Unit 3 NUR Final Exam Review Q's

A client with a diagnosis of addisonian crisis is being admitted to the ICU. Which findings will the interprofessional health care team focus on? Select all that apply. a. Hypotension b. Leukocytosis c. Hyperkalemia d. Hypercalcemia e. Hypernatremia

A & C

A nurse is caring for a client who has SIADH. Which of the following findings should the nurse expect? Select all that apply. a. Decreased serum sodium b. Urine specific gravity 1.001 c. Serum osmolarity 230 mOsm/L d. Polyuria e. Increased thirst

A & C - A decrease in serum sodium and serum osmolarity is caused by an increase in ADH secretion.

Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A) Episodes of high psychosocial stress B) Periods of dehydration C) Episodes of physical exertion D) Administration of a vaccine

A) Episodes of high psychosocial stress During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.

A nurse is planning care for a client who has meningitis and is at risk for increased ICP. Which of the following are appropriate nursing actions? Select all that apply. A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

A, D, E - Seizure precautions for clients at risk for increased ICP; bright lights and flickering can cause increase neuron stimulation and cause a seizure when client is at risk for increased ICP; impaired extraocular movement can indicate increased ICP

To maintain proper alignment of the hips and lower extremities in a baby with a myelomeningocele, the nurse should position the baby with the: A. Hips abducted and feet in a neutral position B. Hips adducted and feet flexed C. Hips subluxed and feet extended D. Hips adducted and feet in a natural position

A. Hips abducted and feet in a neutral position

A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend? A. Teach the child to do self-catheterization. B. Teach the child appropriate bladder control. C. Continue having the parents do the catheterization. D. Encourage the family to consider urinary diversion. A.

A. Teach the child to do self-catheterization.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have close contact with the patient? A. Within 24h after exposure B. Within 48h after exposure C. Within 72h after exposure D. Therapy is not necessary prophylactically and should only be used if the person develops symptoms.

A. Within 24h after exposure

The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statement by the client indicate understanding? Select all that apply. A. "This medication will turn my urine orange." B. "I should decrease my oral fluids when I start this medication." C. "The amount of urine I make should increase if this medicine is working." D. "I need to follow a low-fat diet to avoid pancreatitis when taking this medication." E. "I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin."

B & E

A nurse caring for a patient with possible bacterial meningitis in the ICU knows that which of the following assessment findings would be expected for a patient with bacterial meningitis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B) Neck flexion produces flexion of knees and hips Clinical manifestations of bacterial meningitis include positive Brudzinski's sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski's sign. Positive Homan's sign (pain upon dorsiflexion of the foot) and negative Romberg's sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities and is not an initial assessment to rule out bacterial meningitis

A nurse I scaring for a client who has Addison's disease and is taking hydrocortisone (Cortef). Which of the following medication instructions is appropriate for the nurse to include? Select all that apply. a. Take the medication on an empty stomach b. Notify the provider of any illness or stress c. Report any symptoms of weakness or dizziness d. Do not discontinue the medication suddenly e. Eat a low-sodium diet

B, C, & D - Stress/illness increases the need for cortisone; Weakness and dizziness are indications of adrenal insufficiency; Rapid D/C of cortisone can result in adverse effects including acute adrenal insufficiency. Doses should be tapered to D/C.

The nurse is planning the care of a client dx with SIADH. which interventions should be implemented? Select all that apply 1. restrict fluids per health care provider order 2. assess level of consciousness every 2 hours 3. provide an atmosphere of stimulation 4. monitor urine and serum osmolality 5. weigh the client every 3 days

1, 2, 4 fluids are restricted to 500 to 600 mL/24 hrs. Orientation to person, place, and time should be assessed every 2 hours or more often. Urine and serum osmolality are monitored to determine fluid volume status. 3. a safe environment, not a stimulating one, is provided. 5. the client should be weighed daily not every 3 days

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. Muscle function will gradually return, and recovery is possible in most children. C. Guillain-Barré syndrome results from an apparently toxic reaction to certain medications. D. Guillain-Barré syndrome is inherited as an autosomal recessive, sex-linked gene.

B. Muscle function will gradually return, and recovery is possible in most children.

A child with spina bifida has developed a latex allergy from numerous bladder catheterizations and surgeries. A priority nursing intervention is to A. recommend allergy testing. B. provide a latex-free environment. C. use only powder-free latex gloves. D. limit the use of latex products as much as possible.

B. provide a latex-free environment.

the client dx with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). which interventions should the nurse implement? 1. assess for dehydration and monitor blood glucose levels 2. assess for nausea and vomiting and weigh daily 3. monitor potassium levels and encourage fluid intake 4. administer vasopressin IV and conduct a fluid deprivation test

2. assess for nausea and vomiting and weigh daily early signs and symptoms are nausea and vomiting. the client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. in other words, the client is producing a hormone that will not allow the client to urinate. Vasopressin is the name of the antidiuretic hormone. giving more increases the clients problem. also, water challenge test is performed, not a fluid deprivation test.

