Quiz 3 405
The nurse is caring for a client with acute diverticulitis. Which of the following findings would be essential to follow up? A. abdominal pain B. hemoglobin 11.2 C. lying on side with knees drawn up to abdomen and trunk flexed D. WBC count 12,000/mm3
A Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness) (Option 1). (Option 2) Clients with acute diverticulitis can bleed. Usually this bleeding is quite obvious, often with a large amount of bright red blood seen in the stool. This client's mild anemia is nonspecific and should not be given reporting priority over the peritoneal signs. (Option 3) This indicates fetal position and could be due to pain. Clients with peritonitis are expected to lie still as any movement worsens the pain. Peritonitis takes priority over the expected pain in diverticulitis. (Option 4) Leukocytosis is expected with acute diverticulitis. This client's white blood cell count is only minimally elevated (normal 5000-10,000/mm3 [5-10 x 109/L]) and is not a priority over possible peritoneal signs.
The nurse is caring for an 18-year-old client diagnosed with depression who attempted suicide 4 days ago. Which client behavior is most concerning? A. a client gave a recent model cell phone to another client B.the client has slept 10-12 hrs each night C. the client has not showered since admission D. the client requests that the parents not be allowed to visit
A The nurse should monitor client behavior for warning signs of an impending suicide attempt, which include expressions of hopelessness, development of a lethal suicide plan (with the means to carry it out), giving away meaningful possessions, and sudden improvement in mood (Option 1). If warning signs are present the client requires 1-to-1 vigilant observation and a nonprivate room near the nurse station. (Options 2, 3, and 4) Poor personal hygiene, changes in sleep pattern (eg, hypersomnia), and withdrawing from family and friends are common in depression. Symptoms should improve with treatment (eg, medications, psychotherapy, electroconvulsive therapy). However, the nurse should continue to closely observe the client in the first few weeks of treatment because suicidal ideation may still be present and the client will begin to have the energy to carry out a suicide plan.
A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. asterixis B. fetor hepaticus C. Constructional apraxia D. palmar erythema
A The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find? A. hard, moveable olive shaped mass in the RUQ B. abdominal pain the the epigastric or umbilical region C. tenderness over the McBurney point in the RLQ D. sausage shaped mass in the upper mid-abdomen
A With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be palpated in the right upper quadrant. A sausage-shaped mass in the upper midabdomen would suggest intussusception. Tenderness over the McBurney point would be associated with appendicitis. Epigastric or umbilical pain would be associated with peptic ulcer disease.
The nurse is caring for a child with type 1 diabetes mellitus. The nurse notes the child is drowsy, has flushed cheeks and red lips, a fruity smell to the breath, and there has been an increase in the rate and depth of the child's respirations. Which prescription from the primary health care provider will the nurse question? A. monitor glucose level every 3 hours B. regular insulin per sliding scale IV C. serum ketone testing D. IV fluid replacement
A key word: questtion The client is experiencing diabetic ketoacidosis (DKA), which is the result of fat catabolism. It is characterized by drowsiness, dry skin, flushed cheeks and cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing (abnormal increase in the depth and rate of the respiratory movements). The nurse would question only checking the glucose level every 3 hours as it should be assessed at least hourly to ensure the client's level does not fall more than 100 mg/dL (5.55 mmol/L) per hour. A too-rapid decline in blood glucose predisposes the child to cerebral edema. Fluid therapy is given to treat dehydration, correct electrolyte imbalances (sodium and potassium due to osmotic diuresis), and improve peripheral perfusion. Administration of regular insulin, given intravenously, is preferred during DKA. Ketones would be assessed either in the urine or blood to see how much the client is spilling.
The nurse is caring for a client with Crohn disease. Which of the following findings would be consistent with the condition? Select all that apply. A. steatorrhea B. urinary frequency C. abdominal cramping D. temp 99.5 E. blood pressure 140/88 F. 7.1lb weight loss over one week
A, B, C,D, F symptoms of Crohns disease are abdominal cramping, fever, fatigue, loss of appetite, weight loss, watery diarrhea that may be bloody, and the feeling of needing to pass stool although your bowels are empty, steatorrhea. Vitals are typically normal unless nausea and vomiting is present and alters electrolytes and hydration.
