. The side effect of this therapy is the increased risk of thrombosis or formation of blood clots in deep veins. Hypertension is a side effect of estrogen-progesterone therapy. Dehydration and increased thirst could indicate vasopressin deficiency.
Which clinical manifestation occurs in a client with adrenal insufficiency? 1 Vitiligo 2 Moon face 3 Hypertension 4 Truncal obesity
1 Vitiligo Adrenal insufficiency is clinically manifested as patchy white areas on the skin (vitiligo). Moon face, hypertension, and truncal obesity are clinical manifestations of Cushing's syndrome.
A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? 1 "Did you forget to take your medication?" 2 "You are worried about having more seizures?" 3 "You must be under a lot of stress right now." 4 "Don't be too concerned because your medication needs to be increased."
2 "You are worried about having more seizures?" The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be too concerned because your medication needs to be increased" negates the client's feelings and discourages communication.
A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure? 1 Remain in the house. 2 Avoid holding an infant. 3 Save urine in a lead-lined container. 4 Refrain from using a bathroom used by others
2 Avoid holding an infant. Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed twice after use by the client. Refraining from using a bathroom used by others is not necessary.
A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply. 1 Taste 2 Breathing 3 Heart rate 4 Fluid balance 5 Voluntary movement
2 Breathing 3 Heart rate The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as breathing. The medulla is concerned with vital functions [1] [2] such as heart rate. The opercular-insular area of the parietal cerebral lobe is concerned with taste sensations. The medulla is not concerned with fluid balance. Osmoreceptors of the hypothalamus cause increased or decreased antidiuretic hormone (ADH) secretion depending on serum osmolarity. Voluntary movements are mediated through the somatomotor area of the cerebral cortex.
What action should be included in the nursing care of an infant with increased intracranial pressure? 1 Weighing daily before feedings 2 Elevating the head higher than the hips 3 Checking the reflexes at regular intervals 4 Monitoring alertness with frequent stimulation
2 Elevating the head higher than the hips Elevation of the head helps decrease intracranial pressure by way of gravity. The infant is weighed daily before feedings after the insertion of a shunt; if the infant is in the intensive care unit, this is done routinely. Checking reflexes at regular intervals may be disturbing to the infant and impair the infant's ability to rest. Frequent stimulation may cause further irritability to an already traumatized central nervous system.
A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon? 1 Eat a snack before going to bed. 2 Measure the blood glucose level between 2 AM and 4 AM. 3 Identify whether morning symptoms are typical for hyperglycemia. 4 Administer the prescribed bedtime insulin immediately before going to bed.
2 Measure the blood glucose level between 2 AM and 4 AM. During the hours of sleep, the Somogyi effect may be caused by a decline in the blood glucose level in response to too much insulin. The resulting hypoglycemia stimulates counterregulatory hormones, which precipitate lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. Treatment involves decreasing the evening insulin. The client should check blood glucose between 2 AM and 4 AM and if the blood glucose is less than 70, the client is having a Somogyi effect. The dawn phenomenon is characterized by the release of counterregulatory hormones in the predawn hours, precipitating hyperglycemia on awakening. Treatment involves an increase in insulin. Eating a snack before going to bed should be done when insulin is taken before sleep, but it will not help to differentiate between the Somogyi effect and the dawn phenomenon. Administering the prescribed bedtime insulin immediately before going to bed depends on the insulin regimen prescribed by the health care provider and will not help to differentiate between the Somogyi effect and the dawn phenomenon. The manifestation (symptoms) of hyperglycemia has no role in differentiating the conditions.
What is the action of vasopressin? 1 Promotes sodium reabsorption 2 Reabsorbs water into the capillaries 3 Promotes tubular secretion of sodium 4 Stimulates bone marrow to make red blood cells
2 Reabsorbs water into the capillaries Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).
A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question? 1 Continue anticonvulsants 2 Teach isometric exercises 3 Continue osmotic diuretics 4 Keep head of bed at 30 degrees
2 Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.
A primigravida client with type 1 diabetes is attending her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur? 1 Tenth and twelfth weeks of gestation 2 Eighteenth and twenty-second weeks of gestation 3 Twenty-fourth and twenty-eighth weeks of gestation 4 Thirty-sixth and fortieth weeks of gestation
3 24th and 28th weeks of gestation. At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases and insulin needs decrease accordingly.
The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply. 1 Make the referral after the client is discharged. 2 Select a suitable rehabilitation center for the client. 3 Explain the need for referral to the client and family. 4 Provide the referral with adequate client information. 5 Determine what the referral recommends for client care.
3 Explain the need for referral to the client and family. 4 Provide the referral with adequate client information. 5 Determine what the referral recommends for client care. Clients are discharged from health care facilities as soon as their conditions allow. Therefore they often need referrals for continuing care from another provider. It is important for the nurse to explain the need for the referral to the client and family. The nurse must coordinate with the referral and provide all necessary client information to prevent duplication of effort or exclusion of important information. The nurse must determine the referral recommendations for client care and include it in the treatment plan. Discharge planning starts as soon as the client is admitted to the health care facility. Therefore the nurse must plan for the referral as soon as possible, not after the client is discharged. The nurse should involve the client and family in the referral process. The client and family should be allowed to select a suitable rehabilitation center.