A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? A) The patients diet should be low protein with ample fat. B) The patient may experience short-term changes in cognition. C) The patient is at an increased risk for developing infection. D) The patient is at a decreased risk for development of thrombophlebitis and thromboembolism.

C) The patient is at an increased risk for developing infection. The patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which result would verify the diagnosis? A. Clear CSF, decreased pressure, and elevated protein level B. Clear CSF, elevated protein, and decreased glucose levels C. Cloudy CSF, elevated protein, and decreased glucose levels D. Cloudy CSF, decreased protein, and decreased glucose levels

C. Cloudy CSF, elevated protein, and decreased glucose levels

Which of the following is a clinical manifestation associated with Guillain-Barré syndrome? A) Vertigo B) Ptosis of the eyelid C) Diminished taste for food D) Vocal paralysis

D) Vocal paralysis Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness

A newborn baby is diagnosed with a myelomeningocele. The nurse measures his head circumference daily to assess for the development of what complication? A. Hydrocele B. Hordeolum C. Hypsarrhythmia D. Hydrocephalus

D. Hydrocephalus

A nurse is assessing a client who has SIADH. Which of the following findings indicate the client is experiencing a complication? a. Decreased CVP b. Increased urine output c. Distended neck veins d. Extreme thirst

c. Distended neck veins - Distended neck veins are a manifestation of fluid overload which can lead to pulmonary edema and HF.

The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply. 1. Obtain an informed consent from the client or significant other. 2. Have the client empty the bladder prior to the procedure. 3. Place the client in a side-lying position with the back arched. 4. Instruct the client to breathe rapidly and deeply during the procedure. 5. Explain to the client what to expect during the procedure.

1, 2, 3, 5 1. A lumbar puncture is an invasive procedure; therefore, an informed consent is required. 2. This could be offered for client comfort during the procedure. 3. This position increases the space between the vertebrae, which allows the HCP easier entry into the spinal column. 5. The nurse should always explain to the client what is happening prior to and during a procedure.

The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, calm, and dark room. 4. Weigh the client in hospital attire.

1. Administer an intravenous antibiotic. The antibiotic has the highest priority because failure to treat a bacterial infection can result in shock, systemic sepsis, and death.

The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess intake and output.

1. Administer antibiotics. A nurse administering antibiotics is a collaborative intervention because the HCP must write an order for the intervention; nurses cannot prescribe medications unless they have additional education and licensure and are nurse practitioners with prescriptive authority.

The nurse is admitting a client dx with SIADH. which clinical manifestations should be reported to the hcp? 1. serum sodium of 112 mEq/L and a headache 2. serum potassium of 5.0 mEq/L and a heightened awareness 3. serum calcium of 10 mg/dL and tented tissue turgor 4. serum magnesium of 1.2 mg/dL and large urinary output

1. serum sodium of 112 mEq/L and a headache A serum sodium level of 112 is dangerously low, and the client is at risk for seizures. a headache is a symptom of a low sodium level. 2.this is a normal potassium level, and a heightened level of awareness indicates drug usage 3. this is a normal calcium level and the client is fluid overloaded, not dehydrated, so there would not be tented tissue turgor. 4. this is a normal magnesium level, and a large urinary output is desired

The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home? 1. The Haemophilus influenzae vaccine. 2. Antimicrobial chemoprophylaxis. 3. A 10-day dose pack of corticosteroids. 4. A gamma globulin injection.

2. Antimicrobial chemoprophylaxis. Chemoprophylaxis includes administering medication that will prevent infection or eradicate the bacteria and the development of symptoms in people who have been in close proximity to the client. Medications include rifampin (Rifadin), ciprofloxacin (Cipro), and ceftriaxone (Rocephin).

The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.

2. Residents of a college dormitory. Outbreaks of infectious meningitis are most likely to occur in dense community groups such as college campuses, jails, and military installations.

Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis? 1. This regimen helps to decrease the purulent exudate surrounding the meninges. 2. These medications will decrease intracranial pressure and brain metabolism. 3. These medications will increase the client's memory and orientation. 4. This will help prevent a yeast infection secondary to antibiotic therapy.

2. These medications will decrease intracranial pressure and brain metabolism. Fever increases cerebral metabolism and intracranial pressure. Therefore, measures are taken to reduce body temperature as soon as possible, and alternating Tylenol and Motrin would be appropriate.

The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "This is an inflammation of the brain parenchyma caused by a mosquito bite."

3. Septic meningitis refers to meningitis caused by bacteria; the most common form of bacterial meningitis is caused by the Neisseria meningitides bacteria.