The nurse suspects that a 4 year old with type 1 diabetes is experiencing hypoglycemia based on what findings? Select all that apply. A. tachycardia B diaphoresis C. fruity breath odor D. blurred vision E. slurred speech F. dry, flushed skin
A,B,E Hypoglycemia can cause tachycardia, diaphoresis, slurred speech, and coma fruity breath is seen in DKA. Blurred vision is seen in hyperglycemia as well as dry flushed skin
After teaching the parents of a child diagnosed with celiac disease about nutrition, the nurse determines that the teaching was effective when the parents identify which foods as appropriate for their child? Select all that apply. A. peanut butter B. jelly C. wheat germ D. flavored yoghurt E. carbonated drinks F. shellfish
A,B,E,F pts with celiac disease must avoid wheat, barley, rye, oats. depending on the flavor of the yoghurt, some may contain traces of gluten or be made in a factory that also produces gluten products.
The nurse is assisting with the admission of a client with suspected hypothyroidism. Which of the following client statements support this diagnosis? Select all that apply A. i keep the house very warm because i always seem to be cold b. my bowel movements have become much more frequent c. I have noticed that my skin is rough and dry, my nails are brittle d. my cosmetics do not conceal this puffiness in my face e. i have to cut back on food intake but am still gaining weight
A,C, D, E hypothyroidism causes cold intolerance so a warm house is expected. Bowel movements should decrease. Skin is dry and nails are brittle. A slower metabolism causes vein constriction and a less elastic response, causing water and salt retention, causing face puffiness. weight gain is also a common sign.
A nurse is assessing diabetic clients for their risk of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which client(s) would be at greatest risk for this syndrome? Select all that apply. A. a client with no known history of diabetes who is experiencing an acute illness B. a client with Type 1 diabetes and poor dietary control C. a client that is obese and has type 1 diabetes D. a client with type 2 diabetes and sporadic use of antihyperglycemics E. A client with type 2 diabetes who has a chronic illness
A,D, E HHNS occurs most often in people who have no known history of diabetes or who have type 2 diabetes but have a precipitating event, such as infection (32% to 60%) such as pneumonia, UTI, sepsis, acute or chronic illness (e.g., myocardial infarction, stroke), medications that exacerbate hyperglycemia, or therapeutic procedures, such as surgery or dialysis or inadequate insulin treatment or nonadherence (21% to 41%). This information makes the other options incorrect.
A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? A. STAT admin of vitamin K by IM route B. IV admin of octreotide c. IV amin of albumin D. infusion of IV heparin
B Octreotide—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not given, and heparin would exacerbate, not alleviate, bleeding.
Which of the following clients diagnosed with type 1 diabetes is most likely to meet the therapeutic goal of adequate glucose control? A. a client who skips breakfast when the glucose reading is greater than 220mg/dl B. a client who never deviates from the prescribed dose of insulin C. a client who adheres to a meal plan and meal schedule D. A client who eliminates carbs from their daily intake
B The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals and snacks helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.
The nurse is caring for a 6-month-old with a cleft lip and palate. The mother of the child demonstrates understanding of the disorder with which statements? Select all that apply. A. My smoking dring pregnancy didnt have anything to do with the disorder. smoking primarily cause low birth weight. B. thankfully there are healthcare providers that specialize in correcting this type of disorder C. i know my baby may take a lot longer to feed than most children this age D. it really worries me that my baby may have some other disorders that havent been detected yet E. I wonder if my baby will develop speech problems when language begins
B, C, D, E Smoking during pregnancy can cause babies to be born with cleft lip and palate. It can be surgically fixed. The baby will have difficulty feeding as well as with speech. There also can be problems down the road, involving hearing, breathing, and speech.
A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. a. annual vitamin K injections b. use of standard precautions c. annual vitamin b12 injections d. immunization e. consumption of vitamin rich diet
B, D People who are at high occupational risk for contracting hepatitis B, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.