A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position? 1 Supine 2 On the unaffected side 3 In bed with the head of the bed elevated 4 With sandbags on either side of the head
3 In bed with the head of the bed elevated With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure, which will intensify the ischemic manifestations of hemorrhage. The supine position will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Lying on the unaffected side will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Vomiting can occur with increased intracranial pressure, and placing sandbags to immobilize the head can result in aspiration.
Which drugs may cause an increase in the serum clozapine level? Select all that apply. 1 Rifampin 2 Phenytoin 3 Ketoconazole 4 Erythromycin 5 Bromocriptine
3 Ketoconazole, 4 Erythromycin Ketoconazole and erythromycin increase clozapine levels in the blood by inhibiting P450 isoenzymes. Rifampin and phenytoin reduce clozapine levels in the blood by inducing cytochrome P450 isoenzymes. Bromocriptine is a direct dopamine receptor agonist that activates dopamine receptors.
Which hormones are secreted by the client's hypothalamus? Select all that apply. 1 Growth hormone 2 Follicle-stimulating hormone 3 Prolactin-inhibiting hormone 4 Corticotropin-releasing hormone 5 Melanocyte-stimulating hormone
3 Prolactin-inhibiting hormone 4 Corticotropin-releasing hormone The hormones that are secreted by the hypothalamus include prolactin-inhibiting hormone and corticotropin-releasing hormone. Growth hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone are hormones secreted by the anterior pituitary gland.
The nurse is caring for a client with diabetes mellitus who is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. What does the nurse recognize as the only type of insulin that is compatible with intravenous solutions? 1 NPH insulin 2 Insulin lispro 3 Regular insulin 4 Insulin glargine
3 Regular insulin Regular insulin acts rapidly, is approved for IV administration, and is compatible with intravenous solutions. Insulin lispro is not compatible with intravenous solutions; it is a rapid-acting insulin. Insulin glargine is not compatible with intravenous solutions; it is a long-acting insulin. NPH insulin is not compatible with intravenous solutions; it is an intermediate-acting insulin.
Which statement is true regarding the functions of kidney hormones? 1 Prostaglandin increases blood flow and vascular permeability. 2 Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. 3 Renin raises blood pressure because of angiotensin and aldosterone secretion. 4 Erythropoietin promotes the absorption of calcium in the gastrointestinal tract (GI) tract.
3 Renin raises blood pressure because of angiotensin and aldosterone secretion. Renin is a kidney hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. Prostaglandin is a kidney hormone that regulates intrarenal blood flow via vasodilation or vasoconstriction. Bradykinin is a kidney hormone that increases blood flow and vascular permeability. Erythropoietin is a kidney hormone that stimulates the bone marrow to make red blood cells.
A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? 1 "The use of salt probably contributed to the disease." 2 "Excess weight will be gained if sodium is not limited." 3 "The loss of excess sodium and potassium in the urine requires less renal stimulation." 4 "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
4 "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium." Clients with Cushing syndrome must limit their intake of salt and increase their intake of potassium. The kidneys are retaining sodium and excreting potassium. An excessive secretion of adrenocortical hormones in Cushing syndrome, not increased or high sodium intake, is the problem. Although sodium retention causes fluid retention and weight gain, the need for increased potassium also must be considered. Because of steroid therapy, excess sodium may be retained, although potassium may be excreted.
An occupational health nurse is meeting with a new employee to obtain a health history and schedule an appointment with the nurse practitioner for a physical examination. How can the occupational nurse best respond when the new employee exhibits a moderate level of anxiety and verbalizes extreme nervousness about starting the new job? 1 "It's common to feel a little nervous." 2 "You'll be less nervous when you get used to the job." 3 "I felt the same way when I first started working here." 4 "Feeling upset about starting a new job can be difficult."
4 "Feeling upset about starting a new job can be difficult." The response "Feeling upset about starting a new job can be difficult" focuses on the employee's feelings and demonstrates understanding and empathy. The response "It's common to feel a little nervous" negates the employee's feelings and is not therapeutic. The response "You'll be less nervous when you get used to the job" negates the employee's feelings and provides false reassurance. The response "I felt the same way when I first started working here" focuses on the nurse's, rather than the employee's, feelings.
After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which laboratory result should the nurse check? 1 Increased blood urea nitrogen (BUN) 2 Increased serum sodium level 3 Decreased specific gravity 4 Decreased urine output
4 Decreased urine output ADH causes water retention, resulting in decreased urine output. Blood volume may increase, causing dilution of nitrogenous wastes in the blood. The client is overhydrated so that serum sodium is decreased, producing a dilutional hyponatremia. ADH acts on nephrons to cause water to be reabsorbed from glomerular filtrate, leading to an increased specific gravity of urine.