The nurse is caring for clients on a medical floor. which client should be assessed first? 1. the client dx with syndrome of inappropriate antidiuretic hormone (SIADH) who has a wt. gain of 1.5 lbs since yesterday 2. the client dx with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1500 mL and an output of 1600 mL in the last 8 hours 3. the client dx with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching 4. the client dx with diabetes insipidus (DI) who is c/o feeling tired after having to get up at night

3. the client dx with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching Muscle twitching is a sign of early sodium imbalance. if an immediate intervention isnt made, the client could begin to seize. 1. clients with SIADH have a problem with retaining fluid. this is expected. 2. this clients intake and output are relatively the same 4.the client has to get up all night to urinate, so the client feeling tired is expected

The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze. 3. Assess apical pulse. 4. Assess level of consciousness.

4. Assess level of consciousness Meningitis directly affects the client's brain. Therefore, assessing the neurological status would have priority for this client.

The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A) Establish falls prevention measures. B) Encourage bed rest whenever possible. C) Encourage the use of assistive devices. D) Provide constant supervision.

A) Establish falls prevention measures. The nurse should take action to prevent the patients risk for falls. Bed rest carries too many harmful effects, however, and assistive devices may or may not be necessary. Constant supervision is not normally required or practicable.

The nurse is caring for a patient with GBS in the ICU and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? A. Assess the respiratory rate and oxygen saturation B. Assess the blood pressure and heart rate C. Assess the peripheral pulses D. Listen to the bowel sounds

B. Assess the blood pressure and heart rate

A patient is ordered desmopressin (DDAVP) for the treatment of DI. What therapeutic response does the nurse anticipate the patient will experience? A. A decrease in blood pressure B. A decrease in serum glucose levels C. A decrease in urine output D. A decrease in appetite

C. A decrease in urine output

A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A. Codeine B. Phenytoin (Dilantin) C. Ceftriaxone (Rocephin) D. Acetaminophen (Tylenol)

C. Ceftriaxone (Rocephin) Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed. Dexamethasone may also be prescribed 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 neural tube defect that is not visible externally in the lumbosacral area would be called A. meningocele. B. myelomeningocele. C. spina bifida cystica. D. spina bifida occulta.

D. spina bifida occulta.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

a. Encourage family members to remain at the bedside. Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

b. Restrict oral fluids to 1000 mL daily. The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis

Nurse on clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. 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 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

c. The nursing assistant goes into the patient's room without a mask. Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

d. The patient's blood pressure is 86/42 mm Hg. Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? a) "I may stop taking this medication when I feel better." b) "I will eat lots of chicken and dairy products." c) "I will see my ophthalmologist regularly for a check-up." d) "I will avoid friends and family members who are sick."

a) "I may stop taking this medication when I feel better." - The client requires additional teaching because he states that he may stop taking corticosteroids when he feels better. Corticosteroids should be gradually tapered by the physician. Tapering the corticosteroid allows the adrenal gland to gradually resume functioning.

A nurse is providing teaching to a client who has a new diagnosis of DI. Which of the following statements by the client requires further teaching? a. "I can drink up to 2 quarts of fluids a day." b. "I should expect to urinate frequently at night." c. "I may experience headaches." d. "I may experience a dry mouth."

a. "I can drink up to 2 quarts of fluids a day." - Excessive thirst is a manifestation of DI. Consumption of 4-30L/day can be expected and fluid intake should NOT be limited.

A nurse at the beginning of a shift is assessing a client who has Cushing's disease. Which of the following is the priority assessment? a. Daily weights b. Fatigue c. Fragile skin d. Joint pain

a. Daily weights - The greatest risk to pts. with Cushing's disease is fluid retention, which can lead to hypertension and HF. Therefore, this is priority.

A nurse is caring for a client who has primary adrenal insufficiency. Which of the following findings should the nurse anticipate after an IV injection of ACTH 1.0 mg? a. Decrease in serum plasma cortisol b. Elevated fasting serum blood glucose c. Decrease in serum sodium d. Increase in urine output

a. Decrease in serum plasma cortisol - A decrease in serum plasma cortisol is indicative of primary adrenal insufficiency due to inadequate production of aldosterone and cortisol

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse expect? A. Meningitis B. Spinal cord injury C. Intracranial bleeding D. Decreased cerebral blood flow

A. Meningitis

Prior to surgery for a myelomeningocele, the nurse would place the baby in which of the following positions? A. Prone B. Right side C. Left side D. Dorsal

A. Prone

The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? 1. Purpuric lesions on the face. 2. Complaints of light hurting the eyes. 3. Dull, aching, frontal headache. 4. Not remembering the day of the week.

1. Purpuric lesions on the face. In clients with meningococcal meningitis, purpuric lesions over the face and extremity are the signs of a fulminating infection that can lead to death within a few hours.

