Patho Pharm II Practice Questions Exam 3

The nurse uses the Glasgow Coma Scale to assess a client with a head injury that resulted from a snowboarding accident. The nurse identifies that the client is in a coma when the Glasgow Coma Scale score is: 1. 6 2. 9 3. 12 4. 15

1. 6 The Glasgow Coma Scale is used to assess the extent of neurological damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. 2 To achieve this rating the client must be exhibiting some meaningful responses. 3 To achieve this rating the client must be exhibiting some meaningful responses. 4 A score of 15 represents normal neurological functioning.

After an automobile collision a client who is unconscious and exhibiting decerebrate posturing is brought to the emergency department. What clinical manifestations would the nurse observe? 1. Hyperextension of both the upper and lower extremities 2. Spastic paralysis of both the upper and lower extremities 3. Hyperflexion of the upper extremities and hyperextension of the lower extremities 4. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

1. Hyperextension of both the upper and lower extremities Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. 2 This is associated with an upper motor neuron disease or lesion. 3 This is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. 4 This is associated with a lower motor neuron disease or lesion.

A client who underwent an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temperature is 101.3° F (38.5° C). Which of these actions prescribed by the health care provider will you implement first? 1. Insert a straight catheter PRN for output of less than 300 mL/8 hr. 2. Administer acetaminophen (Tylenol) 650 mg orally. 3. Send a urine specimen to the laboratory for culture and sensitivity testing. 4. Administer ceftizoxime (Cefizox) 1 g IV every 12 hours.

1. Insert a straight catheter PRN for output of less than 300 mL/8 hr. The client has symptoms of a urinary tract infection. Inserting a straight catheter will enable you to obtain an uncontaminated urine specimen for culture and sensitivity testing before the antibiotic is started. In addition, the client is probably not emptying her bladder fully because of the painful urination. The antibiotic therapy should be initiated as rapidly as possible once the urine specimen is obtained. Administration of acetaminophen is the lowest priority, because the client's temperature is not dangerously elevated.

You are caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information will concern you the most? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/dL. 3. The client reports a continuing headache. 4. The daily weight has increased 1 kg.

1. The client no longer recognizes family members. The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies.

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should you take first? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the physician about the change in status.

2. Check the Foley tubing for kinks or obstruction. These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the physician may be necessary if nursing actions do not resolve

You have just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6° F (39.2° C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. 3. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. 4. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

2. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible, but are not as important as starting antibiotic therapy.

A 79-year-old who has just returned to the surgical unit following a TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? 1. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. 2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL daily.

2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 1. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL daily. Bladder spasms after a TURP are usually caused by the presence of clots that obstruct the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate postoperative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged once you are sure that the client is not nauseated and has adequate bowel tone.

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. Which procedure should the nurse expect the practitioner to discuss as a potential treatment option? 1. Hemodialysis 2. Plasmapheresis 3. Thrombolytic therapy 4. Immunosuppression therapy

2. Plasmapheresis A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. 1 A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. 3 Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. 4 Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during her chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3. 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment and/or client teaching but will not require a change in medical treatment for the seizures.

You are providing care for a client with an acute hemorrhagic stroke. The client's spouse tells you that he has been reading a lot about strokes and asks why his wife has not received alteplase (Activase). What is your best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, and this prevents the use of alteplase."

3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug such as alteplase can worsen the bleeding. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.

A client has had a needle biopsy of the prostate gland using the transrectal approach. Which statement is most important to include in the client teaching plan? 1. "The doctor will call you about the test results in a day or two." 2. "Serious infections may occur as a complication of this test." 3. "You will need to call the doctor if you develop a fever or chills." 4. "It is normal to have a small amount of rectal bleeding after the test."

3. "You will need to call the doctor if you develop a fever or chills." Although infection occurs only rarely as a complication of transrectal prostate biopsy, it is important that the client receive teaching about checking his temperature and calling the physician if there is any fever or other signs of systemic infection. The client should understand that the test results will not be available immediately but that he will be notified about the results. Transient rectal bleeding may occur after the biopsy, but bleeding that lasts for more than a few hours indicates that there may have been rectal trauma.

Which information obtained when taking a client's health history will be most important in determining whether the client should receive the human papillomavirus (HPV) immunization? 1. Client is 19 years old 2. Client is sexually active 3. Client has a positive pregnancy test 4. Client has tested positive for HPV previously

3. Client has a positive pregnancy test Centers for Disease Control and Prevention guidelines indicate that the HPV immunization should not be given during pregnancy. Ideally, the immunization series should start at age 11 or 12 for females and males, but it may be started up through age 26. HPV immunization is most effective in preventing HPV infection and cervical cancer when it is started before the individual is sexually active and prior to any HPV infection, but these are not contraindications for vaccination.

A client is admitted to the hospital after sustaining a head injury. The most reliable sign that this client is experiencing an increase in intracranial pressure is a slowly: 1. Rising respiratory rate 2. Narrowing pulse pressure 3. Decreasing level of consciousness 4. Increasing diastolic blood pressure

3. Decreasing level of consciousness This occurs because of the brain's acute sensitivity to hypoxia 1 The respirations usually are depressed because of brainstem compression. 2 The systolic pressure increases and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure. 4 The peripheral vascular resistance is decreased when hypoxia occurs, thereby decreasing, not increasing, the diastolic blood pressure.

A client is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding

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

A 68-year-old client who is ready for discharge from the ED has a new prescription for nitroglycerin 0.4 mg sublingual as needed for angina. Which client information has the most immediate implications for teaching? 1. The client has BPH and some urinary hesitancy. 2. The client's father and two brothers all have had myocardial infarctions. 3. The client uses sildenafil several times weekly for erectile dysfunction. 4. The client is unable to remember when he first experienced chest pain.

3. The client uses sildenafil several times weekly for erectile dysfunction. Sildenafil is a potent vasodilator and has caused cardiac arrest in clients who were also taking nitrates such as nitroglycerin. The other client data indicate the need for further assessment and/or teaching, but it is essential for the client who uses nitrates to avoid concurrent use of sildenafil.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily."

4. "I will limit sun exposure to 1 hour daily." The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

A 67-year-old client with BPH has a new prescription for tamsulosin. Which statement about tamsulosin is most important to include when teaching this client? 1. "This medication will improve your symptoms by shrinking the prostate." 2. "The force of your urinary stream will probably increase." 3. "Your blood pressure will decrease as a result of taking this medication." 4. "You should avoid sitting up or standing up too quickly."

4. "You should avoid sitting up or standing up too quickly." Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change positions slowly. The other information is also accurate and may be included in client teaching but is not as important as decreasing the risk for falls.

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. Which antidote should the nurse anticipate to be prescribed? 1. Pentostatin (Nipent) 2. Auranofin (Ridaura) 3. Fludarabine (Fludara) 4. Acetylcysteine (Mucomyst)

4. Acetylcysteine (Mucomyst) The antidote for acetaminophen is acetylcysteine (Mucomyst). The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL could indicate hepatotoxicity. Auranofin (Ridaura) is a gold preparation used to treat rheumatoid arthritis. Pentostatin (Nipent) and fludarabine (Fludara) are antineoplastic agents.

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

4. Impaired voluntary movements Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

The nurse is caring for a 26-yr-old patient who is being discharged after an induced abortion. Which statement should the nurse include in discharge teaching? a. "Avoid sexual intercourse for 2 weeks." b. "Heavy bleeding is expected for 24 hours." c. "A temperature of 101° F (38.9° C) is normal" d. "Birth control pills should not be taken for 30 days."

a. "Avoid sexual intercourse for 2 weeks." After an abortion, teach the patient to avoid intercourse for 2 weeks. Contraception can be started the day of the procedure. Symptoms of possible complications include a fever and abnormal vaginal bleeding. These symptoms should be reported immediately.

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which statement indicates the patient understands teaching about autonomic dysreflexia? a. "I will perform self-catheterization at least 6 times per day." b. "A reflex erection may cause an unsafe drop in blood pressure." c. "If I develop a severe headache, I will lie down for 15 to 20 minutes." d. "I can avoid this problem by taking medications to prevent leg spasms."

a. "I will perform self-catheterization at least 6 times per day." Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization 5 or 6 times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

A 50-yr-old patient is preparing to begin breast cancer treatment with tamoxifen. What point should the nurse emphasize when teaching the patient about her new drug regimen? a. "Report any changes in your vision immediately." b. "The medication may cause some breast sensitivity." c. "The drug often alleviates some menopausal symptoms." d. "Abstain from drinking alcohol after you begin taking tamoxifen."

a. "Report any changes in your vision immediately." Tamoxifen has the potential to cause cataracts and retinopathy. The drug is likely to exacerbate rather than alleviate perimenopausal symptoms. Breast tenderness is not associated with tamoxifen. It is not necessary to abstain from alcohol.

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? a. A 50-yr-old woman with lethargy from a drug overdose b. A 40-yr-old man with a complete lumbar spinal cord injury c. A 60-yr-old man with severe pain from trigeminal neuralgia d. A 30-yr-old woman with a high fever and bacterial meningitis

a. A 50-yr-old woman with lethargy from a drug overdose The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

A male patient reports fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? a. A very tender prostate gland b. Reports of chills and rectal pain c. Reports of urgency and frequency d. Escherichia coli bacteria in his urine

a. A very tender prostate gland A tender and swollen prostate is indicative of prostatitis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatitis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatitis.

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate? (Select all that apply.) a. Administer penicillin. b. Administer polyvalent antitoxin. c. Control spasms with diazepam (Valium). d. Teach correct processing of canned foods. e. Provide analgesia with opioids (morphine). f. Prepare for tracheostomy for mechanical ventilation.

a. Administer penicillin. c. Control spasms with diazepam (Valium). e. Provide analgesia with opioids (morphine). f. Prepare for tracheostomy for mechanical ventilation. Penicillin is administered to inhibit further growth of Clostridium tetani. Control of the spasms of tetanus is essential because laryngeal and respiratory spasms cause apnea and anoxia. Morphine can be used to manage pain. A tracheostomy is performed early so mechanical ventilation may be done to maintain respirations. Using polyvalent antitoxin and teaching the correct canning process are done for botulism.

A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? a. Antivirals b. Antibiotics c. Vaccination d. Contraceptives

a. Antivirals This patient has a reoccurrence of genital herpes (HSV2). Although not a cure, he will be treated with antiviral medications to decrease the duration of viral shedding and the healing time of genital lesions and reduce outbreaks. Antibiotics and contraceptives are not used to treat acute HSV2. There are no vaccinations for HSV.

A patient presents with mastalgia. After determining cancer is not present, which strategies may provide relief? (Select all that apply.) a. Application of ice b. Oral contraceptives c. Reduce caffeine intake d. Increase intake of fluids e. Oral antibiotic administration f. Wear a supportive bra during the day

a. Application of ice b. Oral contraceptives c. Reduce caffeine intake f. Wear a supportive bra during the day To reduce breast pain, the patient may apply ice, reduce caffeine intake, and use oral contraceptive therapy. Wearing a supportive bra continuously may reduce discomfort. Increasing fluids and use of antibiotics are not indicated for treatment of mastalgia.

The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient? a. Ask the patient a question such as, "Who were the last 3 presidents?" b. Evaluate level of consciousness, body posture, and facial expressions. c. Observe for signs of agitation, anger, or depression during the health check. d. Request that the patient mimic rapid alternating movements with both hands.

a. Ask the patient a question such as, "Who were the last 3 presidents?" Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination. It may include testing rapid alternating movements of the upper and lower extremities.

The nurse is caring for a patient after a lumbar puncture. Which should be a priority action by the nurse? a. Assess for drainage or bleeding from the puncture site. b. Monitor for bladder problems and bowel incontinence. c. Maintain bed rest until lower extremities move normally. d. Check for loss of muscle strength in the upper extremities.

a. Assess for drainage or bleeding from the puncture site. After a lumbar puncture, the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? a. Ataxia b. Apraxia c. Anisocoria d. Anosognosia

a. Ataxia Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

The nurse is caring for a 62-yr-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? a. Avoid straining during defecation. b. Restrict fluids to prevent incontinence. c. Sexual functioning will not be affected. d. Prostate examinations are not needed after surgery.

a. Avoid straining during defecation. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Teach the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

a. Bradycardia Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

A 21-year-old female is infected with Human Papillomavirus (HPV) following unprotected sexual intercourse with a male she recently met. She is now at higher risk of developing which of the following cancers? a. Cervical b. Ovarian c. Endometrial d. Vaginal

a. Cervical

A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? a. Chancre b. Alopecia c. Condylomata lata d. Regional adenopathy

a. Chancre Chancres appear in the primary stage of the bacterial invasion of Treponema pallidum, the causative organism of syphilis. The other findings do not appear until the secondary stage of syphilis, occurring a few weeks after the chancres appear.

The nurse is performing an assessment on a female patient. What assessment finding should be documented and reported to the primary health care provider? a. Dimpling of breast b. Dark pink genitalia c. Watery cervical mucus d. Triangular hair distribution

a. Dimpling of breast Dimpling of the breast is highly suspicious for carcinoma of the breast. Dark pink genitalia, watery cervical mucus, and triangular pubic hair distribution are all normal female reproductive system assessment findings.