An older adult client diagnosed with type 2 diabetes is brought to the emergency department with hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which nursing action(s) would be priority? Select all that apply. A. admin sodium bicarbonate IV B. reversing the hyperglycemic state by admin insulin C. admin antihypertensive medications D. addressing electrolyte replacement needs E. addressing hydration needs
B, D, E HHNS is a serious life-threatening condition characterized by hyperosmolality (usually >320 mOsm/L) and hyperglycemia (at least 600 mg/dL) with or without alterations in level of consciousness. The overall approach to HHNS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHNS due to dehydration. Sodium bicarbonate is not administered to clients with HHNS, as their plasma bicarbonate level is usually normal. Sodium bicarbonate is used for DKA
An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. adopt a low residue diet B. avoid nonsteroidal anti-inflammatories C. take calcium gluconate as prescribed D. prepare for the possibility of surgery E. avoid drinking alcohol
B, E Clients with chronic gastritis are encouraged to avoid alcohol and NSAIDs. Calcium gluconate is not a common treatment and the condition is not normally treated with surgery. Dietary modifications are usually recommended, but this does not necessitate a low-residue diet.
The nurse plans care for a client newly diagnosed with hypothyroidism. Which of the following interventions should the nurse include? Select all that apply. A. administer levothyroxine when the breakfast is delivered B. allow frequent rest breaks during activity C. assist the client in choosing low calorie menu options D. encourage the clients to increase fiber intake E. maintain a room temperature of 60F
B,C,D Primary hypothyroidism is an endocrine disorder identified by low circulating thyroid hormone (ie, T3, T4) and high TSH levels. Therefore, clients with hypothyroidism exhibit clinical manifestations of low metabolic state (eg, cold intolerance, constipation, fatigue, weight gain). Nursing interventions for a client with hypothyroidism include: Allowing frequent rest breaks during activity due to activity intolerance (Option 2) Educating about low-calorie food choices because weight gain is a common result of slowed metabolic rate (Option 3) Encouraging increased fluid and fiber intake to manage constipation (Option 4) (Option 1) Clients should take thyroid replacement medications (eg, levothyroxine) in the morning, 30-60 minutes before eating food. (Option 5) Clients with hypothyroidism have a lowered body temperature and are intolerant to cold. The room temperature should be warm.
The nurse is caring for a 9-year-old client newly diagnosed with diabetes. The client has polyuria, polydipsia, and weight loss. Which nursing diagnoses will the nurse include in the care plan? Select all that apply. A. delayed growth and development B. imbalanced nutrition; less than body requirements C. deficient knowledge regarding disease process D. noncompliance E. deficient fluid volume
B,C,E Polyuria (excessive urination), polydipsia (excessive thirst), and weight loss support the diagnoses of deficient fluid volume and imbalanced nutrition: less than body requirements. Being newly diagnosed with the disease at the age of 9 supports the diagnosis of Deficient knowledge regarding disease process. There is no data to support noncompliance or delayed growth and development.
What clinical manifestations does the nurse recognize would be associated with a diagnosis of hyperthyroidism? Select all that apply. A. intolerance to cold B. weight loss C. an elevated systolic blood pressure D. a pulse rate slower than 90bpm E. muscular fatigability
B,C,E hyperthyroidism symptoms include: heat intolerance, anxiety, hyperactivity, lethargy, increased HR, weight loss, muscle weakness, increased BP
Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration? A. dusky extremities B. tenting skin C. sunken fontanels D. hypotension
C A child with moderate dehydration would exhibit sunken fontanels, pale and slightly dry skin, decreased skin turgor, normal BP, delayed cap refill. Severe dehydration would be characterized by dusky extremities, sunken fontanels, skin tenting, and hypotension.
A client's abdominal ultrasound indicates cholelithiasis (gallstones). When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. increased blood urea nitrogen (BUN) B. decreased serum alkaline phosphatase level C. increased bilirubin D. decreased serum cholesterol
C If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected. BUN (kidney function) ALP (liver disorder or bone disorder)
A nurse is amending a client's plan of care because the client has recently developed ascites. Which will the nurse include in this care plan? Select all that apply. A. mobilization w assistance at least four times daily B. vitamin B12 injections as ordered C. implementation of dietary restrictions of sodium D. admin of diuretics as ordered E. admin of Beta-adrenergic blockers as ordered
C,D Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.