3. A nurse is reviewing the health record of a student newly admitted to a university and licing in a dormitory. The health records indicate the student requires follow-up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against? A. Streptococcus pneumonia B. Neisseria meningitidis C. Bartonella henselae D. Rickettsia rickettsia

B. Neisseria meningitidis - It is recommended that college students living in close proximity be immunized for meningitis

which lab value should be monitored by the nurse for the client dx with DI (diabietes insipidus)? 1. serum sodium 2. serum calcium 3. urine glucose 4. urine white blood cells

1. serum sodium: the client will have an elevated sodium level as a result of low circulating blood volume. the fluid is being lost through the urine. diabetes means to pass through in greek, indicating polyuria, a symptom shared with diabetes mellitus. diabetes insipidus is a totally separate disease process

The nurse is admitting a client with GBS to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room. A. Nebulizer and pulse oximeter B. Blood pressure cuff and flashlight C. Flashlight and incentive spirometer D. Electrocardiographic monitoring electrodes and intubation tray

D. Electrocardiographic monitoring electrodes and intubation tray

The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"? 1. The client will be able to complete activities of daily living. 2. The client will be protected from injury if seizure activity occurs. 3. The client will be afebrile for 48 hours prior to discharge. 4. The client will have elastic tissue turgor with ready recoil.

2. The client will be protected from injury if seizure activity occurs. A client with a problem of altered cerebral tissue perfusion is at risk for seizure activity secondary to focal areas of cortical irritability; therefore, the client should be on seizure precautions.

The nurse is discharging a client dx with diabetes insipidus. Which statement made by the client warrants further intervention? 1. i will keep a list of my medications in my wallet and wear a medic alert bracelet 2. i should take my medication in the morning and leave it refrigerated at home 3. i should weigh myself every morning and record any weight gain 4. if i develop a tightness in my chest, i will call my hcp

2. i should take my medication in the morning and leave it refrigerated at home medication for DI is usually taken every 8 to 12 hours, depending on the client. The client should keep the medication close at hand. The client should keep a list of medication being taken and wear a medic alert bracelet. the client is at risk for fluid shifts. weighing every morning allows the client to follow the fluid shifts. wt gain indicates too much medication. tightness in the chest could be an indicator the medication is not being tolerated; if this occurs, the client should notify the hcp. (the medical treatment of DI involves replacement of ADH. In acute cases, vasopressin, a synthetic form of ADH, is given by the IV or subcu route, in long term therapy synthetic ADH in the form of a nasal spray is used (desmopressin or DDAVP))

The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "This is an inflammation of the brain parenchyma caused by a mosquito bite."

3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." Septic meningitis refers to meningitis caused by bacteria; the most common form of bacterial meningitis is caused by the Neisseria meningitides bacteria.

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

3. Positive Kernig's sign and nuchal rigidity. A positive Kernig's sign (client unable to extend leg when lying flat) and nuchal rigidity (stiff neck) are signs of bacterial meningitis, occurring because the meninges surrounding the brain and spinal column are irritated.

The UAP complains to the nurse she has filled the water pitcher 4 times during the shift for a client dx with a closed head injury and the client has asked for the pitcher to be filled again. which intervention should the nurse implement first? 1. tell the UAP to fill the pitcher with ice cold water 2. instruct the UAP to start measuring the clients I and O's 3. asess the client for polyuria and polydipsia 4. check the clients BUN and creatinine levels

3. asess the client for polyuria and polydipsia the first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma. 1. the client should have the water pitcher filled, but this is not the first action. 2. this should be done but not before assessing the problem 4. this could be done, but it will not give the nurse info. about DI (the nurse must apply a systematic approach to answering priority questions. maslows hierarchy of needs should be applied if it is a physiological problem and the nursing process if it is a question of this nature. assessment is the first step in the nursing process)

The male client dx with SIADH secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. which action by the nurse is an example of the ethical principle of autonomy? 1.discuss the info the client told the nurse with the hcp and significant other 2. explain it is possible the client could have a seizure if he drank fluid beyond the restrictions 3. notify the hcp of the clients wishes and give the client fluids as desired 4. allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the hcp

3. notify the hcp of the clients wishes and give the client fluids as desired This is an example of autonomy (the client has the right to decide for himself) 1. discussing the info with others is not allowing the client to decide what is best for himself. 2. this could be an example of beneficence (to do good) if the nurse did this so the client has info on which to base a decision on whether to continue the fluid restriction 4. this is an example of dishonesty and should never be tolerated in a health care setting

The client is admitted to the medical unit with a dx of rule out diabetes insipidus. Which instructions should the nurse teach regarding a fluid deprivation test? 1. the client will be asked to drink 100 ml of fluid as rapidly as possible and then will not be allowed fluid for 24 hours 2. the client will be administered an injection of ADH, and urine output will be measured for 4 to 6 hours 3. the client will be NPO, and v/s and weights will be done hourly until the end of the test 4. an IV will be started with NS, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done

3. the client will be NPO, and v/s and weights will be done hourly until the end of the test The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and wts are taken every hour to determine circulatory status. if a marked decrease in wt or vital signs occurs, the test is immediately terminated. 1.The client is not allowed to drink during the test. 2.this test does not require any meds to be administered, and vasopressin will treat the DI, not help dx it. 4. no fluid is allowed and a sonogram is not involved

Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.

4. Droplet Precautions. Droplet Precautions are respiratory precautions used for organisms that have a limited span of transmission. Precautions include staying at least four (4) feet away from the client or wearing a standard isolation mask and gloves when coming in close contact with the client. Clients are in isolation for 24 to 48 hours after initiation of antibiotics.