Which conditions predispose the patient to the development of a brain abscess? (Select all that apply.) a. Endocarditis b. Ear infection c. Tooth abscess d. Skull fracture e. Sinus infection f. Scalp laceration

a. Endocarditis b. Ear infection c. Tooth abscess d. Skull fracture e. Sinus infection Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Abdominal distention and absence of bowel sounds d. Decreased level of consciousness and hallucinations

a. Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal problems are not characteristic manifestations.

The patient with type 1 diabetes is having a seizure. Which medication should the nurse anticipate will be administered first? a. IV dextrose solution b. IV diazepam (Valium) c. IV phenytoin (Dilantin) d. Oral carbamazepine (Tegretol)

a. IV dextrose solution This patient's seizure could be caused by low blood glucose, so IV dextrose solution would be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used first to treat seizures from other causes such as head trauma, drugs, and infections. These drugs will be tried if the IV dextrose is ineffective.

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation should the nurse assess in this patient? a. Impaired muscle movement b. Decreased deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature

a. Impaired muscle movement Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.

A 72-yr-old patient had a mastectomy for breast cancer 6 months ago and wants to have breast reconstructive surgery. Which motivation for surgery would be most likely? a. Improve the woman's self-image. b. Be able to experience sexual arousal. c. To get a tummy tuck as well as the breast mound. d. Restore the premastectomy appearance of the breast.

a. Improve the woman's self-image. The most likely motivation for this patient to seek breast reconstructive surgery is to improve her self-esteem. With this surgery, she will not be able to experience sexual arousal through breast stimulation or restore the premastectomy appearance of the breast. The abdominoplasty (tummy tuck) effect will only be a possibility with the transverse rectus abdominis musculocutaneous (TRAM) flap, not with a breast implant or tissue expansion.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? a. Keep a wrench close or attached to the vest. b. Use the frame and vest to assist in positioning. c. Clean around the pins using betadine swab sticks. d. Loosen both sides of the vest to provide skin care.

a. Keep a wrench close or attached to the vest. A halo vest is used to provide cervical spine immobilization while vertebrae heal. There should always be a wrench with the halo vest in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with normal saline or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

a. L1-2

A CT scan of a patient's head reveals a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? a. Maintaining the patient's airway b. Positioning to promote cerebral perfusion c. Controlling fluid and electrolyte imbalances d. Administering tissue plasminogen activator (tPA)

a. Maintaining the patient's airway Maintaining a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.

a. Monitor fluid and electrolyte status carefully. Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.

An 18-year-old male presents with urethral itching, dysuria, and profuse, purulent urethral discharge. He reports recently having unprotected sex with a new partner approximately 4 days ago. What is the most likely cause of his symptoms? a. Neisseria gonorrhea b. Chlamydia trachomatis c. Herpes infection d. Escherichia coli

a. Neisseria gonorrhea

The nurse performs a breast examination on a female patient who has never been pregnant, 1 week after her menstrual period. Which finding, if made by the nurse, would indicate a normal breast examination? a. Nipples are soft without retractions. b. Unilateral breast dimpling is present. c. Milky fluid is expressed from the nipples. d. Axillary lymph nodes are fixed and palpable.

a. Nipples are soft without retractions. Normal breasts are symmetric without dimpling. Nipples are soft with no drainage, retraction, or lesions noted. No masses, tenderness, or lymphadenopathy is present.

The nurse is volunteering at a community center to teach women about breast cancer. What should the nurse include when discussing risk factors? (Select all that apply.) a. Nulliparity b. Alcohol use c. Age 30 or over d. Early menarche e. Late menopause f. Personal history of colon cancer

a. Nulliparity b. Alcohol use d. Early menarche e. Late menopause f. Personal history of colon cancer Women are at an increased risk for development of breast cancer if they are older than the age of 50 years; have a family history of breast cancer; have a personal history of breast, colon, endometrial, or ovarian cancer; have a long menstrual history as seen with early menarche or late menopause; and have had a first full-term pregnancy after the age of 30 years or are nulliparous. Alcohol use may increase the risk of breast cancer.

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins develops diplopia. Which additional findings should the nurse expect? a. Nystagmus or confusion b. An aura or focal seizure c. Abdominal pain or cramping d. Irregular pulse or palpitations

a. Nystagmus or confusion Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

The nurse is caring for a 25-yr-old patient who has polycystic ovary syndrome (PCOS). When preparing the teaching plan, which classic manifestation should the nurse associate with severity of symptoms and infertility? a. Obesity b. Hirsutism c. Amenorrhea d. Irregular menstrual periods

a. Obesity Obesity has been associated with the severity of symptoms such as excess androgens, oligorrhea, amenorrhea, and infertility. This knowledge will affect the teaching the nurse does for this patient to prevent cardiovascular disease and abnormal insulin resistance. Hirsutism, amenorrhea, and irregular menstrual periods are not associated with the severity of the symptoms.

Which factors would place a patient at a higher risk for prostate cancer (select all that apply)? a. Older than 65 years b. Asian or Native American c. Long-term use of an indwelling urethral catheter d. Father diagnosed and treated for early-stage prostate cancer e. Previous history of undescended testicle and testicular cancer

a. Older than 65 years d. Father diagnosed and treated for early-stage prostate cancer

A 48-yr-old man was just diagnosed with Huntington's disease. His 20-yr-old son is upset about his father's diagnosis. What is the nurse's best response? a. Provide emotional and psychologic support. b. Encourage him to get diagnostic genetic testing. c. Explain that cognitive deterioration will be treated with counseling. d. Teach that chorea and psychiatric disorders can be treated with haloperidol.

a. Provide emotional and psychologic support. The patient's son will first need emotional and psychologic support. He should be taught about diagnostic genetic testing but should decide for himself with a genetic counselor if and when he wants this done. The treatment plan for his father will be determined based on his father's needs.

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? a. Reporting any bladder spasms b. Assessing the patient's incision c. Irrigating the patient's urinary catheter d. Evaluating the patient's pain and selecting analgesia

a. Reporting any bladder spasms Cleaning around the catheter, recording intake and output, and reporting any pain or bladder spasms to the registered nurse are appropriate tasks for delegation to the UAP. Selecting analgesia, irrigating the patient's catheter, and assessing the incision are not appropriate skills or tasks for unlicensed personnel.

A 71-yr-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a photoselective vaporization of the prostate. What is the primary goal of this intervention? a. Resumption of normal urinary drainage b. Maintenance of normal sexual functioning c. Prevention of acute or chronic renal failure d. Prevention of fluid and electrolyte imbalances

a. Resumption of normal urinary drainage The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser vaporization technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, impaired sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.

The patient with diabetes had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? a. Safety measures b. Patience with communication c. Mobility assistance on the right side d. Place food in the left side of patient's mouth.

a. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for? (Select all that apply.) a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction e. Parathyroid dysfunction f. Focal neurologic deficits

a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction f. Focal neurologic deficits Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a. Slow, fearful performance of tasks b. Overestimation of physical abilities c. Difficulty judging position and distance d. Impulsivity and impatience at performing tasks

a. Slow, fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) are often slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

The nurse is providing teaching to a group of perimenopausal women. Which herbs and supplements would the nurse include in a discussion about effective alternative therapies for menopausal symptoms? (Select all that apply.) a. Soy b. Garlic c. Gingko d. Vitamin A e. Cinnamon f. Black cohosh

a. Soy f. Black cohosh There is good scientific evidence that soy is useful in decreasing menopausal hot flashes and that black cohosh is safe to use for up to 6 months to decrease menopausal symptoms. Garlic, gingko, vitamin A, and cinnamon do not affect menopausal symptoms.

The patient's MRI showed the presence of a brain tumor. The nurse anticipates which treatment modality? a. Surgery b. Chemotherapy c. Radiation therapy d. Biologic drug therapy

a. Surgery Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

In assessing patients for STIs, the nurse needs to know that many STIs can be asymptomatic. Which STIs can be asymptomatic? (select all that apply) a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes e. Chlamydial infection

a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes e. Chlamydial infection

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply.) a. Ticlopidine b. Clopidogrel c. Enoxaparin d. Dipyridamole e. Enteric-coated aspirin f. Tissue plasminogen activator (tPA)

a. Ticlopidine b. Clopidogrel d. Dipyridamole e. Enteric-coated aspirin Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel, dipyridamole, ticlopidine, combined dipyridamole and aspirin, and anticoagulant drugs such as oral warfarin. Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs or strokes.

Which populations have a higher risk for acquiring sexually transmitted infections (STIs)? (select all that apply) a. Transgender persons b. Young adults (age < 25) c. Men who have sex with men d. Men in long-term care facilities e. Women in correctional facilities

a. Transgender persons b. Young adults (age < 25) c. Men who have sex with men e. Women in correctional facilities

What should general teaching for patients with a sexually transmitted infection (STI) include? (Select all that apply.) a. Treatment of sexual partners. b. Douching will help to provide relief of itching. c. Importance of retesting after treatment to confirm cure. d. Cotton undergarments are preferred over synthetic materials. e. Sexual abstinence is needed during the communicable phase of a disease. f. Condoms should be used during and after treatment during sexual activity.

a. Treatment of sexual partners. c. Importance of retesting after treatment to confirm cure. d. Cotton undergarments are preferred over synthetic materials. e. Sexual abstinence is needed during the communicable phase of a disease. f. Condoms should be used during and after treatment during sexual activity. Teaching for patients with an STI should include the treatment of all sexual partners, retesting after treatment to confirm cure, cotton undergarments are more comfortable, sexual abstinence is needed during the communicable phase of the infection to prevent spread, and condoms should be used for sexual activity during and after treatment to prevent spread and reinfection. Douching may spread the infection or alter the local immune responses and is therefore contraindicated in patients with STIs.

Campylobacter jejuni is the most recognized organism associated with Guillain-Barré syndrome. a. True b. False

a. True C. jejuni gastroenteritis is thought to precede Guillain-Barré syndrome in approximately 30% of cases.

A 33-yr-old patient noticed a painless lump and heaviness in his scrotum during testicular self-examination. The nurse should provide the patient information on which diagnostic test? a. Ultrasound b. Cremasteric reflex c. Doppler ultrasound d. Transillumination with a flashlight

a. Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.

Which care measure is a priority for a patient with multiple sclerosis (MS)? a. Vigilant infection control and adherence to standard precautions b. Careful monitoring of neurologic assessment and frequent reorientation c. Maintenance of a calorie count and hourly assessment of intake and output d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

a. Vigilant infection control and adherence to standard precautions Infection control is a priority in the care of patients with MS because infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit.

You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. Which recommendations you would include? (select all that apply) a. Women over age 55 may have biennial screening. b. Screening should end when the women reaches age 65. c. Women aged 45 to 54 years should be screened annually. d. Regular screening mammography should start at age 45 years. e. Clinical breast examinations can be used if the woman has average risk.

a. Women over age 55 may have biennial screening. c. Women aged 45 to 54 years should be screened annually. d. Regular screening mammography should start at age 45 years.

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydial infection. The nurse understands that symptoms of chlamydial infection in women a. are often absent. b. are similar to those of genital herpes. c. include a macular palmar rash in the later stages. d. may involve chancres inside the vagina that are not visible.

a. are often absent.

When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is a. being a woman over age 60. b. experiencing menstruation for 30 years or more. c. using hormone therapy for 5 years for menopausal symptoms. d. having a paternal grandmother with postmenopausal breast cancer.

a. being a woman over age 60.

A 50-yr-old man reports recurring headaches. He describes them as sharp, stabbing, and around his left eye. He says his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect he has a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches.

a. cluster headaches.

Stimulation of the parasympathetic nervous system results in (select all that apply) a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. d. increased blood glucose levels. e. relaxation of the urinary sphincters.

a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. e. relaxation of the urinary sphincters.

Common psychosocial problems a patient may have post stroke include (select all that apply) a. depression. b. disassociation. c. sleep problems. d. intellectualization e. denial of severity of stroke.

a. depression. c. sleep problems. e. denial of severity of stroke.

Possible social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

Which post-op teaching by the nurse caring for a patient who had a radical orchiectomy for testicular cancer is correct? a. ejaculatory dysfunction may occur post operatively b. therapy for testicular cancer does not affect fertility c. side effects of the surgery include increased male secondary sex characteristics d. report signs and symptoms of testicular tortion to the health care provider immediately

a. ejaculatory dysfunction may occur post operatively

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

a. frontal lobe.

To prevent capsular formation after breast reconstruction with implants, teach the patient to a. gently massage the area around the implant. b. bind the breasts tightly with elastic bandages. c. avoid strenuous exercise until the implant has healed. d. exercise the arm on the affected side to promote drainage.

a. gently massage the area around the implant.