A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder? 1 Diarrhea and pyrexia 2 Edema and hypertension 3 Moon face and hirsutism 4 Hypoglycemia and hypotension
4 Hypoglycemia and hypotension Adrenocortical insufficiency causes decreased glucocorticoids, resulting in hypoglycemia; also, it causes decreased aldosterone, resulting in fluid excretion that leads to hypotension. Although diarrhea can occur initially with steroid replacement, it should subside; pyrexia will occur only if there is a concomitant infection. Edema and hypertension are not related to Addison disease; they are associated with Cushing disease, because of excessive cortisol and aldosterone, resulting in fluid and sodium retention. Moon face and hirsutism are related to Cushing disease, not Addison disease; moon facies is caused by adipose tissue deposition, and hirsutism is caused by excessive androgen secretion.
Which drug may lead to bruxism? 1 Vilazodone 2 Isocarboxazid 3 Clomipramine 4 Levomilnacipran
4 Levomilnacipran Serotonin reuptake inhibitors and serotonin/epinephrine reuptake inhibitors may lead to bruxism. Levomilnacipran is a serotonin/epinephrine reuptake inhibitor that may cause bruxism. Vilazodone is an atypical antidepressant that does not cause bruxism. Isocarboxazid is a monoamine oxidase inhibitor that does not cause bruxism. Clomipramine is a tricyclic antidepressant that does not cause bruxism.
Which drug may increase a client's body temperature when administered along with monoamine oxidase inhibitor? 1 Doxepin 2 Sertraline 3 Citalopram 4 Meperidine
4 Meperidine Meperidine is a strong analgesic that may lead to an increased body temperature when used with monoamine oxidase inhibitors (MAOIs). Doxepin is a tricyclic antidepressant that may cause hypertension when taken with MAOIs. Sertraline and citalopram are serotonergic drugs that may increase the risk of serotonin syndrome when used with MAOIs.
A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? 1 Mannitol 2 Dexamethasone 3 Chlorpromazine 4 Morphine
4 Morphine Morphine injection is contraindicated for an unconscious, neurologically impaired client because it depresses respirations. Mannitol, an osmotic diuretic, is used to reduce increased intracranial pressure. Dexamethasone, a corticosteroid antiinflammatory agent, is used to help reduce increased intracranial pressure. Chlorpromazine, an antipsychotic/neuroleptic/antiemetic, can be given safely to a neurologically impaired client for restlessness.
A client is admitted to the hospital with a diagnosis of Cushing syndrome. What signs and symptoms will the client most likely exhibit? 1 Hyperkalemia and edema 2 Hypotension and sodium loss 3 Muscle wasting and hypoglycemia 4 Muscle weakness and frequent urination
4 Muscle weakness and frequent urination Increased gluconeogenesis may lead to hyperglycemia and glycosuria, which can produce urinary frequency; protein catabolism will cause muscle weakness. As sodium ions are retained, potassium is excreted; the result is hypokalemia. Edema occurs because of sodium retention. Hypotension and sodium loss are signs of Addison syndrome; in Cushing syndrome retention of sodium and fluids leads to hypervolemia and hypertension. Muscle wasting results from increased protein catabolism; however, hyperglycemia rather than hypoglycemia will result from increased gluconeogenesis.
While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for the client? 1 Performing the jaw-thrust maneuver 2 Maintaining vascular access using a large-bore catheter 3 Observing for chest wall trauma or other physical abnormalities 4 Preparing for endotracheal intubation and mechanical ventilation
4 Preparing for endotracheal intubation and mechanical ventilation. The most appropriate intervention for a client with a GCS score of 7 is preparing for endotracheal intubation and mechanical ventilation. The jaw-thrust maneuver is performed in a client if there is any risk of spinal injury. The use of large-bore catheters to maintain vascular access is done to perform resuscitation in traumatic conditions. Observing for chest wall trauma or other physical abnormalities may not be the appropriate intervention for a client with brain injury.
A client is admitted to the hospital for an adrenalectomy. When teaching the client about the prescribed medications, what will the nurse emphasize? 1 Drug therapy will be given in conjunction with insulin. 2 Once regulated, the dosage will remain the same for life. 3 If taken late in the evening, the medications may cause insomnia. 4 Salt intake may have to be restricted while taking the medications.
4 Salt intake may have to be restricted while taking the medications. Administration of adrenocortical hormones causes sodium retention; dietary intake of salt should be limited. Because pancreatic function is unimpaired, insulin therapy is not indicated. Because there is an increased secretion of glucocorticoids under stressful situations, the dosage must be adjusted accordingly. Insomnia is not an adverse effect of adrenocortical hormones.
A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior? 1 Being assertive 2 Responding early 3 Providing choices 4 Teaching relaxation
4 Teaching relaxation Once the client is agitated, teaching will not be effective and may increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.