The nurse is caring for a client dx with DI. which intervention should be implemented? 1. administer sliding scale insulin as ordered 2. restrict caffeinated beverages 3. check urine ketones if blood glucose is >250 4. assess tissue turgor every 4 hours

4. assess tissue turgor every 4 hours the client is excreting large amounts of dilute urine. if the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently. 1. diabetes insipidus is not diabetes mellitus; sliding scale insulin isnt administered. 2. there is no caffeine restriction for DI. 3. checking urine ketones isn't indicated

A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A) Blood glucose B) Assessment of urine for blood C) Weight D) Oral temperature

A) Blood glucose Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The patients blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.

A patient presents at the walk-in clinic complaining of diarrhea and vomiting. The patient has a documented history of adrenal insufficiency. Considering the patients history and current symptoms, the nurse should anticipate that the patient will be instructed to do which of the following? A) Increase his intake of sodium until the GI symptoms improve. B) Increase his intake of potassium until the GI symptoms improve. C) Increase his intake of glucose until the GI symptoms improve. D) Increase his intake of calcium until the GI symptoms improve.

A) Increase his intake of sodium until the GI symptoms improve. The patient will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis. While the patient may experience the loss of other electrolytes, the major concern is the replacement of lost sodium.

When examining a patient with Guillain-Barre' syndrome, the nurse would expect to assess which of the following clinical manifestations? A) Paresthesias of the hands and feet B) Hyperactive deep tendon reflexes C) Hypotension D) Descending weakness

A) Paresthesias of the hands and feet Sensory symptoms of Guillain-Barre' include paresthesias of the hands and feet, and pain related to the demyelinization of sensory fibers. Other clinical manifestations include hyporeflexia and loss of deep tendon reflexes. A classic feature of Guillain-Barre' is ascending weakness.

You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan? A) Risk for injury related to weakness B) Ineffective breathing pattern related to muscle weakness C) Risk for loneliness related to disturbed body image D) Autonomic dysreflexia related to neurologic changes

A) Risk for injury related to weakness The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patients breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.

A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding? A) The patients pituitary function is compromised. B) The patients adrenal insufficiency is not treatable. C) The patient has insufficient hypothalamic function. D) The patient would benefit from surgery

A) The patients pituitary function is compromised. An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested. Hypothalamic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated.

A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem? A) Therapeutic use of corticosteroids B) Pheochromocytoma C) Inadequate secretion of ACTH D) Adrenal tumor

A) Therapeutic use of corticosteroids Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency. The other options also cause adrenocortical insufficiency, but they are not the most common causes.

When developing a plan of care for a patient with Guillain-Barre' syndrome, the nurse knows that which of the following nursing interventions would receive priority? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Assisting the patient with activities of daily living D) Determining abnormalities of cognitive function

A) Using the incentive spirometer as prescribed Impaired gas exchange would be the priority. Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions aimed at enhancing physical mobility and preventing a deep vein thrombosis are utilized. Assisting the patient with activities of daily living is important but would not be the priority nursing intervention. Guillain-Barre' does not affect cognitive function or level of consciousness.

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply. A. Administration of rifampin (Rifadin) B. Administration of ciprofloxacin hydrochloride (Cipro) C. Administration of ceftriaxone sodium (Rocephin) D. Amoxicillin (Amoxil) E. Rofecoxib (Vioxx)

A, B, C

A patient has been taking tricylic antidepresseants for many years for the treatment of depression. The patient has developed SIADH and has been admitted to the acute care facility. What should the nurse carefully monitor when caring for this patient? Select all that apply. a. Strict intake and output b. Neurologic function c. Urine and blood chemistry d. Liver function tests e. Signs of dehydration

A, B, C

A nurse is reviewing serum laboratory results for a client who has Addison's disease. Which of the following findings are typical for a client who has this condition? Select all that apply. a. Sodium 130 mEq/L b. Potassium 6.1 mEq/L c. Calcium 11.6 mg/dL d. Magnesium 2.5 mg/dL e. Glucose 65 mg/dL

A, B, C, E - Addison pts. have hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia.

A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings are expected for this client? Select all that apply. A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocyte count 35% E. Fasting glucose 145 mg/dL

A, B, C, E - Cushing pts. have hypernatremia, hypokalemia, hypoglycemia, and elevated glucose.

A nurse is planning care for a client who has Cushing's disease. In planning care, the nurse should recognize that clients who have Cushing's disease are at increased risk for which of the following? Select all that apply. A. Infection B. Gastric ulcer C. Renal calculi d. Bone fractures E. Dysphagia

A, B, D - Suppression of the immune system places the pt. at risk for infection; overproduction of gastric acid places the pt. at risk for gastric ulcers; pts. with Cushing's are at risk for bone fractures due to decreased calcium absorption leading to osteoporosis.