A child with diabetes reports that he is feeling a little shaky. Further assessment reveals that the child is coherent but with some slight tremors and sweating. A fingerstick blood glucose level is 70 mg/dL. What would the nurse do next? A. admin a sliding scale dose of insulin B. admin glucagon IM C. give 10-15g of simple carbs D. offer complex carb snack
C. The child is experiencing hypoglycemia as evidenced by the assessment findings and blood glucose level. Since the child is coherent, offering the child 10 to 15 g of a simple carbohydrate would be appropriate. Insulin is not used because the child is hypoglycemic. A complex carbohydrate snack would be used after offering the simple carbohydrate to maintain the glucose level. Intramuscular glucagon would be used if the child was not coherent. 15g carbs, wait 15min, check again, if still low, give another 15g
A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem? A. bacteria likely migrated from your intestines and became lodged in your pancreas B. a virus that was likely already present in your body has begun to attack your pancreatic cells C. toxins have accumulated and inflamed your pancreas D. the enzymes that your pancreas produces have damaged the pancreas itself
D Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.
The nurse is taking a health history of an 11-year-old girl with recurrent abdominal pain. Which response would lead the nurse to suspect irritable bowel syndrome? A. the pain comes and goes B. the pain doesnt wake me up in the middle of the night C. i dont take any medicine right now D. i always feel better after I have a bowel movement
D In cases of irritable bowel syndrome, the pain may be relieved by defecation. Use of medications and pain that comes and goes or wakes the person up in the middle of the night are all relevant findings pertinent to recurrent abdominal pain.
A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. many people possess genetic factors causing predisposition to H. pylori infection B. most affected clients acquired the infection during international travel C. the h. pylori microorganism is endemic in warm, moist climates D. infection typically occurs due to ingestion of contaminated food and water
D Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to many areas, not only warm, moist climates. Genetic factors have not been identified.
The school nurse is caring for an adolescent client who was discovered making superficial cuts to the wrist. While treating the client's wounds, which communication by the nurse is priority? A. I know you must be going through a lot. How do you feel after you cut yourself B. i see scars on your wrist. How long have you been cutting yourself? C. Lets discuss other ways that you could manage your feelings D. tell me what was happening just before you began cutting yourself
D Self-harm is characterized by intentionally inflicting physical pain to the body through maladaptive, unhealthy behaviors (eg, cutting, biting, burning, scratching). Adolescent clients may engage in self-harm behaviors to obtain relief from life stressors and/or to soothe difficult emotions (eg, frustration, depression, anger). These behaviors can be highly addictive because endorphins are released when the body is injured, resulting in pleasurable sensation and sense of relief. When caring for a client with self-inflicted wounds, the nurse should assess, clean, and dress wounds as needed. After addressing immediate safety and physical needs, the priority is to identify the precipitating event that caused the self-injurious behavior by asking open-ended questions (eg, "Tell me what was happening just before you began cutting yourself") so that a plan of action can be developed (Option 4). (Options 1, 2, and 3) Establishing a history of previous cutting episodes, discussing coping mechanisms, and promoting discussion of feelings are appropriate actions, but the priority is to understand the precipitating event to create a baseline for the plan of care. Educational objective:When caring for a client with self-inflicted wounds, the nurse should prioritize asking open-ended questions to identify the precipitating event that caused the self-harm behavior so that a plan of action can be developed.
A nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A. perform exercise prior to eating whenever possible B. eat a meal or snack every 8 hours C. check blood sugar at least every 24 hrs D. always carry a form of fast acting sugar
D The following teaching points should be included in information provided to the client on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly (multiple times per day).
A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. drinking beverages after your meal rather than with your meal may bring some relief B. many clients obtain relief by taking over the counter antacids 30 min before eating C. its best to avoid dry foods such as rice and chicken, because they are harder to swallow D. instead of eating three meals a day, try eating smaller amounts more often
D. Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.
The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What would the nurse correlate with disorder? A. the parents report that their child has a cold or flu recently B. blood pressure is decreased when checking vital signs C. auscultation reveals Kussmaul's breathing D. the parents report that their son cant drink enough water.
D. Unquenchable thirst (polydipsia) is a common finding associated with diabetes mellitus, type 1 and 2. However, reports of flu-like illness and Kussmaul breathing are more commonly associated with type 1 diabetes. Blood pressure is normal with type 1 diabetes and elevated with type 2 diabetes.