A patient with symptomatic benign prostatic hyperplasia (BPH) is treated with terazosin (Hytrin) an alpha-adrenergic blocker. The nurse should monitor for which side effect? a. hypotension b. priapism c. hypertension d. decrease in heart rate

a. hypotension

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. inspect all aspects of the mouth and teeth. b. assess the gag reflex and respiratory rate and depth. c. lightly palpate the affected side of the face for edema. d. test for temperature and sensation perception on the face. e. ask the patient to describe factors that initiate an episode.

a. inspect all aspects of the mouth and teeth. d. test for temperature and sensation perception on the face. e. ask the patient to describe factors that initiate an episode.

Postoperative care for the patient who had an abdominal hysterectomy includes (select all that apply) a. monitoring urine output. b. changing position frequently. c. restricting all food for 24 hours. d. observing perineal pad for bleeding. e. encouraging leg exercises to promote circulation.

a. monitoring urine output. b. changing position frequently. e. encouraging leg exercises to promote circulation.

A patient's eyes jerk while the patient looks to the left. The nurse will record this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.

a. nystagmus.

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a. patency of airway.

Luteinizing hormone (LH) secretion by the anterior pituitary (select all that apply) a. results in ovulation. b. causes follicles to complete maturation. c. affects development of ruptured follicles. d. directly inhibits both GnRH and FSH secretion. e. stimulates testosterone production by interstitial cells of testes.

a. results in ovulation. b. causes follicles to complete maturation. c. affects development of ruptured follicles. e. stimulates testosterone production by interstitial cells of testes.

Significant information about a person's health history related to the reproductive system should include (select all that apply) a. tobacco use. b. intellectual status. c. number of sexual partners. d. previous history of shingles. e. previous sexually transmitted infections.

a. tobacco use. c. number of sexual partners. e. previous sexually transmitted infections.

The first nursing intervention for the patient who has been sexually assaulted is to a. treat urgent medical problems. b. contact support person for the patient. c. provide supplies for the patient to cleanse self. d. document bruises and lacerations of the perineum and the cervix.

a. treat urgent medical problems.

Nucleic acid amplification tests (NAATs) used in the diagnosis of STIs can be obtained from (select all that apply) a. urine. b. vagina. c. urethra. d. rectum. e. endocervix.

a. urine. b. vagina. c. urethra. d. rectum. e. endocervix.

An age-related finding during the assessment of the older woman's reproductive system is a. vaginal atrophy. b. increased libido. c. nipple enlargement. d. increased vulvar skin turgor.

a. vaginal atrophy.

A patient with breast cancer has a lumpectomy with sentinel lymph node biopsy that is positive for cancer. You explain that, of the other tests done to determine the risk for cancer recurrence or spread, the results that support the more favorable prognosis are (select all that apply) a. well-differentiated tumor. b. estrogen receptor-positive tumor. c. overexpression of HER-2 cell marker. d. involvement of two to four axillary nodes. e. aneuploidy status from cell proliferation studies.

a. well-differentiated tumor. b. estrogen receptor-positive tumor.

A patient comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which statement made by the patient requires immediate intervention by the nurse? a. "After the injection, I will not need to return to the clinic for further testing." b. "After starting treatment with the antibiotic, it is safe for me to have sex." c. "I should avoid alcohol intake for at least 2 to 3 weeks." d. "I will have my sexual partner come in for treatment."

b. "After starting treatment with the antibiotic, it is safe for me to have sex."

The nurse provides medication teaching for a 30-yr-old woman who is prescribed clomiphene (Clomid). Which patient statement is most important for the nurse to clarify? a. "Hormone production and release will be increased." b. "I should avoid intercourse while taking this medication." c. "This medication will stimulate my ovaries to produce eggs." d. "This drug is like natural estrogen and is used to treat infertility."

b. "I should avoid intercourse while taking this medication." Clomiphene is an oral medication administered for infertility. The medication is a selective estrogen-stimulation modulator that stimulates ovulation, making pregnancy after intercourse or artificial insemination more likely. The drug increases gonadotropin-releasing hormone production. In addition, the release of the follicle-stimulating hormone and luteinizing hormone is increased.

The patient who has been told she will have blood drawn for a prolactin assay asks the nurse, "What is this test for?" What is the best response by the nurse? a. "It will tell you if you are pregnant." b. "It is used to detect a cause of amenorrhea." c. "It will tell us if you have a reproductive cancer." d. "It can indicate if you have a sexually transmitted infection."

b. "It is used to detect a cause of amenorrhea." A prolactin assay will detect pituitary dysfunction that can cause amenorrhea. Human chorionic gonadotropin (hCG) is used to detect pregnancy. The biologic tumor markers α-fetoprotein, hCG, and CA 125 may be used to assess for reproductive cancers and to monitor therapy. The assay does not screen for a sexually transmitted infection.

A nurse is caring for a patient newly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the patient about CIDP? a. "Corticosteroids have little effect on this disease." b. "Maintenance therapy will be needed to prevent relapse." c. "You will go into remission in approximately eight weeks." d. "You should be able to walk without help within three months."

b. "Maintenance therapy will be needed to prevent relapse."

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? a. "I can take the medication with food or milk." b. "The medication should be started 1 week after paralysis." c. "I can take acetaminophen with the prescribed medications." d. "Chances of a full recovery are good if I take the medication"

b. "The medication should be started 1 week after paralysis." Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. Prednisone will be tapered over the last 2 weeks of treatment. Oral prednisone may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 3 to 6 months. No serious drug interactions occur between prednisone and acetaminophen.

The nurse teaches a 38-yr-old woman who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires clarification by the nurse? a. "The injection might feel like a bee sting." b. "This medicine will prevent a migraine headache." c. "I can take another dose if the first does not work." d. "This drug for migraine headaches could cause birth defects."

b. "This medicine will prevent a migraine headache." Sumatriptan is given to abort an ongoing migraine headache and is not used to prevent migraine headaches. When given as a subcutaneous injection, this drug may cause transient pain and redness at the injection site. This drug may be repeated after a specified time period if the first dose is not effective. This drug should be avoided during pregnancy and is classified as a Food and Drug Administration Pregnancy Risk Category C drug.

After a vasectomy, what instruction should be included in discharge teaching? a. "Some secondary sexual characteristics may be lost after the surgery." b. "Use an alternative form of contraception until your semen is sperm free." c. "Erectile dysfunction may be present for several months after this surgery." d. "You will be uncomfortable, but you may safely have sexual intercourse today."

b. "Use an alternative form of contraception until your semen is sperm free." Because vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.

The nurse is teaching clinic patients about risk factors for testicular cancer. Which person is at highest risk for developing testicular cancer? a. A 48-yr-old black man with erectile dysfunction b. A 30-yr-old white man with a history of cryptorchidism c. A 19-yr-old Asian man who had surgery for testicular torsion d. A 28-yr-old Hispanic man with infertility caused by a varicocele

b. A 30-yr-old white man with a history of cryptorchidism The incidence of testicular cancer is four times higher in white men than in black men. Testicular tumors are also more common in men who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to exogenous estrogen, and testicular cancer in the contralateral testis.

Which patient has the highest risk for a having a stroke? a. An obese 45-yr-old Native American. b. A 65-yr-old black man with hypertension c. A 35-yr-old Asian American woman who smokes. d. A 32-yr-old white woman taking oral contraceptives.

b. A 65-yr-old black man with hypertension

Which male patient does the nurse identify is most susceptible to experiencing erectile dysfunction as a consequence of his drug regimen? a. A patient who takes a biguanide for type 2 diabetes. b. A patient who takes a β-adrenergic blocker for hypertension. c. A patient who uses a proton pump inhibitor to control acid reflux. d. A patient who is taking a cephalosporin antibiotic in order to treat cellulitis.

b. A patient who takes a β-adrenergic blocker for hypertension. Antihypertensives are commonly implicated in cases of erectile dysfunction. Antibiotics, PPIs, and biguanides are less likely to negatively impact men's sexual function.

A man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? a. Negative bacterial culture b. Absence of genital lesions c. Reduction of genital warts d. No drainage from chancre sore

b. Absence of genital lesions Primary genital herpes is a viral disorder caused by the herpes simplex virus. Genital herpes results in painful, vesicular lesions. The lesions rupture, form crusts, and heal in 17 to 21 days. Genital warts are caused by the human papillomavirus. Genital herpes is caused by a viral infection (not bacterial). Syphilis is caused by a bacterial organism and results in a chancre, which is a painless, indurated lesion.

The patient is being treated for a recurrent episode of Chlamydia. What should the nurse include in patient teaching? a. If you are treated, your sexual partner will not need to be treated. b. Abstain from sexual intercourse for 7 days after finishing the treatment. c. You will probably get gonorrhea if you have another recurrence of Chlamydia. d. Because you have been treated before, you do not need to take all the medication this time.

b. Abstain from sexual intercourse for 7 days after finishing the treatment. Patients treated for Chlamydia infections should abstain from sexual intercourse for 7 days after treatment until all sexual partners have completed a full course of treatment to prevent recurrence, and a follow-up culture is done. A single-dose treatment is also available. Because Chlamydia and gonococcal infections are closely associated, they are frequently both treated, but having Chlamydia does not give the patient gonorrhea. Each time a patient is treated for Chlamydia, a full course of treatment is required.

A female patient is recovering from rectocele repair surgery. Which interventions should be included in the plan of care? (Select all that apply.) a. Maintain complete bed rest. b. Administer a stool softener. c. Provide a cleansing enema. d. Apply ice to the perineal area. e. Urinary catheter care twice a day. f. Sitz bath may be used in a few days.

b. Administer a stool softener. d. Apply ice to the perineal area. e. Urinary catheter care twice a day. Administering a stool softener will reduce straining and disruption of the surgical repair. Ice will reduce pain and swelling at the surgical site. Urinary catheter care is provided twice a day to reduce catheter-associated urinary tract infections. A sitz bath may be given a few days after surgery for comfort. Maintaining strict bed rest is not indicated. A cleansing enema is provided before surgery, not after.

Which reinforcement of teaching for the patient undergoing a vasectomy is correct? a. The procedure involves ligation of the corpora cavernosa b. Alternative forms of birth control should be used for 6 weeks post operatively c. If the surgery is effective, ejaculation should not occur post operatively d. Weight gain and decrease in muscle mass are common side effects

b. Alternative forms of birth control should be used for 6 weeks post operatively

A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? a. Place packing in the patient's nares. b. Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d. Ask the patient to gently blow the nose to clear the drainage.

b. Apply a loose gauze pad under the patient's nose. Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose.

The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take? a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Have the patient say "ah" while noting elevation of soft palate. d. Ask the patient to push the tongue to either side against resistance.

b. Ask the patient to shrug the shoulders against resistance. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

A 24-yr-old patient had breast augmentation surgery and will be discharged the same day. What instructions should the nurse provide to minimize the risk of complications in the immediate recovery period? a. Avoid wearing a bra until postoperative day 3. b. Avoid strenuous exercise during her recovery period. c. Sleep in a semi-Fowler's position until her scheduled follow-up appointment. d. Enlist a friend or family member to perform passive range-of-motion exercises.

b. Avoid strenuous exercise during her recovery period. As with all types of breast surgery, strenuous exercise is contraindicated during the recovery period after breast augmentation. A bra should be worn to prevent dehiscence and provide comfort. Sleeping in a semi-Fowler's position is not necessary, and passive range-of-motion exercises should be avoided at first.

During the health history interview, a 73-yr-old male patient states that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give anticipatory guidance about what condition? a. A tumor of the prostate b. Benign prostatic hyperplasia c. Bladder atony because of age d. Age-related altered innervation of the bladder

b. Benign prostatic hyperplasia Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men older than age 50 years and 80% of men older than age 80 years. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure

b. Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A 23-yr-old woman admitted with a possible ectopic tubal pregnancy reports sudden intense pelvic pain radiating to the left shoulder. Which action by the nurse should receive the highest priority? a. Observe the amount of vaginal bleeding every 15 minutes for 1 hour. b. Check the vital signs and immediately notify the health care provider. c. Administer the prescribed pain medication and reassess in 30 minutes. d. Assess the fetal heart tones and determine the presence of fetal movement.

b. Check the vital signs and immediately notify the health care provider. A ruptured ectopic pregnancy may produce pelvic or abdominal pain and vaginal bleeding. If the tube ruptures, the pain is intense and may be referred to the shoulder. External vaginal bleeding may not be an accurate indicator of actual blood loss. Vital signs should be monitored closely along with observation for signs of shock. A ruptured ectopic pregnancy is an emergency because of the risk of hemorrhage and hypovolemic shock. The patient may need a blood transfusion and IV fluid therapy. In addition, the patient will need emergency surgery. Fetal assessment is not indicated for an ectopic pregnancy.

The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? a. Provide the patient with diversional activities. b. Document the activity in the patient's health record. c. Take the patient's blood pressure sitting and standing. d. Ask if the patient is feeling either anxious or depressed.

b. Document the activity in the patient's health record. Patients with Parkinson's disease are taught to rock from side to side to stimulate balance mechanisms and decrease akinesia.

The nurse should explain to the patient who has erectile dysfunction (ED) that (select all that apply) a. the most common cause is benign prostatic hypertrophy. b. ED may be due to medications or conditions such as diabetes. c. only men who are 65 years or older benefit from PDE5 inhibitors. d. there are medications and devices that can be used to help with erections. e. this condition is primarily due to anxiety and best treated with psychotherapy.

b. ED may be due to medications or conditions such as diabetes. d. there are medications and devices that can be used to help with erections.

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? (Select all that apply.) a. Drink milk with each meal. b. Eat 20 to 30 g of fiber per day. c. Use an oral laxative every day. d. Limit intake of caffeinated beverages. e. Drink 1800 to 2800 mL of water or juice. f. Establish bowel evacuation time at bedtime.

b. Eat 20 to 30 g of fiber per day. d. Limit intake of caffeinated beverages. e. Drink 1800 to 2800 mL of water or juice. The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A 25-yr-old male patient has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? a. Prevent urinary tract infection. b. Encourage him to share his feelings. c. Monitor the patient every 15 minutes. d. Teach him about using the gastrocolic reflex.

b. Encourage him to share his feelings. To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will need a wheelchair and have impaired sexual function. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.

A male patient with a history of transient ischemic attacks (TIAs) is undergoing rehabilitation following an ischemic stroke. The patient's medical history is likely to be related to what health problems? a. Inguinal hernia b. Erectile dysfunction c. Testosterone deficiency d. Benign prostatic hyperplasia (BPH)

b. Erectile dysfunction Stroke is a common cause of erectile dysfunction. A stroke and underlying cardiovascular disease is unlikely to be related to an inguinal hernia, testosterone deficiency, or BPH.

The nurse is teaching health promotion to a variety of women in a community center. How should the nurse respond when asked about when a female should begin having a Pap smear? a. Every year beginning at age 30 years b. Every 3 years beginning at age 21 years c. Every 3 years beginning at age 18 years if sexually active d. Every year beginning at the onset of menarche and continuing until menopause

b. Every 3 years beginning at age 21 years

The patient at the clinic reports abdominal bloating, depression, and irritability related to premenstrual syndrome. What should the nurse recommend initially? (Select all that apply.) a. Take diuretics. b. Exercise regularly. c. Take antidepressants. d. Take antianxiety agents. e. Increase pork, chicken, and milk intake. f. Consider psychological counseling to resolve symptoms.

b. Exercise regularly. e. Increase pork, chicken, and milk intake. The nurse can recommend regular exercise to help manage stress, elevate the mood, and have a relaxing effect. Eating foods rich in vitamin B6 (pork, milk, and legumes) and tryptophan (dairy and poultry) will promote serotonin production and improve symptoms. Diuretics, antidepressants, and antianxiety agents are not prescribed unless symptoms persist or interfere with daily functioning. Psychological counseling does not address physiological symptoms, but it may improve coping mechanisms.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) a. Judgment b. Eye opening c. Abstract reasoning d. Best motor response e. Best verbal response f. Cranial nerve function

b. Eye opening d. Best motor response e. Best verbal response The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? a. Alcohol use b. Hypertension c. Hyperlipidemia d. Oral contraceptive use

b. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

b. Hypotension

The nurse would expect what assessment finding in a patient admitted with a left-sided stroke? a. Impulsivity b. Impaired speech c. Left-side neglect d. Short attention span

b. Impaired speech Manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

What should the nurse emphasize when teaching a woman diagnosed with pelvic inflammatory disease (PID)? a. The importance of contraception b. Manifestations of further infection c. The importance of maintaining hygiene d. Benefits of hormone replacement therapy (HRT)

b. Manifestations of further infection PID frequently progresses to serious infection of the reproductive structures. The diagnosis does not present a particular need for contraception or specific hygiene measures. HRT is not used to treat PID.

The nurse is asked to teach an adolescent female patient about menstruation. What is important for the nurse to include when teaching the adolescent? a. The length of the menstrual cycle should be 28 days. b. Menstrual cycles are often irregular for the first 1 to 2 years. c. The female loses around 1 cup of blood with each menstrual period. d. Follicle-stimulating hormone (FSH) causes maturity of the follicle for ovulation.

b. Menstrual cycles are often irregular for the first 1 to 2 years. Teaching the patient that menstrual cycles are often irregular for the first 1 to 2 years is important. The length of a menstrual cycle may be from 21 to 35 days, with the average length being 28 days. About 20 to 80 mL (which at most is only 1/3 cup) of blood is lost with each menstrual period. FSH begins the follicle maturation, but LH must be present for complete maturation and ovulation to occur.

A female patient reports a throbbing headache. The nurse learns the patient has had photophobia and headaches previously. Which diagnosis should the nurse suspect? a. Cluster headache b. Migraine headache c. Polycythemia vera d. Hemorrhagic stroke

b. Migraine headache Although a headache may occur with any of these options, a migraine headache is the only one that has a throbbing headache with an aura (the photophobia). Headache from polycythemia vera is from erythrocytosis. The cluster headache pain is sharp and stabbing. The headache associated with a hemorrhagic stroke has a sudden onset and is not recurrent.

Which task could the registered nurse delegate to unlicensed assistive personnel (UAP) during the care of a patient who has had recent transverse rectus abdominis musculocutaneous (TRAM) flap surgery? a. Document the condition of the patient's incisions. b. Mobilize the patient in a slightly hunched position. c. Change the patient's abdominal and chest dressings. d. Change the parameters of the patient-controlled analgesic (PCA) pump.

b. Mobilize the patient in a slightly hunched position. Mobilization of a postsurgical patient may be delegated, and a patient who has had a TRAM flap should not stand or walk fully erect in order to minimize strain on the incisions. Changing dressings, assessing wounds, and reprogramming a PCA pump are not appropriate tasks to delegate to UAP.

When teaching nursing students about the male sexual response, what should the nurse call the phase that includes ejaculation? a. Plateau phase b. Orgasmic phase c. Resolution phase d. Excitement phase

b. Orgasmic phase The orgasmic phase is when ejaculation occurs from contraction of the penile and urethral musculature propelling the sperm outward through the meatus. The excitement phase is manifested by penile erection in response to sexual stimulation. The plateau phase is when the erection is maintained. There is a slight increase in vasocongestion and testicle size, and the glans penis may be more reddish-purple. The resolution phase is after ejaculation when the penis gradually returns to its unstimulated, flaccid state.

The nurse plans to assist with needle aspiration and irrigation of the corpora cavernosa for the patient with which disorder? a. Phimosis b. Priapism c. Benign Prostatic Hyperplasia d. Prostatitis

b. Priapism

The nurse is performing an admission assessment of an older adult male patient prior to bladder resection surgery. What assessment finding of the patient's genitourinary system would be unexpected? a. The patient's left testicle hangs lower than his right. b. Pubic hair is absent from the patient's genital region. c. The patient's intestines are not palpable through the inguinal rings. d. The patient's foreskin can be manually retracted to expose the meatus.

b. Pubic hair is absent from the patient's genital region. An absence of pubic hair is an unexpected finding in an older male patient. It is common for the left testicle to hang lower than the right, and the intestines are often not palpable through the inguinal rings. The foreskin should be easily retractable.

A 50-yr-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What strategy should the nurse use to prevent a common cause of death for patients with ALS? a. Reduce fat intake b. Reduce the risk of aspiration c. Decrease injury related to falls d. Decrease pain secondary to muscle weakness

b. Reduce the risk of aspiration Reducing the risk of aspiration can help prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients.

The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? a. Avoid sexual activity for 24 to 48 hours. b. Remain lying down for at least 15 minutes. c. Return to the clinic in 6 months for a second dose. d. Use two methods of birth control to avoid pregnancy.

b. Remain lying down for at least 15 minutes. To prevent syncope (fainting) during and after the administration of Gardasil, the patient should remain sitting or lying down for 15 minutes. The vaccine is not recommended during pregnancy. Gardasil vaccine is given in three IM doses over a 6-month period. There are no sexual activity restrictions after administration of Gardasil.

The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls? (Select all that apply.) a. Memory deficit b. Sensory deficit c. Motor function deficit d. Cranial and spinal nerves e. Reticular activation system f. Central nervous system changes

b. Sensory deficit c. Motor function deficit f. Central nervous system changes Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.

A pregnant woman is experiencing morning sickness and breast tenderness. In the ninth week after her last menstrual period, she is rushed to the hospital with severe left shoulder pain, blood pressure of 90/60 mm Hg, and heart rate of 112 beats/min. What is the best diagnostic test that is expected to be ordered? a. Serum hemoglobin b. Transvaginal ultrasound c. 12-lead electrocardiogram (ECG) d. Serial β-human chorionic gonadotropin levels

b. Transvaginal ultrasound Because the patient is known to be pregnant, a transvaginal ultrasound will be used to assess for ectopic pregnancy and tubal rupture. Serum hemoglobin and 12-lead ECG would not define a diagnosis related to the manifestations that she has. Serial β-human chorionic gonadotropin levels could be used if the patient was stable to determine if a spontaneous abortion is occurring because the levels would decrease over time.

Syphilis is caused by which microorganism? a. Chlamydia trachomatis b. Treponema pallidum c. Human papillomavirus d. Herpes simplex virus

b. Treponema pallidum

The nurse administers sildenafil (Viagra) to a patient with erectile dysfunction. Which instruction is correct? a. The drug works by decreasing blood flow to the penis b. Viagra should be taken one hour before sexual activity c. The drug is most effective when taken twice daily d. Hearing loss is a common but temporary side effect of the drug

b. Viagra should be taken one hour before sexual activity

In telling a patient with infertility what she and her partner can expect, the nurse explains that a. ovulatory studies can help determine tube patency. b. a hysterosalpingogram is a common diagnostic study. c. for most couples, the cause of infertility is usually not found. d. semen analysis is performed only if testosterone levels are low.

b. a hysterosalpingogram is a common diagnostic study.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

b. altering the endothelial lining of cerebral capillaries.

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient describes "having double vision" when looking down. During the neurologic examination, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. an injury to CN VI on both sides. c. a stiff neck from the hyperextension injury. d. facial swelling from the scrape on the bottom of the pool.

b. an injury to CN VI on both sides.

The most common early symptom of a spinal cord tumor is a. urinary incontinence. b. back pain that worsens with activity. c. paralysis below the level of involvement. d. impaired sensation of pain, temperature, and light touch.

b. back pain that worsens with activity.

A 42-year-old retired sex worker who became sexually active at age 14 is at risk for development of: a. endometriosis b. cervical carcinoma c. breast cancer d. uterine carcinoma

b. cervical carcinoma

A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.

b. controlling fever with prescribed drugs and cooling techniques.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

b. elevate the head of the bed to 30 degrees.

A patient scheduled for a radical prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to this patient, the nurse should keep in mind that a. PD5 inhibitors are not recommended in prostatectomy patients. b. erectile dysfunction can occur even with a nerve-sparing procedure. c. the most common complication of this surgery is bowel incontinence. d. the provider will place a penile implant during surgery to treat any dysfunction.

b. erectile dysfunction can occur even with a nerve-sparing procedure.

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. helping the patient to stand to void. c. keeping a urinal in place at all times. d. catheterizing the patient every 4 hours.

b. helping the patient to stand to void.

During the admitting neurologic examination, the nurse determines the patient has speech difficulties with weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.

b. left middle cerebral artery.

The nurse is assessing the muscle strength of an older adult. The nurse knows the findings cannot be compared with those of a younger adult because a. nutritional status is better in young adults. b. muscle tone and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.

b. muscle tone and strength decrease in older adults.

The nurse explains to the patient with chronic bacterial prostatitis who is undergoing antibiotic therapy that (select all that apply) a. all patients require hospitalization. b. pain will lessen once treatment has ended. c. the course of treatment is generally 1 to 2 weeks. d. long-term therapy may be needed in immunocompromised patient. e. if the condition is not treated appropriately, he is at risk for prostate cancer.

b. pain will lessen once treatment has ended. d. long-term therapy may be needed in immunocompromised patient.

In assessing a patient for testicular cancer, the nurse understands that the manifestations of this disease often include a. urinary frequency. b. painless mass in the scrotal area. c. erectile dysfunction with retrograde ejaculation. d. rapid onset of dysuria with scrotal swelling and fever.

b. painless mass in the scrotal area.

Provide emotional support to a patient with an STI by a. offering information on how safer sexual practices can prevent STIs. b. showing concern when listening to the patient who expresses negative feelings. c. reassuring the patient that the disease is highly curable with appropriate treatment. d. helping the patient who received an STI from their sexual partner in forgiving the partner.

b. showing concern when listening to the patient who expresses negative feelings.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: a. central cord syndrome. b. spinal shock syndrome. c. anterior cord syndrome. d. Brown-Séquard syndrome.

b. spinal shock syndrome. About 50% of people with acute spinal cord injury develop spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

A primary HSV infection differs from recurrent HSV episodes in that (select all that apply) a. only primary infections are sexually transmitted. b. symptoms are less severe during recurrent episodes. c. transmission of the virus to a fetus is less likely during primary infection. d. systemic manifestations, such as fever and myalgia, are more common in primary infection. e. lesions from recurrent HSV are more likely to transmit the virus than lesions from primary HSV.

b. symptoms are less severe during recurrent episodes. d. systemic manifestations, such as fever and myalgia, are more common in primary infection.

For a patient who is suspected of having a stroke, the most important piece of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared.

A patient comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? a. "I should avoid alcohol use for at least 2 weeks." b. "I will have my sexual partner come in for treatment." c. "After I start the antibiotic, it is safe to have sex again." d. "After treatment, I do not need to return to the clinic for retesting."

c. "After I start the antibiotic, it is safe to have sex again." Patients should avoid sexual intercourse for 7 days after completing treatment with antibiotics. All sexual contact of patients with gonorrhea must be evaluated and treated to prevent reinfection. Patients should abstain from sexual intercourse and alcohol during treatment. Sexual intercourse allows the infection to spread and can delay healing. Alcohol is irritating to the healing urethral walls. Patients with uncomplicated gonorrhea who are treated do not need to return to the clinic to confirm the disease has been cured.

The nurse provides dietary instructions to the in-home caregiver of a 45-yr-old man with Huntington's disease. The nurse should be most concerned if the caregiver makes which statement? a. "Depression is common and may cause a decrease in appetite." b. "If swallowing becomes difficult, a feeding tube may be needed." c. "Calories should be restricted to prevent unnecessary weight gain." d. "Muscles in the face are affected, and chewing may become impossible."

c. "Calories should be restricted to prevent unnecessary weight gain." Patients with Huntington's disease may require 4000 to 5000 calories/day to maintain body weight. Weight loss occurs in patients with Huntington's disease because of choreic movements, difficulty swallowing, depression, and mental deterioration.

A woman has sought care because of urinary incontinence. She states that running or jumping often precipitates leakage of urine, an event that has been occurring with increasing regularity in recent months. Which assessment question is most relevant to try to determine the cause of the patient's problem? a. "Do you know if your mother or sisters have had similar problems?" b. "Do you find that you are prone to frequent urinary tract infections?" c. "Did you have any muscle damage when giving birth to your children?" d. "Do you take part in a regular program of physical exercise and stretching?"

c. "Did you have any muscle damage when giving birth to your children?" Trauma to the pelvic musculature during birth is often the cause of urge and stress incontinence in female patients. UTIs, family history, and exercise are less likely to contribute to an ongoing pattern of incontinence.

A woman is scheduled for her first Pap test. The nurse should provide which instructions? a. "A full bladder is needed for more accurate results." b. "You should rest for 2 to 3 hours after the procedure." c. "Do not douche for at least 24 hours before the procedure." d. "A Pap test will screen for sexually transmitted infections."

c. "Do not douche for at least 24 hours before the procedure." The patient should be told to not douche for at least 24 hours before a Pap test. The patient should empty the bladder before a Pap test. There are no activity restrictions after a Pap test. The patient should rest for 2 to 3 days after a conization. A culture or a smear tests for sexually transmitted infections. A Pap test is a cytologic study used to detect abnormal cells.

The nurse provides information to the caregiver of a 68-yr-old man with epilepsy who has tonic-clonic seizures. Which statement by the caregiver indicates a need for further teaching? a. "The jerking movements may last for 30 to 40 seconds" b. "It is normal for a person to be sleepy after a seizure." c. "I should call 911 if breathing stops during the seizure." d. "Objects should not be placed in the mouth during a seizure."

c. "I should call 911 if breathing stops during the seizure." Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.

The nurse is caring for an obese woman after a right mastectomy with axillary lymph node dissection. Which discharge instruction should the nurse include? a. "Arm exercises should not be started for 4 to 6 weeks." b. "Discontinue arm exercises if you have discomfort or pain." c. "Special massage therapy can decrease swelling in your arm." d. "Keep your right arm in a sling to decrease pain and swelling."

c. "Special massage therapy can decrease swelling in your arm." Decongestive therapy may be used for acute lymphedema and includes a massage-like technique to mobilize the subcutaneous accumulation of fluid. Arm exercises should be performed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. The arm exercises should be initiated after surgery and increased gradually. Pain medications should be administered 30 minutes before arm exercises. The operative arm should be kept at the level of the heart but not in a sling; a sling discourages use of the arm.

The nurse in the emergency room is performing an assessment on a client who sustained a right finger laceration from a fishhook while fishing. The nurse asks the client which priority question?​ a. "When was your last physical examination?" b. "Have you had a chest X-ray in the last year?" c. "When did you receive your last tetanus immunization?" d. "Have you ever sustained this type of injury in the past?"

c. "When did you receive your last tetanus immunization?" A client who sustains a laceration is at risk of developing complications such as osteomyelitis, gas gangrene, and tetanus. During the assessment, the nurse asks the client about the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. Although options a. and d. may be components of the assessment, these questions are not the priority. Option b. is unrelated to the data in the question.

A 22-yr-old man is being treated at a college health care clinic for gonorrhea. What should the nurse include in patient teaching? a. "While being treated for the infection, you will not be able to pass this infection on to your sexual partner." b. "It is important to complete your full course of antibiotics in order to ensure that you become resistant to reinfection." c. "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." d. "The symptoms will resolve on their own, but it is important for you to abstain from sexual activity while this is occurring."

c. "While you're taking the antibiotics, you will need to abstain from participating in sexual activity and drinking alcohol." Treatment for gonorrhea necessitates abstinence from sexual activity (to prevent infection of partners) and alcohol (to avoid urethral irritation). The disease is not self-limiting, nor does successful treatment confer future resistance.

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? a. A 42-yr-old patient with multiple sclerosis who was admitted with sepsis b. A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia. c. A 38-yr-old patient with myasthenia gravis who declined prescribed medications d. A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings.

c. A 38-yr-old patient with myasthenia gravis who declined prescribed medications Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a. A 92-yr-old female patient who takes warfarin for atrial fibrillation b. A 28-yr-old male patient who uses marijuana after chemotherapy to ease nausea c. A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco. d. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches

c. A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco. Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes is a significant stroke risk factor. Smoking nearly doubles the risk of a stroke. Other risk factors include drug use (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease, such as atrial fibrillation.

The nurse caring for patients in a primary care clinic identifies which patient as at highest risk for developing breast cancer? a. A 59-yr-old who has inherited the APC gene b. A 25-yr-old with fibrocystic breast disease c. A 72-yr-old with a family history of breast cancer d. A 43-yr-old who is obese and leads a sedentary lifestyle

c. A 72-yr-old with a family history of breast cancer The risk factors most associated with breast cancer are female gender, advancing age, and family history. The incidence of breast cancer increases dramatically after age 60 years. Mutations in BRCA genes may cause 5% to 10% of breast cancers; The APC gene is associated with colon cancer. Obesity and physical inactivity increase the risk for breast cancer. Fibrocystic breast disease is not associated with the development of breast cancer.

A patient with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? a. Reduction of genital warts b. Negative bacterial culture c. Absence of genital lesions d. No drainage from chancre sore

c. Absence of genital lesions

In working with teenagers, what should the nurse include when teaching about prevention of STIs? a. Spermicidal jellies reduce the risk of getting STIs. b. Douches for women and cleaning the penis will prevent STIs. c. Abstinence and then latex barriers, such as condoms, are the best prevention. d. Getting an STI is embarrassing so you will want to use preventive measures.

c. Abstinence and then latex barriers, such as condoms, are the best prevention. Abstinence and then latex barriers, such as condoms, are the best prevention of STIs. Spermicidal jellies or creams do not reduce the risk of contracting STIs. Most STIs are curable, but complications are serious and costly if they are not cured. Douches may spread the infection, undermine local immune responses, and do not prevent STIs. Cleansing of the penis will provide comfort after an STI has been diagnosed but will not prevent STIs. Nurses should provide supportive counseling and not reinforce feelings of embarrassment.

Which problem is the nursing priority when caring for a patient with myasthenia gravis (MG)? a. Acute confusion b. Bowel incontinence c. Activity intolerance d. Disturbed sleep pattern

c. Activity intolerance The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG. Although sleep disturbance is likely, activity intolerance is of primary concern.

The nurse coordinates postoperative care for a 70-year-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Teach the patient how to perform Kegel exercises. b. Provide instructions to the patient on catheter care. c. Administer oxybutynin (Ditropan) for bladder spasms. d. Manually irrigate the urinary catheter to restore catheter flow. e. Monitor catheter drainage for clots and increase flow of irrigation as needed.

c. Administer oxybutynin (Ditropan) for bladder spasms. d. Manually irrigate the urinary catheter to restore catheter flow. e. Monitor catheter drainage for clots and increase flow of irrigation as needed. The nurse may delegate the following to an LPN/VN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, and administer antispasmodics and analgesics as needed. A registered nurse may not delegate teaching, assessments, or clinical judgments to the LPN/VN.

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach the patient about self-care? (Select all that apply.) a. Use of antiseizure medications b. Preparing for a nerve block to manage pain c. Administration of corticosteroid medications d. Surgery if conservative therapy is not effective e. Dark glasses and artificial tears to protect the eyes f. A facial sling to support the muscles and facilitate eating

c. Administration of corticosteroid medications e. Dark glasses and artificial tears to protect the eyes f. A facial sling to support the muscles and facilitate eating Self-care for Bell's palsy includes use of corticosteroid medications to decrease inflammation of the facial nerve (cranial nerve VII). Dark glasses and artificial tears protect the cornea from drying because of the inability to close the eyelid. The occupational therapist may fit a facial sling to support muscles and facilitate eating. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.

A patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? a. Position the patient on her weak side most of the time. b. Avoid the use of pillows to promote independence in positioning. c. Alternate the patient's positioning between supine and side-lying. d. Establish a schedule for the massage of areas where skin breakdown emerges.

c. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a. Ask the patient to close their eyes and slowly bring the tips of the index fingers together. b. Ask the patient to close their eyes and identify the presence of a common object on the forearm. c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes their eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

The nurse is caring for a patient diagnosed with breast cancer who just underwent an axillary lymph node dissection. What intervention should the nurse use to decrease the lymphedema? a. Keep affected arm flat at the patient's side. b. Apply an elastic bandage on the affected arm. c. Assess blood pressure only on unaffected arm. d. Restrict exercise of the affected arm for 1 week.

c. Assess blood pressure only on unaffected arm. Blood pressure readings, venipunctures, and injections should not be done on the affected arm. Elastic bandages should not be used in the early postoperative period because they inhibit collateral lymph drainage. The affected arm should be elevated above the heart, and isometric exercises are recommended and gradually increased starting in the recovery room to reduce fluid volume in the arm.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? a. Insert a rectal stimulant suppository. b. Have the patient to gradually increase intake of high-fiber foods. c. Assess bowel movements for frequency, consistency, and volume. d. Teach the patient to avoid all caffeinated and carbonated beverages.

c. Assess bowel movements for frequency, consistency, and volume. The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study? a. Assess the patient's immunization history. b. Screen the patient for any metal parts or a pacemaker. c. Assess the patient for allergies to shellfish, iodine, or dyes. d. Assess the patient's need for tranquilizers or antiseizure medications.

c. Assess the patient for allergies to shellfish, iodine, or dyes. Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c. Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees.

c. Assess the patient's level of consciousness. The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

A client is admitted with the diagnosis of tetanus. For which clinical indicator(s) should the nurse not assess the client? a. Restlessness b. Muscular rigidity​ c. Atony of facial muscles​ d. Respiratory tract spasms​ e. Spastic voluntary muscle contractions​

c. Atony of facial muscles​ Toxins from bacilli invade nervous tissue, causing restlessness. Toxins from bacilli invade nervous tissue, causing muscle spasms and muscular rigidity. Toxins from the bacillus invade nervous tissue; respiratory spasms may result in respiratory failure. Toxins from bacilli invade nervous tissue, causing spastic contraction of voluntary muscles. Tetanus causes spasms of facial muscles, resulting in a grotesque grinning expression (risus sardonicus) and spasms of masticatory muscles (trismus), not atony of facial muscles.

A hospitalized older patient reports his foreskin is retracted and will not return to normal. Which action is the priority? a. Start oral antibiotics. b. Apply ice to reduce swelling. c. Attempt to move the foreskin over the glans. d. Call the provider to prepare for circumcision.

c. Attempt to move the foreskin over the glans. Paraphimosis can occur when the foreskin is pulled back during bathing, during catheter insertion, or after intercourse and not returned to the normal position. Attempting to return the foreskin over glans is the priority action. If the nurse is unsuccessful, then ice would be applied to decrease swelling. If the foreskin is not returned to the normal position manually by the health care provider, then circumcision would be indicated. Paraphimosis is considered a urologic emergency because arterial blood flow to the glans penis is impaired.

The nurse teaches a 30-yr-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? a. Hamburger with cheese, pudding, and coffee b. Grilled steak, French fries, and vanilla shake c. Baked chicken, peas, apple slices, and skim milk d. Grilled cheese sandwich, onion rings, and hot tea

c. Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.

When establishing a diagnosis of multiple sclerosis (MS), which diagnostic tests should the nurse expect? (Select all that apply.) a. EEG b. ECG c. CT scan d. Carotid duplex scan e. Evoked response testing f. Cerebrospinal fluid analysis

c. CT scan e. Evoked response testing f. Cerebrospinal fluid analysis No definitive diagnostic test exists for MS. Along with history and physical examination, CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI are used to establish a diagnosis of MS. EEG, ECG, and carotid duplex scan are not used to diagnose MS.

A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? a. Codeine b. Phenytoin c. Ceftriaxone d. Acetaminophen

c. Ceftriaxone Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A patient is 1 day postoperative after a transurethral resection of the prostate (TURP). Which event is an unexpected finding? a. Requires 2 tablets of Tylenol #3 during the night. b. Reports fatigue and claims to have minimal appetite. c. Continuous bladder irrigation infusing with decreased output. d. Expresses anxiety about his planned discharge home the next day.

c. Continuous bladder irrigation infusing with decreased output. A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

To monitor the progression of decreased urinary stream, the nurse should encourage which type of regular screening? a. Uroflowmetry b. Transrectal ultrasound c. Digital rectal examination (DRE) d. Prostate-specific antigen (PSA) monitoring

c. Digital rectal examination (DRE) DRE is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia (BPH) in men older than 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.

A daily dose of prednisone is prescribed for a client. A nurse provides instructions to the client regarding the administration of the medication and instructs the client that the best time to take this medication is which of the following? a. At noon b. At bedtime c. Early morning d. Any time, at the same time, each day

c. Early morning Corticosteroids (glucocorticoids) should be administered before 9 am. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning.

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Check for bowel impaction c. Elevate the head of the bed d. Administer intravenous hydralazine

c. Elevate the head of the bed Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

A 58-yr-old woman is 1-day postoperative after an abdominal hysterectomy. Which intervention should the nurse perform to prevent VTE? a. Place the patient in a high Fowler's position. b. Provide pillows to place under the patient's knees. c. Encourage the patient to change positions frequently. d. Teach the patient deep breathing and coughing exercises.

c. Encourage the patient to change positions frequently. The patient should be encouraged to change positions frequently and ambulate to prevent venous stasis. The high Fowler's position and pressure under the knees should be avoided to prevent VTE. Deep breathing and coughing are therapeutic exercises but do not directly address the risk of VTE.

A 29-yr-old primiparous patient is breastfeeding a 3-wk-old infant. She reports recent breast tenderness, redness, and fever. Which teaching point should the nurse reinforce when following up on her care? a. Refer the patient for a mammogram as quickly as possible. b. Encourage the patient to continue breastfeeding her infant. c. Ensure patient adheres to her prescribed antibiotic regimen. d. Teach the patient to use warm compresses and the self-limiting nature of illness.

c. Ensure patient adheres to her prescribed antibiotic regimen. Mastitis normally requires antibiotic therapy that is closely adhered to. Breastfeeding should be continued if possible, but effective treatment of infection would be the immediate priority. If a palpable mass develops, medical follow-up may be needed to determine if an abscess is present. Mastitis is not necessarily self-limiting, and mammography is not normally indicated.

An older adult male patient with hypertension is prescribed amlodipine. The nurse should assess for which possible adverse effect? a. Gynecomastia b. Increased sex drive c. Erectile dysfunction d. Prostate gland enlargement

c. Erectile dysfunction Some antihypertensive medications (e.g., amlodipine) may cause erectile dysfunction (or impotence), decreased sex drive, and difficulty achieving orgasm.

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

c. Flexion-rotation

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/VN? a. Screen patient for tPA eligibility. b. Assess the patient's ability to swallow. c. Give scheduled anticoagulant medications. d. Place seizure precaution equipment in room.

c. Give scheduled anticoagulant medications. Assessment and screening are considered part of the registered nurse scope of practice. The LPN/VN can give PO or subcutaneous anticoagulant medications. Anticoagulant medications are considered high risk and should be double-checked with another LPN/VN or RN. The UAP can place equipment needed for seizure precautions in the room.

The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional problems should the nurse expect in this patient? a. Lack of reflexes b. Endocrine problems c. Higher cognitive function problems d. Respiratory, vasomotor, and cardiac dysfunction

c. Higher cognitive function problems Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

A 19-year-old female presents with genital warts. Which of the following would cause this condition? a. Chlamydia trachomatis b. Adenovirus c. Human papillomavirus d. Herpes simplex virus

c. Human papillomavirus

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a. High blood flow to the brain b. Normal intracranial pressure c. Impaired blood flow to the brain d. Adequate autoregulation of blood flow

c. Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? a. Constipation b. Difficulty coping c. Impaired breathing d. Impaired nutritional status

c. Impaired breathing Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Respiratory needs are always the highest priority (ABCs).

When doing breast self-examination, the female patient should report which finding to the health care provider? a. Denser breast tissue b. Palpable rib margins c. Left nipple deviation d. Different sized breasts

c. Left nipple deviation Unilateral deviation of a nipple may be a clinical indicator of breast cancer or other problem and should be reported to the health care provider. Dense breast tissue, palpable rib margins, and different sized breasts are all normal findings.

The nurse is caring for a patient with breast cancer who is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make? a. Observe for alopecia. b. Determine visual acuity. c. Monitor cardiac rhythm. d. Assess mouth and throat.

c. Monitor cardiac rhythm. Doxorubicin (especially at high doses) may cause cardiotoxicity and heart failure. The nurse should monitor for dysrhythmias, electrocardiogram changes, and manifestations of heart failure. Other adverse effects of doxorubicin include stomatitis and alopecia, but these effects are not as serious as cardiac problems. Tamoxifen may cause visual changes.

A client recently diagnosed with Bell's palsy has many questions about the course of the disorder. The nurse explains which of the following? a. Pain occurs with transient ischemic attacks​ b. Cool compresses decrease facial involvement​ c. Most clients recover from the effects in a few months​ d. Body changes should be expected with residual effects​

c. Most clients recover from the effects in a few months​ The client should be assured that the symptoms are not caused by a stroke; the majority of clients recover in a few months. Bell's palsy is not caused by a transient ischemic attack (TIA). Paresis or paralysis of cranial nerve VII occurs; discomfort may or may not be present. Moist heat, not a cool compress, increases blood circulation to the nerve. The majority of clients recover without residual effects; occasionally some clients are left with evidence of Bell's palsy; exercises may help to maintain muscle tone; also, surgery may be necessary.

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Evaluate laboratory results for changes in the white cell count. b. Give acetaminophen for the headache and fever before the procedure. c. Notify the provider if signs of increased intracranial pressure are present. d. Administer antibiotics before the procedure to treat the potential meningitis.

c. Notify the provider if signs of increased intracranial pressure are present.

The patient has a history of cardiovascular disease and has developed erectile dysfunction. He is frustrated because he is taking nitrates and cannot take erectogenic medications. What should the nurse do first? a. Give the patient choices for penile implant surgery. b. Recommend counseling for the patient and his partner. c. Obtain a thorough sexual, health, and psychosocial history. d. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.

c. Obtain a thorough sexual, health, and psychosocial history. The nurse's first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.

What should the nurse include when teaching about early detection of ovarian cancer? a. Report any unusual vaginal bleeding. b. Use estrogen with progestin for menopause. c. Obtain annual bimanual pelvic examinations. d. Receive a preventive bilateral oophorectomy.

c. Obtain annual bimanual pelvic examinations. Because it is difficult for a patient to detect early clinical indicators of ovarian cancer, the best method of early detection is to have a yearly bimanual pelvic examination to palpate for an ovarian mass. Although pelvic or vaginal bleeding should be reported soon after it occurs, this rarely occurs with ovarian cancer and is not an early symptom. Oral contraceptives may be used or a preventive bilateral oophorectomy may be done to reduce the risk, but they would not be done to detect early ovarian cancer.

The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging should the nurse expect to note in older adults? a. Quicker reaction time b. Improved sense of taste c. Orthostatic hypotension d. Hyperactive deep tendon reflexes

c. Orthostatic hypotension Older adults are more likely to have orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score, diminished deep tendon reflexes, and slowed reaction times.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. An older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale

Which nursing action is indicated when providing immediate care for a female patient who is a victim of a sexual assault? a. Administering a pregnancy test b. Monitoring of the patient's vital signs c. Providing emotional and nonjudgmental support d. Ensuring the patient is left alone whenever possible

c. Providing emotional and nonjudgmental support Many sexual assault survivors need emotional and nonjudgmental support following the assault. A pregnancy test is premature, and the patient should not be left alone. There is rarely a specific indication for close monitoring of vital signs unless the extent of physical injury indicates a need.

The nurse is planning psychosocial support for the family of the patient who had a stroke. What factor will have the greatest impact on family coping? a. Specific patient neurologic deficits b. The patient's ability to communicate c. Rehabilitation potential of the patient d. Presence of complications of a stroke

c. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe, the ability of the patient to recover is most likely to positively impact the family's coping. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? a. Pain assessment b. Glasgow Coma Scale c. Respiratory assessment d. Musculoskeletal assessment

c. Respiratory assessment Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

The patient has a low-grade cancer on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago, his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations indicate prostate cancer may be extending and require a change in the plan of care? (Select all that apply.) a. Casts in his urine b. Presence of α-fetoprotein c. Serum PSA level 10 ng/mL d. Onset of erectile dysfunction e. Nodularity of the prostate gland f. Development of a urinary tract infection

c. Serum PSA level 10 ng/mL e. Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth. Development of a urinary tract infection may indicate urinary retention or could be related to other issues.

An older adult female patient reports hair growing on her chin. How should the nurse explain this occurrence to this patient? a. There is too much estrogen in your body. b. There is not enough testosterone in your body. c. The estrogen in your body is decreased since menopause. d. The negative feedback system for your hormones is working.

c. The estrogen in your body is decreased since menopause. Many of the reproductive changes associated with aging for women occur related to the decrease in estrogen associated with menopause. After menopause there may be increased androgens. Estrogen stimulation is related to negative feedback, and GnRH would stimulate greater follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which results in a higher level of estrogen production by the ovaries. The negative feedback mechanism is not active because this system occurs when there is decreased level of circulating estrogen, which increases the level of GnRH production by the hypothalamus, leading to increased FSH and LH from the pituitary, which results in higher estrogen production.

The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test? a. The patient will be tilted on a table during the test. b. It is noninvasive, and there is no risk of electric shock. c. The pain that occurs is from the insertion of the needles. d. The passive sensor does not make contact with the patient.

c. The pain that occurs is from the insertion of the needles. With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.

Which characteristic should the nurse associate with a focal seizure? a. The patient lost consciousness during the seizure. b. The seizure involved both sides of the patient's brain. c. The seizure involved lip smacking and repetitive movements. d. The patient fell to the ground and became stiff for 20 seconds.

c. The seizure involved lip smacking and repetitive movements. Complex focal seizure is often characterized by lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? a. Seizures will develop within weeks or months. b. The family will be unable to cope with role reversals. c. There are often residual changes in personality and cognition. d. Referrals will be made to eliminate residual deficits from the damage.

c. There are often residual changes in personality and cognition. In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the nurse explain as the rationale for Chlamydia screening? a. Chlamydia is frequently comorbid with HIV. b. Untreated chlamydia infections can lead to sepsis. c. Untreated chlamydia infections may cause infertility. d. Chlamydia infections are treatable only in the early stages.

c. Untreated chlamydia infections may cause infertility. Because of the potential for infertility, routine screening for Chlamydia is recommended for women sexually active younger than age 25 years and annually for those older than 25 years with one or more risk factors for the infection. Chlamydia is not a primary risk for sepsis and is not noted to be strongly correlated with HIV infection. The disease is treatable at all stages of infection.

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? a. Present several thoughts at once so the patient can connect the ideas. b. Ask open-ended questions to give the patient the opportunity to speak. c. Use simple, short sentences with visual cues to enhance comprehension. d. Finish the patient's sentences to minimize frustration associated with slow speech.

c. Use simple, short sentences with visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the patient to comprehend and respond to conversation.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? a. Administer IV mannitol as ordered. b. Ventilator use to hyperoxygenate the patient. c. Use strict aseptic technique with dressing changes. d. Be aware of changes in ICP related to cerebrospinal fluid leaks.

c. Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The history and physical of a 29-year-old female patient are indicative of human papillomavirus (HPV) infection. What treatment option should be discussed with the patient? a. Gardasil b. Antibiotic therapy c. Wart removal options d. Treatment with antiviral drugs

c. Wart removal options Although discussion should focus on the various options for physically removing the symptomatic warts, the removal may or may not decrease infectivity. The HPV vaccine (Gardasil) is ineffective in cases of existing HPV, and neither antiviral nor antibiotic drugs are effective treatments.

A client with trigeminal neuralgia is being treated with carbamazepine (Tegretol). Which laboratory result would indicate that the client is experiencing an adverse reaction to the medication? a. Sodium level, 140 mEq/L b. Uric acid level, 5.0 mg/dL c. White blood cell count, 3000 cells/mm3 d. Blood urea nitrogen (BUN) level, 15 mg/dL

c. White blood cell count, 3000 cells/mm3 Adverse effects of carbamazepine (Tegretol) appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. The other options identify normal laboratory values.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

c. assisting and supporting the family in understanding any changes in behavior. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c. develops decreased level of consciousness and a headache within 48 hours of a head injury.

Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a 3-way urinary catheter with a 30-mL balloon. When he reports bladder spasms with the catheter in place, the nurse should a. deflate the balloon to 10 mL to decrease bulk in the bladder. b. deflate the balloon and then reinflate to ensure that the catheter is patent. c. explain that this feeling is normal and that he should not try to urinate around the catheter. d. stop the irrigation, assess the patient's vital signs, and notify the HCP of possible obstruction.

c. explain that this feeling is normal and that he should not try to urinate around the catheter.

A pregnant nurse is preparing to administer medications to a male patient with benign prostatic hypertrophy (BPH). The nurse should ensure she wears gloves when handling which medication? a. tamsulosin (Flomax) b. doxazosin (Cardura) c. finasteride (Proscar) d. terazosin (Hytrin)

c. finasteride (Proscar)

The nurse should advise the woman recovering from surgical treatment of an ectopic pregnancy that a. she has an increased risk for salpingitis. b. maintaining bed rest for 12 hours will assist in healing. c. having an ectopic pregnancy increases her risk for another. d. intrauterine devices and infertility treatments must be avoided.

c. having an ectopic pregnancy increases her risk for another.

A patient is having word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c. left middle cerebral artery.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. measure the patient's blood pressure.

A patient with benign prostatic hyperplasia (BPH) currently has no symptoms. Which type of collaborative care is most likely indicated first? a. a-adrenergic receptor blockers b. transurethral microwave thermotherapy c. monitoring with the "watchful waiting" approach d. Transurethral resection of the prostate (TURP)

c. monitoring with the "watchful waiting" approach

In caring for a patient with endometriosis, the nurse teaches the patient that interventions used to treat or cure this condition may include (select all that apply) a. radiation. b. antibiotic therapy. c. oral contraceptive pills. d. surgical removal of tissue. e. total abdominal hysterectomy and salpingo-oophorectomy.

c. oral contraceptive pills. d. surgical removal of tissue. e. total abdominal hysterectomy and salpingo-oophorectomy.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c. patency of the cerebral blood vessels.

To prevent or decrease age-related changes that occur after menopause in a patient who chooses not to take hormone therapy, the most important self-care measure to teach is a. maintaining usual sexual activity. b. increasing the intake of dairy products. c. performing regular aerobic, weight-bearing exercise. d. taking vitamin E and B-complex vitamin supplements.

c. performing regular aerobic, weight-bearing exercise.

A patient having TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.

Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would a. discuss the limitations of breast reconstruction. b. include her significant other in all conversations. c. promote an environment for expression of feelings. d. explain the importance of regular follow-up screening.

c. promote an environment for expression of feelings.

A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. helping the caregiver explore respite care options. c. promoting physical exercise and a well-balanced diet. d. teaching about the benefits and risks of ablation surgery.

c. promoting physical exercise and a well-balanced diet.

Which screening test is recommended by the American Cancer Society for men beginning at age 50 who are at risk for prostate cancer? a. serum cancer marker CA 125 b. computed tomography (CT) scan c. prostate specific antigen (PSA) d. transrectal ultrasound (TRUS)

c. prostate specific antigen (PSA)

Female orgasm is characterized by a. resolution. b. increased breast size. c. relaxation of cervical os. d. vasoconstriction and dystonia.

c. relaxation of cervical os.

An abnormal finding noted during physical assessment of the male reproductive system is a. descended testes. b. symmetric scrotum. c. slight clear urethral discharge. d. the glans covered with prepuce.

c. slight clear urethral discharge.

During neurologic testing, the patient can perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense. b. patellar reflexes. c. temperature perception. d. heel-to-shin movements.

c. temperature perception.

A normal male reproductive function that may be altered in a patient who undergoes an orchiectomy (removal of testes) is the production of a. PSA. b. GnRH. c. testosterone. d. seminal fluid.

c. testosterone.

Postoperative nursing care for the woman with a gynecologic fistula includes (select all that apply) a. bed rest. b. bladder training. c. warm sitz baths. d. perineal hygiene. e. use of daily enemas.

c. warm sitz baths. d. perineal hygiene.

A 60-yr-old woman comes to the clinic reporting unexpected bleeding. What statement should the nurse use regarding diagnosing the cause of bleeding? a. "It is probably the end of menopause." b. "A Pap smear is used to diagnose endometrial cancer." c. "A hysterectomy may be indicated to treat the bleeding." d. "An endometrial biopsy will help determine the cause of bleeding."

d. "An endometrial biopsy will help determine the cause of bleeding." With unexpected bleeding in a postmenopausal woman, an endometrial biopsy should be done to exclude or diagnose endometrial cancer. The abnormal bleeding should not be ignored just because she is postmenopausal. A hysterectomy with bilateral salpingo-oophorectomy with lymph node biopsies will be done to treat endometrial cancer if diagnosed. A Pap smear will not diagnose endometrial cancer unless it has spread to the cervix.

The nurse is obtaining a sexual history from a woman who is a new patient in the primary care clinic. It would be most appropriate for the nurse to ask which question first? a. "Have you ever had a sexually transmitted infection?" b. "Have you ever been in a relationship with anyone who hurt you?" c. "Have you ever been forced into sexual acts as a child or an adult?" d. "Are you satisfied with your sexual relationship with your partner?"

d. "Are you satisfied with your sexual relationship with your partner?" When taking a sexual health history, the nurse should begin with the least sensitive area of questioning and then move to more sensitive areas.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement provides the group accurate information? a. "Take the person to the hospital if a headache lasts for more than 24 hours." b. "Stroke symptoms usually start when the person is awake and physically active." c. "A person with a transient ischemic attack has mild symptoms that will go away." d. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

d. "Call 911 immediately if a person develops slurred speech or difficulty speaking." Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

While summarizing teaching about genital herpes, which patient statement indicates a need for further instruction? a. "No cure is available for my genital herpes." b. "I will utilize my medication when I begin to have symptoms." c. "Genital herpes may be caused by herpes simplex virus type 1 or 2" d. "I am not able to infect a sexual partner unless I have active lesions."

d. "I am not able to infect a sexual partner unless I have active lesions." The majority of herpes simplex virus (HSV) transmission occurs during asymptomatic periods. When active lesions are present, the patient is most likely to infect others. There is no cure for HSV, but antiviral medication is prescribed for current infections or suppression of recurrent infections. Early treatment reduces the duration of ulcers and risk of transmission. HSV-1 is often associated with cold sores or fever blisters. HSV-2 has been more associated with genital disease. However, HSV-1 and HSV-2 can cause oral or genital lesions.

A nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs additional information if the client made which of the following statements? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on the unaffected side." c. "I should rinse my mouth if toothbrushing is painful." d. "I will try to eat my food either very warm or very cold."

d. "I will try to eat my food either very warm or very cold." Facial pain can be minimized by using cotton pads to wash the face, using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, sometimes an oral rinse after meals is helpful instead.

The nurse obtains a history from a 34-year-old man diagnosed with chlamydia. Which patient statement indicates additional teaching is required? a. "This infection can be cured by taking antibiotics." b. "It is important to use condoms for all sexual activity." c. "I will avoid sexual contact for 1 week after taking the antibiotics." d. "My sexual partner does not have symptoms and will not need treatment."

d. "My sexual partner does not have symptoms and will not need treatment." All sexual partners require treatment. Most men and women with chlamydial infections are either asymptomatic or have minor symptoms. Chlamydial infections are caused by Chlamydia trachomatis, a gram-negative bacterium. Antibiotics will cure this disease. Patients should avoid sexual intercourse for 7 days after completing treatment with antibiotics. Condoms should be used for all sexual contacts.

The nurse teaches a 53-yr-old patient about screening for early detection of breast cancer. Which statement requires clarification by the nurse? a. "I should plan to have a mammogram every year." b. "A breast examination should be done right after my menstrual period." c. "I will see the health care provider every year for a breast examination." d. "Self-breast examination is a reliable way to detect breast cancer early."

d. "Self-breast examination is a reliable way to detect breast cancer early." Screening for the early detection of breast cancer includes yearly mammograms starting at age 45 years. Breast self-examination (BSE) has benefits and limitations and may not be a reliable method for early detection of breast cancer. BSE is optional, but it should be done in premenopausal women right after the menstrual period when the breasts are less lumpy and tender.

The nurse is reinforcing teaching with a patient newly diagnosed with amyotrophic lateral sclerosis (ALS). Which statement would be appropriate to include in the teaching? a. "Even though the symptoms you have are severe, most people recover with treatment." b. "ALS results from excess chemicals in the brain, so symptoms can be controlled with medication." c. "You need to consider advance directives now, because you will lose cognitive function as the disease progresses." d. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."

d. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."

An appropriate question to ask the patient with painful menstruation to distinguish primary from secondary dysmenorrhea is a. "Does your pain become worse with activity or overexertion?" b. "Have you had a recent personal crisis or change in your lifestyle?" c. "Is your pain relieved by nonsteroidal antiinflammatory medications?" d. "When in your menstrual history did the pain with your period begin?"

d. "When in your menstrual history did the pain with your period begin?"

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? a. "I want to be rehabilitated for my daughter's wedding in 2 weeks." b. "Rehabilitation will be more work done by me alone to try to get better." c. "I will be able to do all my normal activities after I go through rehabilitation." d. "With rehabilitation, I will be able to function at my highest level of wellness."

d. "With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at their highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.

A 55-yr-old woman diagnosed with endometrial cancer is receiving brachytherapy. The nurse is most concerned if what is observed? a. Foul-smelling vaginal discharge b. 5 to 8 liquid stools over a period of 24 hours c. Using a bedpan instead of a bedside commode or toilet d. A personal companion is staying in the room for company

d. A personal companion is staying in the room for company Brachytherapy is internal radiation applied directly to the tumor. Health care providers should limit close contact with the patient to less than 30 minutes/day. Internal radiation causes the destruction of cells and results in a foul-smelling vaginal discharge. Internal radiation may cause systemic reactions such as nausea, vomiting, diarrhea, and malaise. The patient receiving brachytherapy is placed in a lead-lined private room and on absolute bed rest.

The nurse prepares to give temozolomide (Temodar) to a patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? a. Serum potassium and serum sodium levels b. Urine osmolality and urine specific gravity c. Cerebrospinal fluid pressure and cell count d. Absolute neutrophil count and platelet count

d. Absolute neutrophil count and platelet count Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/µL and platelet count greater than 100,000/µL.

Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? a. Contact with a person with syphilis 2 weeks ago b. Treatment for gonococcal pharyngitis before conception c. Treatment for C. trachomatis at her 20th week of gestation d. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery

d. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery The woman with active herpes simplex virus type 2 at the time of delivery has the greatest risk for the fetus, and the baby will be delivered by cesarean section to prevent infection. Syphilis has an average incubation period of 21 days, so even if the contact was sexual, the syphilis should not infect the baby at birth. The woman treated for gonococcal pharyngitis should have been cured with treatment, but the baby's eyes will be treated at birth to prevent gonorrheal eye infection regardless. Treatment of the pregnant woman with C. trachomatis prevents transfer of the infection to the fetus.

A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit because of the surgery? a. Increased heart rate b. Loss of coordination c. Impaired swallowing d. Altered sense of smell

d. Altered sense of smell Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.

The patient with breast cancer has a left mastectomy with axillary node dissection. Ten lymph nodes are resected with 3 positive for cancer cells. The patient has stage IIB breast cancer. Which nursing intervention would be most effective in planning care? a. Evaluate left arm lymphatic accumulation. b. Maintain joint flexibility and left arm function. c. Teach her about chemotherapy and radiation therapy. d. Assess the patient's response to the diagnosis of breast cancer.

d. Assess the patient's response to the diagnosis of breast cancer. Assessment is the first step in planning patient care. Because the nurse is the patient's advocate and this is an extremely stressful time for the patient and family, the nurse should focus on the patient's response to the diagnosis of breast cancer when planning care. The approach for the care of the left arm and teaching the patient about further therapy will be based on the initial assessment.

The nurse observes a student nurse assigned to start oral feedings for a patient with an ischemic stroke. Which action by the student will require the nurse to intervene? a. Giving the patient 1 ounce of water to swallow b. Telling the patient to perform a chin tuck before swallowing c. Assisting the patient to sit in a chair before feeding the patient d. Assessing cranial nerves III, IV, and VI before attempting feeding

d. Assessing cranial nerves III, IV, and VI before attempting feeding Many patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial nerves III, IV, and VI are responsible for ocular movements. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

What action should be recommended to a woman recovering from surgical repair of a fistula? a. Douche daily to prevent postoperative infection. b. Remove and cleanse her pessary on a daily basis. c. Resume normal activity to prevent adhesion formation. d. Ensure that she does not place stress on the repaired area.

d. Ensure that she does not place stress on the repaired area. After surgical repair of a fistula, the patient should avoid placing stress on the repaired region. Normal activity is not resumed until significant healing has occurred. Douching is contraindicated, and pessaries are used to treat prolapses, not fistulas.

A 30-yr-old woman reports the recent appearance of itchy, slightly painful lesions on her vulva, some of which have recently burst. Which STI should the nurse suspect first? a. Gonorrhea b. Chlamydia c. Genital warts d. Genital herpes

d. Genital herpes A primary episode of genital herpes is often marked by multiple small, vesicular lesions on the genitals. This symptomatology is not associated with genital warts, gonorrhea, or Chlamydia.

The nurse performs a breast examination on a 68-yr-old female patient. Which finding indicates further evaluation for breast cancer is needed? a. Bilateral pendulous breasts b. Right breast is warm, painful to touch c. Palpable lump that is tender and movable d. Irregular, nontender lump with induration

d. Irregular, nontender lump with induration Manifestations of breast cancer may include a palpable lump that is hard, irregular, poorly delineated, nonmobile, and nontender. Nipple retraction, peau d'orange, induration, and dimpling of the overlying skin may also be noted. Mastitis presents with breasts that are warm to touch, indurated, and painful. Atrophy of the mammary glands associated with aging may result in pendulous breasts. Manifestations of fibrocystic breast changes include palpable lumps that are round, well delineated, and freely movable. The lump is usually tender and increases in size and tenderness before menstruation.

Because of the risks, a 50-yr-old patient does not want hormone replacement therapy for perimenopausal symptoms. She asks the nurse how to minimize hot flashes and night sweats. What should the nurse recommend first? a. Increase warmth to avoid chills. b. Good nutrition to avoid osteoporosis c. Vitamin B complex and vaginal lubrication d. Keep the bedroom cool and limit alcohol use.

d. Keep the bedroom cool and limit alcohol use. To avoid hot flashes and sweating at night, decrease heat production with a cool environment, limit caffeine and alcohol, and practice relaxation techniques. Heat loss may be facilitated with increased circulation in the room, avoidance of heavy bedding, and wearing loose-fitting clothes. Warmth will facilitate hot flashes. Nutrition, vitamin B complex, and vaginal lubrication will help with other complications of perimenopause but not hot flashes and sweating at night.

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema.

d. Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.

A patient recently had a unilateral, right total mastectomy and axillary node dissection for the treatment of breast cancer. What nursing intervention should the nurse include in the patient's care? a. Immobilize the patient's right arm until postoperative day 3. b. Maintain the patient's right arm in a dependent position when at rest. c. Administer diuretics prophylactically for the prevention of lymphedema. d. Promote gradually increasing mobility as soon as possible following surgery.

d. Promote gradually increasing mobility as soon as possible following surgery. Mobility should be encouraged beginning in the postanesthesia care unit (PACU) and increased gradually throughout the patient's recovery. Immobilization is counterproductive to recovery, and the limb should not be in a dependent position. Diuretics are not used to prevent lymphedema but may be used in active treatment of the problem.

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding? a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift

d. Pronator drift Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

Which instruction by the nurse is correct when reinforcing teaching for the patient undergoing a transurethral resection of the prostate (TURP)? a. A TURP is performed using local anesthesia in an outpatient surgery center b. Dressing changes to an external incision in the lower abdomen will be needed c. Aspirin should be initiated prior to surgery to prevent post op clotting d. Prostate tissue is removed using a resectoscope inserted through the urethra

d. Prostate tissue is removed using a resectoscope inserted through the urethra

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? a. Assist the patient to the bathroom every 2 hours. b. Provide incontinence briefs to wear during the day. c. Give a bisacodyl (Dulcolax) rectal suppository every day. d. Provide several servings daily of cooked fruits and vegetables.

d. Provide several servings daily of cooked fruits and vegetables. Patients after a stroke often have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit 3 times daily, cooked vegetables 3 times daily, and whole-grain cereal or bread 3 to 5 times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

A patient with a diagnosis of Parkinson's disease (PD) is admitted to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? a. Administer multivitamins every morning and with each meal. b. Provide a diet that is low in complex carbohydrates and high in protein. c. Give the patient with a pureed diet that is high in potassium and low in sodium. d. Provide small, frequent meals throughout the day that are easy to chew and swallow.

d. Provide small, frequent meals throughout the day that are easy to chew and swallow. Nutritional support is a priority in the care of persons with PD. Patients may benefit from smaller, more frequent meals that are easy to chew and swallow. Multivitamins are not necessary at each meal. Vitamin and protein intake must be monitored to prevent interactions with medications. Introducing a minced or pureed diet is likely premature, and a low carbohydrate diet is not indicated.

A patient with heart failure and type 1 diabetes is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? a. Furosemide 20 mg IV b. Alprazolam 0.5 mg oral c. Ciprofloxacin 500 mg oral d. Regular insulin 6 units subcutaneous

d. Regular insulin 6 units subcutaneous Patients with type 1 diabetes must receive insulin the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).

The nurse administers the Gardasil (HPV Vaccine) to a female patient at the clinic. It is most important for the nurse to advise the patient to take which action? a. Avoid pregnancy by using two methods of birth control. b. Return to the clinic in 6 months for a second dose. c. Avoid sexual activity for 24 to 48 hours. d. Remain lying down for at least 15 minutes.

d. Remain lying down for at least 15 minutes.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? a. Tonic spasms of the legs b. Curling in a fetal position c. Arching of the neck and back d. Resistance to flexion of the neck

d. Resistance to flexion of the neck Nuchal rigidity is a manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

The nurse prepares to administer intravenous (IV) acyclovir to a patient diagnosed with a disseminated herpes simplex virus 2 (HSV-2) infection. What should the nurse assess before administering the medication? a. D-Dimer b. Platelet count c. White blood cell count d. Serum creatinine

d. Serum creatinine

A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? a. Serum sodium of 120 mEq/L b. Urine specific gravity of 1.001 c. Fasting blood glucose of 80 mg/dL d. Serum osmolality of 290 mOsm/kg

d. Serum osmolality of 290 mOsm/kg Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes.

A female patient presents to the emergency department reporting the most severe headache of her life. Which type of stroke should the nurse anticipate? a. TIA b. Embolic stroke c. Thrombotic stroke d. Subarachnoid hemorrhage

d. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

A woman with endometriosis is seeking a cure. After identifying childbearing is no longer desired, the nurse should introduce which potential treatment? a. Danazol b. Leuprolide (Lupron) c. Nonsteroidal antiinflammatory drugs d. Surgical removal of endometrial implants

d. Surgical removal of endometrial implants The only cure for endometriosis is the surgical removal of all endometrial implants, which may include the uterus, fallopian tubes, and ovaries. Leuprolide is a gonadotropin-releasing hormone agonist that causes amenorrhea with menopausal side effects. Danazol is a synthetic androgen that inhibits the anterior pituitary. Nonsteroidal antiinflammatory drugs relieve pain but do not affect the problem of endometriosis.

A nurse is teaching a health promotion workshop to a group of women in their 40s and 50s. What information about nipple discharge should the nurse teach to participants? a. Inappropriate lactation necessitates breast biopsy. b. Nipple discharge of any type is a precursor to cancer. c. Galactorrhea is a normal symptom related to perimenopause. d. Unexpected nipple discharge of any type needs medical follow-up.

d. Unexpected nipple discharge of any type needs medical follow-up. Although most cases of nipple discharge are not related to malignancy, further medical assessment is indicated. Other testing would be done for inappropriate lactation before a breast biopsy would be necessary. Galactorrhea is not considered a normal age-related change, nor is it a common perimenopausal symptom.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

Drugs or diseases that impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature. b. regulation of the autonomic nervous system. c. integration of somatic and special sensory inputs. d. automatic movements associated with skeletal muscle activity.

d. automatic movements associated with skeletal muscle activity.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. O2 content of the blood. b. amount of cardiac output. c. level of CO2 in the blood. d. degree of collateral circulation.

d. degree of collateral circulation.

Which pharmacological therapy is indicated for a patient with bacterial prostatitis? a. testosterone (Androderm) b. tadalafil (Cialis) c. cisplatin (Platinol) d. doxycycline (Vibramycin)

d. doxycycline (Vibramycin)

You are caring for a patient with breast cancer following a simple mastectomy. Postoperatively, to restore arm function on the affected side, you would a. apply heating pads or blankets to increase circulation. b. place daily ice packs to minimize the risk for lymphedema. c. teach passive exercises with the affected arm in a dependent position. d. emphasize regular exercises for the affected shoulder to increase range of motion.

d. emphasize regular exercises for the affected shoulder to increase range of motion.

Nursing care for the patient with endometrial cancer who had a total abdominal hysterectomy and salpingectomy and oophorectomy includes a. maintaining absolute bed rest. b. keeping the patient in high-Fowler's position. c. need for supplemental estrogen after removal of ovaries. d. encouraging movement and walking as much as tolerated.

d. encouraging movement and walking as much as tolerated.

You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out the presence of breast cancer. b. teaching that symptoms will subside if she stops using oral contraceptives. c. preparing her for surgical removal of the lumps, since they will become larger and more painful. d. explaining that restricting coffee and chocolate and supplementing with vitamin E may relieve some discomfort.

d. explaining that restricting coffee and chocolate and supplementing with vitamin E may relieve some discomfort.

To decrease the patient's discomfort related to discussing his reproductive organs, the nurse should a. relate his sexual concerns to his sexual partner. b. arrange to have male nurses care for the patient. c. give him written material and ask if he has questions. d. maintain a nonjudgmental attitude toward his sexual practices.

d. maintain a nonjudgmental attitude toward his sexual practices.

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the a. microglia. b. astrocytes. c. ependymal cells. d. oligodendrocytes.

d. oligodendrocytes.

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

d. paralysis ascending to the nerves that stimulate the thoracic area.

The nurse finds an 87-yr-old patient is continually rubbing, flexing, and kicking her legs throughout the day. The night shift reports this same behavior escalates at night, preventing her from obtaining sleep. The next step the nurse should take is to a. ask the provider for a daytime sedative for the patient. b. request soft restraints to prevent her from falling out of her bed. c. ask the provider for a nighttime sleep medication for the patient. d. perform an assessment, suspecting a disorder such as restless legs syndrome.

d. perform an assessment, suspecting a disorder such as restless legs syndrome.

To prevent the infection and transmission of STIs, the nurse's teaching plan would include an explanation of a. the appropriate use of oral contraceptives. b. the need for annual Pap tests for women with HPV. c. sexual positions that can be used to avoid infection. d. sexual practices that are considered high-risk behaviors.

d. sexual practices that are considered high-risk behaviors.

Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes a. sensory changes. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d. sudden onset of severe headache.

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk for electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. teach the patient that pain may be experienced during the study.

d. teach the patient that pain may be experienced during the study.

The nurse encourages serologic testing for the human immunodeficiency virus (HIV) in the patient with syphilis primarily because a. syphilis is more difficult to treat in patients with HIV infection b. the presence of HIV infection increases the risk for contacting syphilis c. central nervous system (CNS) involvement is more common in patients with HIV infection and syphilis d. the incidence of syphilis is highest in those with high rates of sexual promiscuity and drug abuse

d. the incidence of syphilis is highest in those with high rates of sexual promiscuity and drug abuse

Explain to the patient with gonorrhea that treatment will include both ceftriaxone and azithromycin because a. azithromycin helps prevent recurrent infections. b. some patients do not respond to oral drugs alone. c. coverage with more than one antibiotic will prevent reinfection. d. the increasing rates of drug resistance requires using at least 2 drugs.

d. the increasing rates of drug resistance requires using at least 2 drugs.

The nurse is caring for a patient scheduled for hysteroscopy. The nurse explains to the woman that a. the procedure treats cervical dysplasia. b. bleeding and discharge are rare after the procedure. c. the procedure involves curettage of the endometrial lining. d. the procedure allows visualization of the lining of the uterus.

d. the procedure allows visualization of the lining of the uterus.

Due to the precipitating stimuli, a patient with trigeminal neuralgia may choose to do which of the following? a. Choose not to eat properly b. Choose to neglect hygienic practices c. Choose to wear a cloth over the face d. Choose to withdraw from interaction with other individuals e. Choose to sleep excessively as a means of coping with the pain f. All of the answer choices

f. All of the answer choices Due to the different precipitating stimuli, a patient may choose to not eat properly, neglect hygienic practices, wear a cloth over the face, withdraw from interaction with other individuals, and sleep excessively to cope with the pain.

Guillain-Barre Syndrome is often preceded by immune system stimulation from which of the following? a. A viral infection b. Trauma c. Surgery d. Viral immunizations e. Human immunodeficiency virus (HIV) f. All of the answer choices

f. All of the answer choices Guillain-Barre Syndrome is often preceded by immune system stimulation from a viral infection, trauma, surgery, viral immunizations, or human immunodeficiency virus (HIV).

What are some other potential pathogens for Guillain-Barre Syndrome? a. Mycoplasma pneumoniae b. Cytomegalovirus c. Epstein-Barr virus d. Varicella-zoster virus e. Vaccines (rabies, swine influenza) f. All of the answer choices

f. All of the answer choices Other potential pathogens include Mycoplasma pneumoniae, cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and vaccines (rabies, swine influenza).