A nurse is caring for a client who has primary DI. Which of the following manifestations should the nurse expect to find? Select all that apply. a. Serum sodium of 155 mEq/L b. Fatigue c. Serum osmolality of 250 mOsm/L d. Polyuria e. Nocturia

A, B, D, E - Primary DI is caused by a decrease in secretion of ADH, which can lead to increased serum sodium, fatigue due to electrolyte imbalance, polyuria, and nocturia.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique? Select all that apply. A. Place the client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest

A, C, D

A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. A) Foods high in vitamin D B) Foods high in calories C) Foods high in protein D) Foods high in calcium E) Foods high in sodium

A, C, D Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.

The nurse is admitting a client who is diagnosed with SIADH and has serum sodium of 118 mEq/L. Which healthcare provider prescriptions should the nurse anticipate receiving? Select all that apply. a. Initiate an infusion of 3% NaCl b. Administer IV furosemide c. Restrict fluids to 800 mL over 24 hours d. Elevate the HOB to high Folwer's e. Administer a vasopressin antagonist as prescribed

A, C, E

A nurse is reviewing the health record of a client who has SIADH. Which of the following laboratory findings should the nurse anticipate? Select all that apply. a. Low serum sodium b. High serum potassium c. Decreased urine osmolarity d. High urine osmolarity e. Increased urine-specific gravity

A, D, E - SIADH results in water retention causing a low serum sodium, high urine sodium level, and increase in urine-specific gravity.

What should the nurse teach a patient on corticosteroid therapy in order to reduce the patients risk of adrenal insufficiency? A) Take the medication late in the day to mimic the bodys natural rhythms. B) Always have enough medication on hand to avoid running out. C) Skip up to 2 doses in cases of illness involving nausea. D) Take up to 1 extra dose per day during times of stress.

B) Always have enough medication on hand to avoid running out. The patient and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The patient should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms.

A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? A) Activity limitation to conserve energy B) Consumption of a high-protein diet C) Use of OTC vitamin D and calcium supplements D) Passive range-of-motion exercises

B) Consumption of a high-protein diet Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.

A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what? A) Risk for peripheral neurovascular dysfunction B) Excess fluid volume C) Hypothermia D) Ineffective airway clearance

B) Excess fluid volume The priority nursing diagnosis for a patient with SIADH is excess fluid volume, as the patient retains fluids and develops a sodium deficiency. Restricting fluid intake is a typical intervention for managing this syndrome. Temperature imbalances are not associated with SIADH. The patient is not at risk for neurovascular dysfunction or a compromised airway.

The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B) Heart rate and BP C) Breath sounds and bowel sounds D) Color, warmth, movement, and sensation of extremities

B) Heart rate and BP The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.

It is important to frequently monitor the patient with Guillain-Barre' syndrome when ascending paralysis is occurring. When assessing the patient for bulbar muscle weakness, the nurse should be alert to which of the following clinical manifestations? A) Decreased level of consciousness B) Inability to clear secretions C) Hypersensitivity of hands and feet D) Increased intracranial pressure

B) Inability to clear secretions Bulbar muscle weakness related to demyelinization of the glossopharyngeal and vagus nerves results in an inability to swallow or clear secretions. Guillain-Barre' does not affect cognitive function or level of consciousness. Sensory symptoms include paresthesias of the hands and feet related to demyelinization of the sensory fibers. Guillain-Barre' does not cause increased intracranial pressure.

A patient with Guillain-Barre' has had arterial blood gases (ABGs) drawn. Which of the following ABG values indicates that the patient's status is deteriorating? A) pH 7.37 B) PaCO2 60 C) HCO3 24 D) Oxygen saturation of 94%

B) PaCO2 60 A PaCO2 of 60 places the patient with Guillain-Barre' in an acidotic state due to hypoventilation from respiratory muscle weakness. The pH, HCO3, and oxygen saturation are within normal levels.

The nurse is caring for a patient with Addisons disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? A) The possibility of precipitous weight gain B) The need for lifelong steroid replacement C) The need to match the daily steroid dose to immediate symptoms D) The importance of monitoring liver function

B) The need for lifelong steroid replacement Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the patient and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.

A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? Select all that apply. A. Use the GCS when assessing the client. B. Assist the client to eat meals while lying flat in bed. C. Administer an opioid medication. D. Encourage client to increase fluid intake. E. Place the client in a "cannonball" position.

B, C, D - Prone position may relieve a headache following a lumbar puncture; Administering an opioid for a client's report of headache pain is an appropriate action by the nurse; maintaining positive fluid balance may relieve a headache following a lumbar puncture.

5. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? Select all that apply. a. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication as prescribed D. Perform a skin assessment E. Keep the HOB flat

B, C, D - Pt. with meningitis may have nausea and vomiting; antipyretic for fever; skin assessment for macular rash associated with meningiococcalmeningitis. - Pts. with meningitis have tachycardia NOT bradycardia; HOB should be at 30* to promote venous drainage from the head and prevent increased ICP

A nurse is admitting a client who has acute adrenal insufficiency to the ICU. Which of the following prescriptions should the nurse anticipate? Select all that apply. a. IV therapy with 0.45% sodium chloride b. Regular insulin c. Hydrocortisone sodium succinate (Solu-Cortef) d. Sodium polystyrene sulfonate (Kayexalate) e. Furosemide (Lasix)

B, C, D, E - Addison pts. are hyperkalemic and insulin shifts potassium into the cells; Hydrocortisone sodium succinate is administered as a replacement for glucocorticoid and mineralocorticoid; Addison pts. are hyperkalemic and sodium polystyrene sulfonate absorbs potassium; Loop and thiazide diuretics promote potassium excretion and treats hyperkalemia.

The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. A) Epistaxis B) Pallor C) Rapid respiratory rate D) Bounding pulse E) Hypotension

B, C, E The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.

17. The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunctive antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? A. 1 hour after the antibiotic that has infused and daily for 7 days B. 15 to 20 minutes before the first dose of antibiotic and every 6 days for the next 4 days C. 2 hours prior to the administration of antibiotics for 7 days D. It can be administered every 6 hours for 10 days

B. 15 to 20 minutes before the first dose of antibiotic and every 6 days for the next 4 days

A patient suspected of having GBS has had a lumbar puncture for CSF evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease? A. Glucose in the CSF B. Elevated protein levels in the CSF C. RBCs present in the CSF D. WBCs in the CSF

B. Elevated protein levels in the CSF

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's sign. Which of the following should the nurse perform first? A. Administer antibiotics B. Implement droplet isolation precautions C. Initiate IV access D. Decrease bright lights

B. Implement droplet isolation precautions - Priority action is to prevent spread of the disease to others

A baby was born 2 hours ago by Cesarean section. The newborn has a myelomeningocele with the sac intact and has been placed in an incubator. The nurse, when planning care for the baby, should focus on potential for: A. Disuse syndrome B. Infection C. Fluid volume deficit D. Decreased cardiac output

B. Infection

A nurse us providing discharge instructions to a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? Select all that apply. a. Brush teeth after every meal or snack b. Avoid bending at the knees c. Eat a high-fiber diet d. Notify the provider if he has sweet-tasting drainage e. Notify the provider if he has diminished sense of smell.

C & D - Constipation contributes to increased ICP so the client should eat a high-fiber diet. Docusate sodium (Colace) can be used to prevent constipation; Sweet tasting fluid is an indication of CSF leak. The client should notify the provider.

The nurse knows that plasmapheresis is being utilized in the treatment of the patient with Guillain-Barre' syndrome for which of the following reasons? A) Removal of anti-acetylcholine receptor antibodies B) Reduction in the number of bacteria in the bloodstream C) Decrease in antibodies attacking peripheral nerve myelin D) Removal of potassium and fluid

C) Decrease in antibodies attacking peripheral nerve myelin Plasmapheresis and IV immunoglobulin (IVIG) are used to directly affect the peripheral nerve myelin antibody level. Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. In myasthenia gravis, plasmapheresis is used to remove anti-acetylcholine receptor antibodies. Antibiotics reduce the number of bacteria in the bloodstream. Hemodialysis removes fluid and potassium.

A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patients care? A) Decisional conflict related to treatment options B) Spiritual distress related to changes in cognitive function C) Disturbed body image related to changes in physical appearance D) Powerlessness related to disease progression

C) Disturbed body image related to changes in physical appearance Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image. Decisional conflict and powerless may exist, but disturbed body image is more likely to be present. Cognitive changes take place in patients with Cushing syndrome, but these may or may not cause spiritual distress.

Which of the following clinical manifestations would alert the nurse caring for a patient with Guillain-Barré syndrome that his status is deteriorating? A) Tidal volume of 500 mL B) Residual lung volume of 1200 mL C) Vital capacity of 11 mL/kg D) Oxygen saturation of 97%

C) Vital capacity of 11 mL/kg A vital capacity of 12 to 15 mL/kg in a patient with Guillain-Barre' means that the patient's condition has deteriorated to the point that he may need to be mechanically ventilated. Thus, a vital capacity of 11 mL/kg is a warning. The tidal volume, residual lung volume, and oxygen saturation are within normal values. Breathing in a Guillain Barre' patient would become increasingly labored as the paralysis ascended toward the intercostals and diaphragm.

The nurse is caring for a patient with a diagnosis of Addisons disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face

C) muscle weakness Patients with Addisons disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Patients with Cushing syndrome demonstrate truncal obesity, moon face, acne, abdominal striae, and hypertension.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig's sign B. Absence of nuchal rigidity C. A positive Brudenski's sign D. A GCS score of 15

C. A positive Brudenski's sign

Appropriate nursing interventions for a newborn's myelomeningocele sac prior to surgery include using sterile technique and: A. Leaving the sac open to air B. Applying petrolatum to cover the sac C. Applying moist saline dressings D. Applying dry dressings

C. Applying moist saline dressings

A client with GBS has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active ROM C. Providing information, giving positive feedback, and encouraging relaxation D. Providing IV administered sedatives, reducing distractions, and limiting visitors

C. Providing information, giving positive feedback, and encouraging relaxation

What most accurately describes bowel function in children born with a myelomeningocele? A. Incontinence cannot be prevented. B. Enemas and laxatives are contraindicated. C. Some degree of fecal continence can usually be achieved. D. A colostomy is usually required by the time the child reaches adolescence.

C. Some degree of fecal continence can usually be achieved.

The nurse recognizes that corticosteroid therapy, when used in the treatment of Guillain-Barre' syndrome, reduces the inflammation and edema associated with this neuromuscular disorder. It is most important for the nurse to monitor which of the following lab values for the patient on corticosteroid therapy? A) pH of urine B) Hemoglobin C) Serum potassium D) Serum glucose

D) Serum glucose Corticosteroid therapy increases the blood glucose level. Corticosteroids have an effect on insulin and can produce symptoms related to glucose intolerance.

A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? A) Take the drug concurrent with levothyroxine (Synthroid). B) Take each dose of prednisone with a dose of calcium chloride. C) Gradually replace the prednisone with an OTC alternative. D) Slowly taper down the dose of prednisone, as ordered.

D) Slowly taper down the dose of prednisone, as ordered. Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. There are no OTC substitutes for prednisone and neither calcium chloride nor levothyroxine addresses the risk of adrenal insufficiency.

The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the bodys natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids? A) In the evening between 4 PM and 6 PM B) Prior to going to sleep at night C) At noon every day D) In the morning between 7 AM and 8 AM

D) In the morning between 7 AM and 8 AM In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? A. Maintain enteric precautions B. Maintain neutropenic precautions C. No precautions are required as long as antibiotics have been started D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

What is important when caring for a child with myelomeningocele in the preoperative stage? A. Place the child on one side to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep the skin clean and dry to prevent irritation from diarrheal stools. D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

The client is admitted to the hospital with a diagnosis of GBS. Which past medical history finding makes the client most at risk for this disease? A. Meningitis or encephalitis during the last 5 years B. Seizures or trauma to the brain within the last years C. Back injury or trauma to the spinal cord during the last 2 years D. Respiratory or gastrointestinal infection during the previous month

D. Respiratory or gastrointestinal infection during the previous month

A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. Which of the following is being tested? a) Parathyroid functioning b) Adrenal functioning c) Thymus functioning d) Thyroid functioning

b) Adrenal functioning - The adrenal cortex manufactures and secretes glucocorticoids, such as cortisol, which affect body metabolism, suppress inflammation, and help the body withstand stress. The adrenal cortex manufactures and secretes cortisol.

A nurse should perform which intervention for a client with Cushing's syndrome? a) Suggest a high-carbohydrate, low-protein diet. b) Explain that the client's physical changes are a result of excessive corticosteroids. c) Offer clothing or bedding that's cool and comfortable. d) Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather.

b) Explain that the client's physical changes are a result of excessive corticosteroids. - The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids.

A nurse is caring for a client who has DI. Which of the following urinalysis laboratory findings should the nurse anticipate? a. Absence of glucose b. Decreased specific gravity c. Presence of ketones d. Presence of RBCs

b. Decreased specific gravity - DI clients will have diluted urine with a decreased specific gravity (less than 1.005)

A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak and has had an 8-lb weight loss since admission. What should the client be tested for? a) Hypothyroidism b) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) c) Diabetes insipidus (DI) d) Pituitary tumor

c) Diabetes insipidus (DI) - Urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine exertion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop.

A nurse is planned to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base her instructions to the client on which of the following? a. The ACTH stimulation test measures the response by the kidneys to ACTH b. In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH c. ACTH is a hormone produced by the pituitary gland d. The client is instructed to take a dose of ACTH by mouth the evening before the test.

c. ACTH is a hormone produced by the pituitary gland - Secretion of corticotropin-releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH.

10. A nurse is caring for a client who is 6hr postoperative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? a. RBCs b. Ketones c. Glucose d. Streptococcus

c. Glucose - CSF contains glucose. Therefore, the nurse should test nasal drainage for glucose to determine whether nasal drainage contains glucose.

Which of the following disorders is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? a) Graves' disease b) Addison's disease c) Hashimoto's disease d) Cushing syndrome

d) Cushing syndrome - The patient with Cushing syndrome demonstrates truncal obesity, moon face, acne, abdominal striae, and hypertension. Regardless of the cause, the normal feedback mechanisms that control the function of the adrenal cortex become ineffective, and the usual diurnal pattern of cortisol is lost. The signs and symptoms of Cushing syndrome are primarily a result of the oversecretion of glucocorticoids and androgens, although mineralocorticoid secretion also may be affected.

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a) Imbalanced nutrition: Less than body requirements b) Risk for infection c) Impaired physical mobility d) Decreased cardiac output

d) Decreased cardiac output - An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse.